Statement of Emergency Basis and Purpose for Amendment of Rule Xiv. L. of the Workers' Compensation Rules of Procedure, 7 C.C.R

STATEMENT OF EMERGENCY BASIS AND PURPOSE FOR AMENDMENT OF RULE XIV. L. OF THE WORKERS' COMPENSATION RULES OF PROCEDURE, 7 C.C.R. 1101-3

BASIS: The Director of the Division of Workers' Compensation is responsible for administering the workers' compensation system in Colorado. Sections 8-47-107 and 24-4-103(6), C.R.S. provide the Director of the Division of Workers' Compensation with authority to adopt rules and regulations to govern proceedings and hearings of the Division on an emergency basis. In certain situation obtaining a Division Independent Medical Examination (DIME) is a necessary prerequisite before a party may proceed to hearing.

SB 03-240 becomes effective on or about August 6, 2003. SB 240 amends portions of the statutes involving the DIME process, including section 24-42-107(8)(b.5) and (c), as well as section 8-42-107.2(3) (a) and (5). Pursuant to SB 03-240 the Director is required to promulgate rules regarding the selection process of a panel of three physicians from which the parties are to select the physician to conduct the DIME. Factors to be considered in the selection process, as well as the general process by which the parties will select the physician to perform the DIME, are also spelled out. In addition, SB 03-240 gives the Director specific statutory authority to promulgate rules to determine when a claimant is indigent, as well as setting forth the process for the parties to submit medical records prior to the DIME.

PURPOSE: Amendment to Rule XIV.L are needed to conform with the new statutory mandates. The proposed rule:

● Establishes a process whereby the Division selects three physicians from which the parties can choose one to perform the DIME. The three physicians are selected on a revolving basis from a pool of physicians who are qualified to perform the examination based on the condition or injury at issue. The rule also specifies the obligations of the parties when selecting the physician to perform the DIME;

● Updates the guidelines for determining indigence, clarifies how fees are paid when a claimant is determined to be indigent;

● Sets forth guidelines to apply in the determination of when a DIME physician has a conflict of interest in individual cases.

Pursuant to section 24-4-103(4)(b), C.R.S. (2002), the director also finds that:

Immediate adoption of the amendments is imperatively necessary to comply with SB 03-240 and compliance with the notice requirements of the Colorado Administrative Procedure Act would be contrary to the public interest.

This emergency rule shall be effective August 6, 2003 and will continue in effect until October 31, 2003.

Dated this 5th day of August, 2003

MaryAnn Whiteside Director Division of Workers' Compensation

STATEMENT OF BASIS AND PURPOSE FOR AMENDMENT OF RULE XIV. L. OF THE WORKERS' COMPENSATION RULES OF PROCEDURE, 7 C.C.R. 1101-3

BASIS: The Director of the Division of Workers' Compensation is responsible for administering the workers' compensation system in Colorado. Section 8-47-107, C.R.S. provides the Director of the Division of Workers' Compensation with authority to adopt proper rules and regulations to govern proceedings and hearings of the Division, and the discretion to amend said rules from time to time. In certain situation obtaining a Division Independent Medical Examination (DIME) is a necessary prerequisite before a party may proceed to hearing.

PURPOSE: Amendment to Rule XIV.L are needed to conform with the new statutory mandates, as well as to clarify other sections of the current rule. The proposed rule:

● Updates the guidelines for determining indigence, clarifies how fees are paid when a claimant is determined to be indigent;

● Sets forth guidelines to apply in the determination of when a DIME physician has a conflict of interest in individual cases.

Other non-substantive changes in the rule are included for purposes of clarification, typographical correction, or to make the text more readable.

Pursuant to section 24-4-103(4)(b), C.R.S. (2002), the director also finds that:

(1) there is a demonstrated need for these rules amendments; (2) the proper statutory authority exists for this regulation; (3) to the extent practicable, the rule is clearly stated so that its meaning will be understood by any party required to comply with the regulation;

(4) the rule does not conflict with other provisions of the law; and

(5) the duplicating or overlapping of regulations is explained by the agency proposing the rule.

This rule shall be effective November 1, 2003.

Dated this 5th day of August, 2003

MaryAnn Whiteside Director Division of Workers' Compensation

STATEMENT OF BASIS AND PURPOSE FOR AMENDMENT TO RULE XVIII, MEDICAL FEE SCHEDULE, OF THE WORKERS' COMPENSATION RULES OF PROCEDURE 7 CCR 1101-3

BASIS: Section 8-47-107, C.R.S. (2002), provides the Director of the Division of Workers' Compensation with authority to adopt and amend proper rules and regulations to govern the proceedings and hearings of the Division. This rule amendment is promulgated pursuant to Section 8-42-101 (3) (a) (I), C.R.S., which requires the Director to annually review the medical fee schedules established by the Division.

PURPOSE: The purpose of this amendment to Rule XVIII is to: ● repeal the incorporation by reference to the 2000 edition of the Relative Values for Physicians (RVP) as published by McGraw-Hill, and replace and incorporates by reference the most current edition of the RVP (2003) as published by McGraw-Hill;

● specify that current American Medical Association's Current Procedural Terminology (CPT), 2003 edition listed in the RVP are to be used;

● specify updated conversion factors to maintain the competitive fees in relation to other revenue sources for health care providers

● specify by rule the surgical codes for which the anesthesia relative value is to be used with a separate conversion factor;

● specify by rule specific surgery codes' relative value units, anesthesia base units, and global days that are different from those published in the 2003 RVP;

● clarify the use of starred procedures to be consistent with CPT 2003;

● move and update fees for office visit codes for Acupuncturist;

● increase fees for physicians rendering impairment ratings;

● increase the in-patient hospital per diem rates and corresponding outliers;

● update the Dental codes and fees to maintain access for injured workers to dental providers;

● clarify and update all other Rule XVIII established fees, as applicable or necessary; and,

● make minor grammatical and housekeeping corrections.

Pursuant to Section 24-4-103 (4) (b), C.R.S., the Director finds that: 1) There is a demonstrated need for this rule amendment; 2) The proper statutory authority exists for this regulation; 3) To the extent practicable, the rule is clearly stated so that its meaning will be understood by any party required to comply with the regulation; 4) The rule does not conflict with other provisions of law; and 5) The duplicating or overlapping of regulations is explained by the agency proposing the rule.

This rule shall be effective January 1, 2004. Mary Ann Whiteside August 13, 2003 Mary Ann Whiteside Date Director Division of Workers' Compensation

RULE I INTRODUCTION

A. Statement of Basis and Purpose

These rules are promulgated by the director pursuant to section 8-47-107, C.R.S. to implement legislative requirements contained in the Workers' Compensation Act of Colorado, to set forth the director's administrative interpretation of statutory provisions and to establish procedures for the administration and enforcement of the act.

B. Rule-making Procedure These rules have been promulgated in accordance with the State Administrative Procedure Act, section 24-4-101 et seq., C.R.S., and shall be effective March 1, 1992.

RULE II GENERAL DEFINITIONS

A. The following definitions shall apply unless otherwise indicated in these rules.

1. “Act” means articles 40 through 47 of title 8 of the Colorado Revised Statutes.

2. “Claimant” means an employee or dependents of a deceased employee claiming entitlement to benefits under the Act. For the purpose of notification and pleadings, the term “claimant” shall include the claimant's legal representative.

3. “Director” means the director of the Division of Workers' Compensation.

4. “Division” means the Division of Workers' Compensation in the Department of Labor and Employment.

5. “Employee” means an individual who meets the definition of “employee” in the Act.

6. “Employer” means anyone who meets the definition of “employer” in the Act.

7. “Insurance carrier” means every mutual company or association, every captive insurance company, and every other insurance carrier, including the Colorado Compensation Insurance Authority, providing workers' compensation insurance in Colorado, and every employer authorized by the Executive Director of the Department of Labor and Employment to act as its own insurance carrier.

8. “Calendar days” and the computation thereof is as defined by Colorado Rules of Civil Procedure, Rule 6.

9. “Business days” or “working days” are synonymous and defined as business days for the State of Colorado. The computation thereof is as defined by Colorado Rules of Civil Procedure, Rule 6.

RULE III INSURANCE COVERAGE

A. REPORTING REQUIREMENTS FOR INSURANCE CARRIERS AND POLICYHOLDERS

1. The Division designates the National Council on Compensation Insurance, Inc. (“NCCI”) as its agent to receive, process, and make available to the Division, the required notices in subsections (2), (3) and (4) below. Insurance carriers shall transmit this data and all other data elements in the electronic format as directed by the Division through NCCI.

2. Every insurance carrier shall advise the Division, by filing with NCCI, notice of the issuance or renewal of insurance coverage within thirty (30) calendar days of the effective date of coverage.

3. Every insurance carrier shall advise the Division, by filing with NCCI, final notice of the cancellation of insurance coverage no later than thirty (30) calendar days after coverage is actually canceled. This subsection does not pertain to the preliminary notice of cancellation referenced in section 8- 44-110, C.R.S.

4. Every employer shall provide on request to its insurance carrier all federal employer identification number(s) (“FEINS”) or other taxpayer identification number(s) for all the employer's business operations in Colorado to which the insurance applies. All changes in FEIN or other taxpayer I.D. numbers shall be reported immediately to the insurance carrier. The insurance carrier shall report all changes in FEINS and taxpayer I.D. numbers to NCCI within thirty (30) calendar days of receipt.

B. CARRIER REPRESENTATIVE

Every insurance carrier shall notify the Division's designated agent of the name, address and telephone number of its representative responsible for reporting coverage information. This information shall be provided within thirty (30) days upon request of either the Division or its agent, or within thirty (30) days of a change in the information.

C. SELF-INSURED EMPLOYERS

1. Any pool authorized to self-insure shall advise the Division in writing of the effective date of self- insurance, the name and address of the pool administrator and the federal employer identification number of each covered member.

2. All individual self-insurance permit holders shall advise the Division in writing of the federal employer identification number of the permit holder as well as of all covered subsidiaries.

D. ELECTION TO REJECT COVERAGE

1. An officer of a corporation or a member of a Limited Liability Company who elects to reject the provisions of the Act under section 8-41-202, C.R.S., shall complete and send Division Form WC 43, titled “Rejection of Coverage by Corporate Officers or Members of a Limited Liability Company,” or a substantial equivalent, to the insurance carrier for the corporation's or company's other employees, if any, by certified mail. A Certificate of Fact of Incorporation or a copy of date- stamped Articles of Incorporation or, for a Limited Liability Company, a copy of the Articles of Organization date-stamped by the Colorado Secretary of State shall be included with the form. An agricultural corporation electing to reject coverage for its corporate officers pursuant to 8-40- 302(6), C.R.S., shall notify the insurance carrier in writing. A Certification of Fact of Incorporation or a copy of date-stamped Articles of Incorporation shall be included with the notification. Failure to attach the appropriate document(s) will render the application or notification incomplete. If there is no insurance carrier, such documents shall be provided, by certified mail, to the Division.

2. The Notice of Election to Reject Coverage shall become effective the next business day following receipt of the notice by the insurance carrier or, if none, by the Division.

E. NOTICES TO EMPLOYEES

1. Every employer shall continuously post a notice to employees in one or more conspicuous places on the employer's work site advising employees that the employer is insured for workers' compensation as required by law, identifying the name of the employer's insurance carrier or stating that the employer is self-insured, and containing information about the Colorado workers' compensation system on a form prescribed or approved by the Division and furnished by the carrier or self-insured.

2. Every employer also shall continuously post a notice to employees in one or more conspicuous places on the employer's work site meeting the requirements set forth in section 8-43-102(1) or (1.5), C.R.S.

RULE IV CLAIMS ADJUSTING REQUIREMENTS

A. Filing of Employer's First Report of Injury 1. An employer shall report a work-related injury or illness on the employer's first report of injury form prescribed by the Division. The employer shall transmit the employer's first report of injury form to its insurance carrier within the 10-day period specified by Statute.

2. Whenever an Employer's First Report of Injury or Worker's Claim for Compensation form is filed with the Division and assigned a workers' compensation claim number, the carrier shall state whether liability is admitted or contested within 20 days after notice or knowledge of the injury pursuant to statute.

3. Written report of injury by any employee of the employer shall constitute sufficient notice by the claimant.

B. Initial Notice to Claimant

At the time an in or out-of-state insurance carrier notifies the Division of its position on a claim, the insurance carrier shall notify the claimant in writing of the carrier's claim number, the name and address of the individual assigned to the adjustment of the claim, and the toll-free telephone number of the adjuster.

C. Employer's Supplemental Report

Upon an employee's return to work, an employer's supplemental report shall be filed by the insurance carrier on the form prescribed by the Division.

D. Filing of Medical Reports

1. Medical reports shall not be filed with the Division except under the following circumstances:

a. When attached to an admission of liability form, or a petition to suspend benefits, or

b. In connection with a request to the Division to determine the claimant's eligibility for vocational rehabilitation benefits or to review a vocational rehabilitation plan, or to review requests regarding the provision of vocational rehabilitation services, or

c. When otherwise required by any other rule or the Act, or

d. At the request of the director.

E. Timely Payment of Compensation Benefits

1. Benefits awarded by order are due on the date of the order, except when a petition to review the order is filed or a request for specific findings of fact is filed. In such case benefits for those issues under review are due on the date the order becomes final.

2. Temporary disability benefits awarded by admission are due on the date of the admission and payable once every two weeks thereafter.

3. Permanent disability benefits awarded by admission are due on the date of the admission.

4. For all admissions dated on or after January 1, 1993, permanent disability benefits shall be paid every two weeks.

F. Permanent Partial Disability Benefit Rate

Permanent partial disability benefits paid as compensation for a non-scheduled injury or illness which occurred on or after July 1, 1991, shall be paid at the temporary total disability rate, but not less than one hundred fifty dollars per week and not more than fifty percent of the state average weekly wage at the time of the injury.

G. Final Payment of Compensation

1. Whenever an insurance carrier terminates temporary disability benefits pursuant to Rule IX on the grounds the claimant has reached maximum medical improvement, the admission of liability form shall contain an admission for permanent disability benefits, if any.

2. An insurance carrier shall receive credit against permanent disability benefits for any temporary disability benefits paid beyond the date of maximum medical improvement.

a. Paragraph 2 of this section shall not apply in cases where vocational rehabilitation is offered, or

b. In claims based upon an injury or illness occurring prior to 7/2/87 at 4:16 p.m. where the claimant is ordered to undergo a vocational rehabilitation evaluation but has not commenced a vocational rehabilitation program or received a director's determination that the claimant is not eligible for vocational rehabilitation services.

3. Whenever a worker's compensation claim has been closed by final order of the director, administrative law judge, Industrial Claims Appeal Panel or court, the insurance carrier shall file a final payment notice within 30 days of the date of the final order.

H. Receipts

Upon demand of the director, an insurance carrier shall produce a receipt, canceled check, or other proof substantiating payment of compensation to the claimant or medical reimbursement to a provider or claimant.

I. Certificates Of Mailing

Any document that is certified for mailing, including admissions, must be placed in the U.S. mail or delivered on the date of certification.

J. Information on Claims Adjusting

Every insurance carrier, or its designated claims adjusting administrator, in or out of state, shall provide the following information on claims adjusting practices to the Division:

1. The name, address and telephone number of the administrator(s) responsible for its claims adjusting. This information shall be provided upon request or within 30 days of any change in the administrator(s) or the geographical location of the administrator(s). Notice of such change shall be provided in writing to both the claimant and the Division. Notice shall include the name, address, and toll-free telephone number of the claims administrator(s).

2. A list of all claims established with the Division that are affected by the change described in the preceding paragraph. The list shall include claimant name, social security number, date of injury, carrier claim number, and workers' compensation claim number, if available.

3. Upon request of the director, any or all records, including any insurance carrier administrative policies or procedures, pertaining to the adjusting of Colorado Workers' Compensation claims. This authority shall not extend to personnel records of claims personnel. All documents shall remain confidential. K. Admission for Permanent Total Disability Benefits

1. An insurance carrier shall file an admission of liability for permanent total disability benefits on a final admission of liability form prescribed by the Division.

2. An insurance carrier may terminate permanent total disability benefits without a hearing by filing an admission of liability form with all of the following attachments:

a. A death certificate or written notice advising of the death of a claimant;

b. A receipt or other proof substantiating payment of compensation to the claimant through the date of death; and

c. A statement by the carrier as to its liability for payment of:

(1) Death benefits and

(2) The unpaid portion of permanent total disability benefits the claimant would have received had s/he lived until receiving compensation at the regular rate for a period of six years.

L. Revising Admissions

1. Within the time limits for objecting to the final admission of liability pursuant to 8-43-203, the director may allow a carrier to amend the admission for permanency, by notifying the parties that an error exists due to a miscalculation, omission, clerical error, or misapplication of the statute.

2. The period for objecting to a final admission begins on the mailing date of the last final admission.

3. This subsection applies to claimants with an open claim with dates of injury on or after July 1, 1991 and before August 5, 1998 with the most recent and valid Final Admission of Liability filed before September 1, 1999 to which a timely objection was filed by the claimant but no Division independent medical examination was held before September 1, 1999. The carrier, self-insured employer, or non-insured employer may file an amended Final Admission of Liability providing notice to the claimant of the requirement to mail a notice and proposal to select an independent medical examiner per C.R.S. section 8-42-107.2. Failure to provide such notice by amended Final Admission of Liability as indicated in this subsection shall preclude the carrier, self-insured employer or non-insured employer from asserting that the claimant failed to timely file a notice and proposal to select an independent medical examiner per C.R.S. section 8-42-107.2. If the notice is provided by amended Final Admission of Liability the carrier, self-insured employer or non-insured employer is not precluded from subsequently raising any relevant equitable argument, such as waiver, laches or estoppel, regarding whether the notice and proposal was timely filed.

M. Filing of Vocational Rehabilitation Reports

1. All vocational rehabilitation forms and reports for claims based upon an injury occurring on or prior to July 2, 1987 at 4:16 p.m. shall be filed with the Division and all parties copied.

2. Vocational reports for claims based upon an injury on or after July 2, 1987 at 4:16 p.m. shall not be filed with the Division except when requested by the director, when attached to a final admission, or filed pursuant to Rule VIII I. If the claimant participates in a vocational evaluation, or if the carrier offers vocational services and the claimant accepts, written reports must be produced and a copy of every vocational report not filed with the Division shall be exchanged with all parties within 15 working days of receipt. N. Admissions of Liability

1. When the final admission is predicated upon medical reports, such reports shall accompany the admission including any evaluation record (worksheets) associated with an impairment rating. The admission shall specify and describe the insurance carrier's position on the provision of medical benefits after MMI, as may be reasonable and necessary within the meaning of the Act. The admission shall make specific reference to the medical report by listing the physician's name and the date of the report.

a. For dates of injury on or after August 5, 1998, an objection form prescribed by the Division, shall accompany every final admission of liability and shall precede any other attachment.

2. When an admission is filed for medical benefits only, the admission shall include remarks outlining the basis for denial of temporary and permanent disability benefits.

3. Admissions shall be filed with supporting attachments immediately upon termination or reduction in the amount of compensation benefits. An admission shall be filed within 30 days of resumption or increase of benefits.

4. For all injuries required to be filed with the Division with dates of injury on or after July 1, 1991:

a. Where the claimant is a state resident at the time of MMI:

(1) When an authorized treating physician providing primary care is not level II accredited and has determined the claimant has reached MMI and has sustained any permanent impairment, such physician shall, within 20 days after the determination of MMI, refer the claimant to a level II accredited physician for a medical impairment rating. If the referral is not timely made, the insurance carrier shall refer the claimant to a level II accredited physician within 40 days after the determination of MMI for a medical impairment rating.

(2) If the authorized treating physician determining MMI is level II accredited, within 20 days after the determination of MMI, such physician shall determine the claimant's permanent impairment, if any.

b. Where the claimant is not a state resident at the time of MMI:

(1) When an authorized treating physician providing primary care is not level II accredited and has determined the claimant has reached MMI and has sustained any permanent impairment, within 20 days after the determination of MMI, such physician shall conduct tests to evaluate impairment and shall transmit to the insurance carrier all test results and relevant medical information. Within 20 days of receipt of the medical information, the insurance carrier shall appoint a level II accredited physician to determine the claimant's medical impairment rating from the information that was transmitted.

(2) When the claimant chooses not to have the treating physician providing primary care conduct tests to evaluate impairment, or if the information is not transmitted in a timely manner, the insurance carrier shall arrange and pay for the claimant to return to Colorado for examination, testing, and rating, at the expense of the insurance carrier. The insurance carrier shall provide to the claimant at least 20 days advance written notice of the date and time of the impairment rating examination, and a warning that refusal to return for examination may result in the loss of benefits. Such notification shall also include information identifying travel and accommodation arrangements. 5. For those injuries required to be filed with the Division with dates of injury on or after July 1, 1991, and subject to section8-42-107(8), C.R.S., medical impairment:

Within 30 days after the date of mailing or delivery of a determination of medical impairment by an authorized level II accredited physician, or within 30 days after the date of mailing or delivery of a determination by the authorized treating physician providing primary care that there is no impairment, the insurance carrier shall either:

a. File an admission of liability consistent with the physician's opinion, or

b. Request a Division Independent Medical Examination (IME) on the issue of medical impairment in accordance with Rule XIV L.3.

6. Within 30 days after the date of mailing of the IME's report determining medical impairment pursuant to Section8-42-107(8), the insurance carrier shall either admit liability consistent with such report or file an application for hearing. This section does not pertain to IMEs rendered under Section 8- 43-502.

7. The insurance carrier may modify an existing admission regarding medical impairment, whenever the medical impairment rating is changed pursuant to a binding IME, an IME selected in accordance with Part 5 of this Rule IV N., or an order. Any such modifications shall not affect an earlier award or admission as to monies previously paid.

8. For those injuries required to be filed with the Division with dates of injury on or after July 1, 1991, and subject to Section 8-42-107(2), scheduled injuries:

a. The time requirements as set forth in part 4 of this Rule IV N. apply.

b. Within 30 days after a determination of permanent impairment from an authorized level II accredited physician is mailed or delivered, or a determination by the authorized treating physician providing primary care that there is no impairment is mailed or delivered, the insurance carrier shall either:

(1) File an admission of liability consistent with the physician's opinion, or

(2) Set the matter for hearing.

O. Compliance Review

1. Every insurance carrier shall submit to reviews of its claim files for injuries arising on or after July 1, 1991, by the Carrier Practices Unit, on behalf of the Division of Workers' Compensation. The Division shall conduct reviews for the purpose of ensuring that benefits are calculated accurately and paid timely and that claims are otherwise handled in accordance with the Workers' Compensation Act and these Rules of Procedure.

a. The Division shall inform the insurance carrier of the review in writing and provide a list of files to be reviewed at least 15 calendar days prior to the commencement of the review.

b. At the time of the review, and for each file listed, the insurance carrier shall make the file available or provide to the Division a copy of the following documents: all wage records and reports, all records of medical and compensation payments, all copies of paid medical billings, all medical reports, all vocational rehabilitation reports, all notices of contest, all admissions of liability, and all correspondence pertaining to that claim, excluding work product. If an insurance carrier elects an on-site audit and the audit requires that the reviewers travel out-of-state, said carrier shall cover travel costs necessitated by and incidental to the review.

c. Failure to provide information as defined under 1.b. above shall be considered a violation of the claims management efforts of the Division as subject to section 8-43-218, C.R.S., and may subject the carrier to penalties pursuant to Rule XI G. and section 8-43-218(3), C.R.S. In the event sanctions are imposed pursuant to the above section, the carrier shall be provided remedies as set forth in section 8-43-207, C.R.S.

2. The insurance carrier shall establish dates of receipt by the carrier on all documents filed with the Division and on all medical bills and reports required to be exchanged among parties of interest. For those documents which are required to be exchanged by the insurance carrier, the carrier shall verify the date of mailing on the face of the document. For those claims filed prior to the effective date of this rule, if there is no date stamp, date of receipt may be presumed to occur three days after the date of the document or billing date. The carrier may establish its date of receipt of the Worker's Claim for Compensation by its date stamp in the first instance or by three days after the date of the transmittal letter from the Division.

3. The issues to be considered during the review shall include, but shall not be limited to, the following:

a. A comparison of the date of receipt of the Employer's First Report of Injury or Worker's Claim for Compensation form and the date of the admission or Notice of Contest pursuant to the provisions of section 8-43-203, C.R.S.

b. The calculation of average weekly wage as set forth in sections 8-40-201(19) and 8-42-102, C.R.S.; verification for the basis of the calculation may be required.

c. The calculation of compensation benefits pursuant to sections 8-42-105, 8-42-106, 8-42-107, and 8-42-111, C.R.S.

d. The date of each payment of compensation to ensure that benefits are paid timely and regularly, pursuant to section 8-42-105(2)(a), C.R.S. and Rule IV E.

e. A comparison of the medical billing date and the date of payment in accordance with Rule XVI K.

f. Compliance with procedures for contesting liability for medical payments or for returning medical billings due to insufficient data in accordance with Rule XVI(K).

g. Modification, termination or suspension of benefits pursuant to section 8-42-105 and Rule IX.

h. Service of documents in accordance with Rule XI, and other applicable Rules of Procedure.

4. Reporting Process

a. The Division shall provide a report of the review findings to the carrier within 30 calendar days from the date the unit completes the review. The report shall contain the unit's findings and recommendations, identifying each claim for which a correction is indicated, if applicable.

b. The carrier shall have 30 calendar days from the date of the report to respond to or comply with the recommendations contained in the report, unless otherwise specified.

The response shall be mailed to the Director of the Division of Workers' Compensation. The carrier shall provide evidence of compliance by providing applicable documents such as amended admissions, supplemental reports, wage history, medical reports, etc. c. The carrier or the Division may request a conference to discuss the review, within 30 days from the date of the report.

d. Nothing in this rule shall preclude the Division's ability to proceed under enforcement mechanisms provided by statute or rule.

e. Information, documentation and reports obtained from any individual, carrier representative, or any other person pursuant to the administration of this rule, in accordance with sections 8-47-202 and 8-47-203, C.R.S., except to the extent necessary for the proper administration of a claim for workers' compensation, shall be held confidential and shall not be published or be open to public inspection in any manner, other than to public employees in the performance of their public duties or to an agent of the Division of Workers' Compensation designated as such in writing for the purpose of accomplishing the Division's functions under this rule.

RULE V VOCATIONAL REHABILITATION RULES APPLICABLE TO CLAIMS BASED UPON AN INJURY OR ILLNESS OCCURRING PRIOR TO JULY 2, 1987 at 4:16 p.m.

A. Statement of Basis and Purpose

The rules of procedure governing the vocational rehabilitation component of worker's compensation are promulgated to afford the injured worker an opportunity to re-enter the workforce with a minimum of lost time. These rules accomplish that purpose through establishing procedures for early intervention by providing guidelines for comprehensive vocational evaluation to yield appropriate, achievable vocational rehabilitation plans. The rules also set guidelines for rehabilitation facilities and assisting in the vocational rehabilitation process, to gain the approval of the Division pursuant to C.R.S. 1973, section 8-49-101(4).

B. Definitions

In addition to the definitions already adopted in the rules, the following definitions apply to vocational rehabilitation procedures:

1. “Job Modification” is the environmental adaptation of a job either through the use of aids or devices or the alteration of the physical environment of the job, or both, to allow an impaired individual to perform within the scope of tasks originally designed for the job flow.

2. “Job Restructuring” is a special application of job analysis that involves the identification of jobs within the context of the system of which they are a part and the analysis and rearrangement of the job tasks to achieve a desired purpose.

3. “Qualified Worker” means an employee who because of the effects of a work-related injury or occupational disease, (a) is permanently precluded from engaging in his/her usual and customary occupation and is unable to perform work for which the individual has previous training or experience, and (b) can reasonably be expected to attain suitable, gainful employment upon successful completion of a vocational rehabilitation program.

4. “Qualified Rehabilitation Consultant” means a person authorized by a rehabilitation vendor to conduct a vocational evaluation and develop a rehabilitation plan for a qualified worker. This individual must demonstrate a level of professional training and experience as may be required by the director. The qualifications may consider, among other things education, experience and cumulative levels of expertise.

5. “Rehabilitation Vendor” means an individual, firm or facility which exists to provide any or all of the services necessary to determine an injured employee's eligibility as a qualified worker, and/or provide those services designed to return an individual to work. A vendor must register with the Division and be approved by the director.

6. “Suitable Gainful Employment” means employment which is reasonably attainable and which offers an opportunity to restore the injured worker as soon as possible and as nearly as possible to employment with the employee's qualifications, including but not limited to the em-ployee's age, education, previous work history, interests and skills. Special consideration shall also be given to the economic level of the employee at the time of injury and to the present and future labor markets, to attempt to restore him/her to the maximum level attainable.

7. “Transferable Skills” means those skills an individual possesses which were attained through previous training or experience and are readily marketable and a need for them exists in the current labor market and would provide suitable gainful employment. Transferable skills may also mean those skills gained through experience which can be redirected into a related occupation (Example: plumber-counter sales or sales representative for plumbing supply house, or contract estimator for plumbing work).

8. “Vocational Evaluation” means the service and/or rehabilitation services required to determine an injured employee's eligibility as a qualified worker. The services may include, but are not limited to work evaluation, vocational testing, counseling, job analysis and labor market analysis.

9. “Vocational Rehabilitation Plan” means a written document completed and signed by a qualified rehabilitation consultant which describes the manner and means by which it is proposed that a qualified worker may be returned to suitable gainful employment through the participation in a rehabilitation program.

10. “Vocational Rehabilitation Program” means the actual providing of services as prescribed in the vocational rehabilitation plan and approved by the director as reasonably necessary to restore a qualified worker to suitable gainful employment. Such services shall include but are not limited to medical services, counseling, education, vocational training (including on-the-job training), books, supplies and tools, job development and placement assistance and on-site followup.

C. Initiation of Vocational Evaluation and Director's Determination of Eligibility

1. A vocational avaluation shall be provided by a rehabilitation vendor designated by the insurance carrier, or self-insured employer, or upon failure of such designation, by the Division in consultation with the employee, as soon as the need is identified as outlined below. The carrier shall commence a vocational evaluation upon the occurrence of either of the following:

a. Immediately upon receipt of the first report of an injury in which liability is admitted and involves any of the following: (1) mangling, crushing or amputation of a major portion of an extremity, (2) traumatic injury to spinal cord that has caused or may cause paralysis, (3) severe burns that require burn center care, (4) serious head injury or loss of both eyes.

b. Immediately upon knowledge that an injured employee is unlikely to be able to return to his/her usual and customary occupation on a permanent basis as determined by competent medical evidence and opinion.

2. Immediately following one hundred twenty (120) days of temporary total disability for injuries or occupational diseases not evaluated under 1a & 1b above, one of the following must occur: a. The employee will be referred for vocational evaluation.

b. The employee will be referred for re-evaluation of his/her medical conditions to determine maximum medical improvement and the likelihood of a need for vocational rehabilitation or that (s)he will return to work and a report thereupon shall be filed with the Division.

c. The self-insured employer or insurance carrier will file with the Division a report that the employee will be able to return to work accompanied by competent medical evidence that also provides a date for maximum medical improvement.

3. A vocational evaluation shall contain the elements listed below and be submitted in a summary report to the director:

a. An on-site analysis of the tasks and duties of the job the employee was performing as his/her usual and customary occupation at the time of injury.

b. An analysis of the previously submitted medical reports and physicians' evaluations as they relate to the physical and skill requirements of the job the employee was performing as his/her usual or customary occupation at the time of injury.

c. An analysis of the employee's work history and academic achievement to determine transferable skills to other occupations within the scope of medical limitation and the prognosis for rehabilitation.

d. A medical report, either supplemental or previously filed, from the authorized treating physician providing: a diagnosis of the injury, a medical prognosis, prescribed medications, medical limitations, necessary continued medical care, and a reasonable commencement date for vocational rehabilitation, if applicable.

e. An assessment by a qualified rehabilitation consultant regarding the employee's likelihood of benefiting from rehabilitation services, considering such factors as attitude, interests, aptitudes, motivation and physical condition.

f. And where it is deemed necessary, the rehabilitation vendor shall provide for vocational testing and shall attach a written justification for such provision to the summary report submitted to the director.

g. In cases where it is determined that an individual possesses transferable skill or skills, there must be an analysis that the skill or skills are current and marketable.

4. A vocational evaluation shall be completed within sixty (60) days of assignment to the rehabilitation vendor or within one hundred eighty (180) days of the injury, whichever occurs first, at which time a comprehensive summary report shall be submitted.

5. A summary report of the vocational evaluation, signed by the qualified rehabilitation consultant responsible for the evaluation, shall be submitted to the director and shall contain a recommendation that the injured employee is or is not eligible for a vocational rehabilitation program.

6. If the recommendation indicates that the employee is in need of vocational rehabilitation, the recommendation shall include a description of the suggested occupation(s) that would be considered for plan development.

7. Upon submission of the summary report, the director shall determine the status of eligibility within twenty (20) days and shall issue a “Notice of Determination of Eligibility for Vocational Rehabilitation Benefits” to the self-insured employer or insurance carrier, and employee and his/her attorney.

8. Either party may object to the determination concerning eligibility within fifteen (15) days of the date of the director's determination. The objecting party may request a hearing or reserve the objection to a later date in writing.

D. Submission and Implementation of the Vocational Rehabilitation Plan

1. If the employee is determined a qualified worker, the director shall order that a vocational rehabilitation plan be developed. The plan shall be developed and submitted to the director and the parties within forty-five (45) days of the Director's determination of eligibility, unless said determination has been contested.

2. In developing the plan, the rehabilitation vendor shall strive to achieve vocational objectives in the following priorities:

a. Return to work for the same employer to a modified or restructured job requiring rehabilitation services, which is deemed to be suitable gainful employment and within the feasibility of the medical and physical limitations determined in the vocational evaluation.

b. Return to work for the same or a new employer in a related occupation, deemed to be suitable gainful employment, for which the individual has received rehabilitation services to upgrade skills attained from previous training or experience so as to achieve marketable transferable skills, and is within the feasibility of the medical and physical limitations determined in the vocational evaluation.

c. Return to work in an on-the-job training capacity at an occupation which is deemed to be suitable gainful employment and that is within the feasibility of the medical and physical limitations determined in the vocational evaluation.

d. Return to work after the completion of a vocational program into a new occupation, deemed to be suitable gainful employment, within the medical and physical limitations determined in the vocational evaluation.

3. Once developed, the proposed plan shall be written and submitted to the parties. The written plan shall include:

a. The vocational objective(s) leading to suitable gainful employment.

b. The name and location of the educational institution, vocational training agency, company or business involved in vocational rehabilitation program.

c. The nature, extent, duration of services to be provided in the rehabilitation program which will include, but are not limited to physical and occupational therapy, counseling, job development and placement activities, and medical treatment.

d. The expected length of the vocational rehabilitation program.

e. A labor market analysis showing the feasibility of employment for a qualified worker retraining for a new occupation if the proposed program is success-fully completed.

f. The amount of weekly income maintenance benefits, tuition, fees, and transportation costs, if any, and the time and manner of such payments to the employee during rehabilitation. g. The name of the qualified rehabilitation consultant responsible for the plan and the vendor's name and registration number.

4. The vocational rehabilitation plan submitted to the parties shall include copies of the summary report in its entirety.

5. The director, upon receipt of a proposed vocational rehabilitation plan and upon review, shall order the plan either approved or disapproved or modified. Implementation of the plan may begin as soon as the employee is capable of participating in the program, as indicated by competent medical evidence. The plan shall begin upon the director's approval or the date specified in the plan as applicable, whichever is later. The insurance carrier shall continue to provide temporary disability benefits, if applicable, until implementation of the plan and the employee begins his vocational rehabilitation program.

6. All matters regarding rehabilitation plans or programs shall be initially submitted to the director except in those cases where the question of need for vocational rehabilitation first arises during the course of a hearing or hearings on other issues.

7. Where the parties indicate area of disagreement, the director shall attempt to resolve the differences and upon obtaining agreement, order the plan approved. If the differences cannot be resolved, the director shall set the case for hearing to resolve the areas of disagreement.

8. If the employee does not choose to enroll in a vocational rehabilitation program, nothing in these rules and regulations shall require the employee to do so.

E. Modification, Suspension or Termination of the Vocational Rehabilitation Plan or Vocational Evaluation

Problems, disputes or other matters regarding modification, suspension, or termination of a vocational rehabilitation plan or vocational evaluation shall be reviewed by the director upon the request of the insurance carrier, or the self-insured employer, or the employee, or upon the director's own motion. The Division shall issue an order modifying, suspending, or terminating the rehabilitation plan or vocational evaluation if it finds:

1. That satisfactory progress is not being made, or

2. That the plan is not likely to prepare the employee for suitable, gainful employment due to unexpected contingencies, or

3. That the employee refuses to complete or obstructs the vocational rehabilitation plan or vocational evaluation, or

4. That a more suitable plan becomes available so that a vocational evaluation is no longer necessary as shown by competent evidence.

F. Reporting Requirement

Copies of the vocational evaluation, interim reports, vocational rehabilitation plan, progress of the rehabilitation plan, and final report including medical and vocational reports shall be sent to the employer or its insurance carrier, the employee and his/her attorney by the rehabilitation vendor. Copies of the vocational evaluation, vocational rehabilitation plan, and the final report shall be sent to the Division of Workers' Compensation by the rehabilitation vendor. A certificate of mailing shall be attached to all reports required under this rule.

G. Registration and Approval of a Rehabilitation Vendor Every person, firm, or facility providing services as a rehabilitation vendor as defined, must register with the Division and be approved as a qualified facility in accordance with C.R.S., 1973, section 8-49-101(4). In granting approval the director may consider, among other things, that the vendor have available to it the services of a qualified rehabilitation consultant who demonstrates one of the following credentials:

1. The individual is a Certified Rehabilitation Counselor under the guidelines of the Commission on Rehabilitation Counselor Certification or can demonstrate equivalent credentials.

2. The individual has a Master's degree in Vocational Rehabilitation, Guidance and Counseling, Psychology, or in a related field or can demonstrate equivalent work experience on a year for year basis for formal education. The individual must also have one (1) year of experience as a practitioner in the field of vocational rehabilitation.

3. The individual has a Bachelor's degree in Vocational Rehabilitation, Guidance and Counseling, Psychology, or a related field or can demonstrate equivalent work experience on a year for year basis for formal education. The individual must also have two (2) years experience as a practitioner in the field of vocational rehabilitation

RULE VI APPLICATIONS FOR ADMISSION AND PAYMENT OF BENEFITS FROM THE MAJOR MEDICAL INSURANCE FUND AND THE MEDICAL DISASTER FUND

A. Applications for Admission

1. All applications for admission shall be filed in duplicate with the Division on the prescribed forms. Upon receipt of an application, the director shall examine the claim file to determine whether the employer has exhausted its limits of liability for medical aid as provided in C.R.S. 1973, section 8- 49-101. Those applications not meeting this requirement shall be dismissed and the applicant will be so notified by the director.

2. Applications meeting the above requirement shall be examined by the director in accordance with the relevant provisions of the act. The director may approve or disapprove an application for admission from the fund without conducting a hearing.

B. Appeal of Order Denying Admission or denying benefits

1. A party who is dissatisfied with an order dismissing or denying an application for admission or dissatisfied with a written denial of benefits may request mediation services and/or apply for a hearing.

2. When mediation or a hearing is requested after a dismissal or denial of an application for admission or for a denial of benefits from the fund, the director shall be listed as a party and served with all notices, pleadings, reports, and other documents. Where an assistant attorney general has entered an appearance for the director in a case, such service shall be made on that attorney.

RULE VII APPEAL PROCEDURES

A. Appeal of a Summary Order

A party may appeal a summary order by filing a request for specific findings of fact and conclusions of law in accordance with section 8-43-215, C.R.S. Such request shall be a prerequisite to a petition to review under section 8-43-301, C.R.S.

B. Petition to Review

1. A petition to review filed pursuant to section 8-43-301, C.R.S. shall: a. set forth the date of the order which is the subject of the petition to review and the name of the administrative law judge or director who entered the order.

b. include a designation of record which specifies the exact hearing date for any transcript being ordered and the name of the court reporter preparing the transcript.

c. be served by mail on all parties at the same time it is filed.

2. A party appealing an order who is appearing without an attorney may use the petition to review form provided by the Division.

3. A petition to review an order of the director shall be filed at the Division's office in Denver. A petition to review an order entered by an administrative law judge shall be filed at the place indicated in the order, or, if a place is not indicated, at the Division's office in Denver.

C. Requests for Transcripts

1. A party designating a transcript as part of the record shall contact the court reporter(s) directly and make arrangements to pay for the transcript. A court reporter may demand payment of a deposit prior to preparation of a transcript.

2. When arrangements to pay for a transcript have not been made with a court reporter on a timely basis, the court reporter shall notify the Division. Upon such notification, an administrative law judge or the director may determine, after reasonable notice to the parties, that the order of the transcript has been withdrawn. An administrative law judge or the director may then issue a briefing schedule pursuant to section 8-43-301 (4), C.R.S.

3. A party who wishes to cancel a request for a transcript shall contact the court reporter(s) directly. A withdrawal of a petition to review does not automatically cancel a request for a transcript.

D. Submission of Briefs

1. When the transcript(s) designated as part of the record have been filed or the record is otherwise complete, the Division or Division of Administrative Hearings shall issue a briefing schedule in accordance with section 8-43-301, C.R.S.

2. The petitioner's brief shall be titled “Brief in Support of Petition to Review” and shall contain, in the following sequence:

a. a short introduction of the matter to be reviewed including the date of the order which is the subject of the petition and the name of the administrative law judge or director who entered the order.

b. a statement of the issues presented for review.

c. the arguments of the petitioner regarding the issues presented, along with supporting rationale, citations of authority, and references to the record. Where a party relies upon testimony, reference shall be made to the page of the transcript on which the testimony may be found. Where a party relies upon documentary evidence, reference shall be made to the date, author and relevant page(s) of the document relied upon.

d. a short conclusion stating the precise relief sought.

3. A brief filed by an opposing party shall be titled, “Brief in Opposition to Petition to Review” and shall be subject to the requirements of paragraph D.2. of this rule. 4. A request for an extension of time in which to file a brief shall be filed within the time period specified for the filing of the brief or the request shall be denied. If the petitioner has not filed a brief or a request for an extension of time on a timely basis, the opposing parties shall have 40 days after the date of the certificate of mailing of the briefing schedule to file briefs in opposition to the petition to review.

E. Appeal of a Supplemental Order

A petition to review a supplemental order shall be filed with a brief, as provided in section 8-43-301, C.R.S.

F. Withdrawal of Petition to Review

A party may withdraw a petition to review by writing a letter addressed to the administrative law judge or director who entered the order which was the subject of the petition to review. If the case has been transmitted to the Industrial Claim Appeals Panel said letter shall be filed with it.

G. Attorney Fees

When the Industrial Claim Appeals Panel has determined that a party is entitled to reasonable attorney fees and costs under section 8-43-301(14), C.R.S., the matter shall be remanded to the director for determination of the amount of fees and costs to be awarded. The director may make this determination based on an affidavit of the time spent, and the fees and costs incurred, in responding to the appeal. If there is a dispute concerning the number of hours or the amount of fees and costs incurred in responding to the appeal, the director may refer the matter to an administrative law judge for a hearing, or to a prehearing conference or a mediation conference to resolve the disputed issues.

RULE VIII WORKERS' COMPENSATION HEARINGS

It is the intent of these rules that all lay, expert and medical testimony shall be presented at or before the hearing. These rules shall be referred to as the “Adjudication Rules.” Unless otherwise provided herein, “days” shall be calculated pursuant to the provisions of Rules 6(a) and 6(e) of the Colorado Rules of Civil Procedure.

A. REQUEST FOR FORMAL HEARING ON THE RECORD BEFORE THE DIVISION OF ADMINISTRATIVE HEARINGS

When a formal hearing on the record is requested the following procedures shall prevail:

1. A written application shall be filed with the Division of Administrative Hearings on a prescribed form and shall contain:

a. A statement of the issues(s) to be determined at the hearing.

(1) Issues brought before the ALJ must be ripe for adjudication.

(2) For cases with dates of injury on or after July 1, 1991, disputes about MMI, and or whole person impairment determinations by the authorized treating physician are not ripe for review until a Division Independent Medical Examination (IME) has been completed or an administrative law judge determines that such issues are ripe for hearing.

b. A statement setting forth the names and addresses of all witnesses to be presented at the hearing, or to be presented by deposition. 2. The application for formal hearing shall be mailed by the requesting party to all parties. A certificate of mailing shall be filed with the application. If an attorney has entered an appearance for a party, mailing to the attorney is mandatory. The adverse party shall have 20 days after the date of the setting to file a response. The response shall be filed on a prescribed form and shall contain all information required by paragraph 1.a. and 1.b. of this section.

3. An application or response will not be accepted for filing unless it contains all information required by this rule.

4. A party may not add a witness or an issue after the filing of the application or response except upon agreement of all parties, or approval of an administrative law judge for good cause shown.

5. A party may not produce a witness at a formal hearing who has not been listed in the application or response, or added by agreement or order, except to present rebuttal testimony or upon approval of the administrative law judge for good cause shown.

6. The file at the Division of Workers' Compensation will be retained at the Division and is not subject to subpoena for administrative hearings. Certified copies of any documents in the Division file can be tendered by a party to the Division of Administrative Hearings. Parties may obtain certified copies of documents in the Division file by contacting the Division of Workers' Compensation, Customer Service Section.

B. SETTING PROCEDURES

1. A party who wishes to set a case for formal hearing on the record shall notify all parties and the Division of Administrative Hearings of the date and time of the setting on a Notice to Set prescribed form. The Notice to Set shall be accompanied by a completed application form. The Notice to Set and Application for Hearing shall be mailed at least 10, but no more than 20 days before the setting date. This 10 day minimum requirement may be waived by the parties and the Division of Administrative Hearings.

2. When a formal hearing on the record is set by referral of the Director of the Division of Workers' Compensation, or by a party appearing at the Division of Administrative Hearings or by telephoning the Division of Administrative Hearings, the Notice of Hearing shall be prepared by the Division of Administrative Hearings, unless setting counsel is requested to prepare the notice. If requested, the party setting the formal hearing shall send written notice of the hearing, as official agent of the Division of Administrative Hearings, to all other parties by regular mail on a prescribed form within 20 days after the setting date and, in no event, fewer than 30 days prior to the hearing date. The original copy of the notice shall be filed with the Division of Administrative Hearings.

3. A party requesting a formal hearing on the records shall do so by filing an application for hearing in the appropriate office of the Division of Administrative Hearings so the hearing is set at the hearing location closest to the claimant's residence. The location of the hearing can be moved by order of an administrative law judge for good cause shown. When a party requests a formal hearing on the record in Denver, Boulder, Fort Collins, or Greeley, the application for hearing shall be filed in the main office of the Division of Administrative Hearings in Denver. When a party requests a formal hearing on the record in Colorado Springs, Pueblo, or Alamosa, the application for hearing shall be filed with the Southern Regional Office of the Division of Administrative Hearings in Colorado Springs. When a party requests a formal hearing on the record in Grand Junction, Glenwood Springs, or Durango, the application for hearing shall be filed with the Western Regional Office in Grand Junction.

4. The director may set any case for formal hearing on the record by order or by referral to the Division of Administrative Hearings. C. SCHEDULING OF FORMAL HEARINGS ON THE RECORD

1. If at least 20 days have passed since the insurance carrier or self insured employer has received written notice of the claim, and no admission has been filed, or a denial has been filed within 45 days of the request for the formal hearing, the claimant may request an expedited hearing. The request for an expedited hearing shall be made by a written request which shall certify that each of the requirements for an expedited hearing is present in the case. Expedited cases under this section shall be set pursuant to statute.

2. a. A hearing shall be set within 80 to 100 days of any occurrence listed in section 8-43-211(2), C.R.S. At any time following the setting of the hearing, any party may, by written motion, seek an extension of time to commence a hearing and a re-setting of the hearing upon good cause shown, as provided in section 8-43-209, C.R.S. Once a case has commenced, it may be continued only upon motion and good cause shown.

b. Good cause for an extension of time to commence a hearing or to continue a hearing that has commenced includes, but is not limited to, the following:

(1) Death or incapacitation of a party or an attorney for a party;

(2) A court order staying proceedings or otherwise necessitating an extension;

(3) Entry or substitution of an attorney for a party a reasonable time prior the hearing, if the entry or substitution reasonably requires an extension;

(4) A change in the parties or pleading sufficiently significant to require an extension;

(5) Failure of a witness to appear when the witness is under a valid subpoena;

(6) A showing that more time is clearly necessary to complete authorized discovery or other mandatory preparation for the hearing; or

(7) Agreement of the parties that a settlement has been reached, or that settlement negotiations are ongoing and likely to be approved.

c. Absent additional grounds, the following do not constitute good cause:

(1) Unavailability of counsel because of an engagement in another judicial or administrative proceeding;

(2) Unavailability of a necessary witness who is not under a valid subpoena;

(3) Failure of an attorney timely to prepare for the hearing; or

(4) That a motion for an extension of time is unopposed or stipulated by other parties.

D. MOTIONS

1. A motion for entry of a procedural order may be submitted with a separate, properly captioned, proposed order. The motion shall be filed in the location specified in Rule VIII L. The certificate of mailing shall show the office in which the motion was filed.

2. A response to a motion shall be filed in the same location that the motion was filed within 10 days from the date of the certificate of mailing of the motion, or the motion may be deemed confessed. 3. When appropriate to do so, every motion must include a certification by the party or counsel that he or she has conferred, or attempted to confer, with opposing counsel and a statement regarding whether the motion is contested, uncontested, or stipulated. If no conference has occurred, an explanation must be included in the motion.

4. The Director of the Division of Administrative Hearings designee clerk in the main or regional offices of the Division of Administrative Hearings may grant any unopposed or stipulated motion for:

a. Additional time to file a pleading or perform any act required by applicable statute or rules, except (i) a motion to extend the time for a hearing when good cause is not alleged or an extension of more than 20 days to commence the hearing is requested; or (ii) a motion to continue a hearing that has been commenced;

b. Substitution or withdrawal of counsel; or

c. Adding or striking an issue or witness for hearing.

5. The proponent of an order shall submit a copy of the proposed order, and an addressed stamped envelope or fax number. The proponent of the order is responsible for the timely distribution of the conformed order to all parties.

6. Filing by facsimile is permitted as follows:

a. Motions shall not be filed by facsimile unless the hearing date is less than 15 days from the date of the facsimile transmission. Motions filed by facsimile 15 or more days prior to the hearing will not be considered.

b. Responses to motions may be filed by facsimile at any time within the limits set by this Rule VIII.

c. Motions and responses to motions filed by facsimile must be served on opposing parties by facsimile or personal delivery on the date of filing.

d. When a proposed order is filed by facsimile transmission, the Division clerk shall return the signed order by facsimile to the party who submitted the proposed order. This party will be instructed to serve copies of the order on all other parties.

e. When a motion, response or proposed order is filed by facsimile, copies of the motion, response or proposed order and envelopes should not be filed with the Division clerk, and will not be returned if filed.

7. The requirements of this section shall not apply when a motion for entry of a procedural order is made during a formal hearing or during a prehearing conference.

E. DISCOVERY

Discovery in workers' compensation cases is limited to:

1. Interrogatories

a. One set of written interrogatories and requests for production of documents may be served upon each adverse party. The number of interrogatories, including the requests for production of documents, to any one party shall not exceed 20, each of which shall consist of a single question or request. b. The responses to the interrogatories and production of documents shall be provided to all opposing parties within 20 days of mailing of the interrogatories and requests.

c. The interrogatories and the requests for production of documents may not be submitted later than 40 days prior to hearing, except for expedited hearings.

2. Depositions

a. A deposition of a party may be taken upon written motion and order. Permission to take a deposition of a party will be granted only when there is a specific showing:

(1) That a party who has been served with written interrogatories has failed to respond to the interrogatories; or

(2) That the responses to the written set of interrogatories are insufficient; or

(3) All parties agree to the taking of a deposition.

b. Depositions of other witnesses may be taken upon written motion, order, and written notice to all parties.

3. Each party is under a continuing duty to timely supplement or amend responses to discovery up to the date of the hearing.

4. Discovery, other than evidentiary depositions, shall be completed no later than 20 days prior to the hearing date, except for expedited hearings.

5. If any party fails to comply with the provisions of this rule and any action governed by it, an administrative law judge may impose sanctions upon such party pursuant to statute and rule. However, attorney fees may be imposed only for violation of a discovery order.

6. All asserted privileges shall be accompanied by a privilege log with sufficient description to allow the other parties to assess the applicability of the privilege claims.

7. Once an order to compel has been issued and properly served upon the parties, failure to comply with the order to compel shall be presumed willful.

8. Upon agreement of the parties or for good cause shown, an administrative law judge may allow additional discovery, may limit discovery or may modify the time limits set forth in this rule. Setting of a formal hearing on an expedited schedule shall constitute good cause. Good cause shall include but not be limited to an agreement of the parties.

F. DATE OF FILING

The date of filing for purposes of this rule shall mean the date stamped on the document by the Division of Administrative Hearings or Division when the document is delivered, or the date on the certificate of mailing when the document is mailed. The date of filing for a facsimile received after 5:00 p.m. will be the following business day.

G. MEDIATION, SETTLEMENT CONFERENCES, PREHEARING CONFERENCES AND ARBITRATION

1. Mediation. Parties to a dispute may consent to submit any dispute to mediation pursuant to the provisions of this Rule VIII and section 8-43-205, 3B C.R.S. a. The Division shall schedule a mediation conference after all parties agree to participate pursuant to any party's request for mediation services, in writing or orally. The mediation conference shall be scheduled at the earliest practical time, but not later than 30 days from the date of receipt of the request for such mediation conference by the Division.

2. Settlement Conferences. Parties to a dispute may request a settlement conference subject to the limitations set forth in section 8-43-206, 3B C.R.S.

3. Prehearing Conferences. The director, administrative law judges in the Division of Administrative Hearings, or any party to a claim may request a prehearing conference before a prehearing administrative law judge. Prehearing administrative law judges may order any party to a claim to participate in a prehearing conference.

a. The issues raised for consideration may be raised by motion, either written or oral. At least five days prior to the prehearing conference, the parties shall notify each other of the issues they intend to present to the prehearing administrative law judge. Additional time to respond to an issue raised at the prehearing conference may be requested by any party. It shall be within the discretion of the prehearing administrative law judge to determine if such additional time is necessary to protect the rights of the parties.

b. Once a prehearing conference has been requested by a party to a claim, it shall be set. If any party objects to the prehearing conference as set, the following procedures shall apply:

(1) Where a party objects to the setting of a prehearing conference or refuses to participate therein, it shall fax or hand-deliver its objections to the prehearing conference unit at the Division of Administrative Hearings within 2 days after the date the prehearing conference is set. If the prehearing administrative law judge orders that the prehearing conference proceed as set, the requesting party shall send written notice of the time and place of the prehearing conference to all other parties.

c. At the time of the prehearing conference, each party may submit a prehearing statement setting forth a brief summary of the issues in dispute, the names of all witnesses each party intends to call, the estimated time each party will require to present testimony and evidence, and the status of settlement discussions. Each party may also submit any discovery or pre-trial motion.

d. Any party to a claim may request, either in advance or on the date of the prehearing conference, that the prehearing conference be recorded electronically or by court reporter. If a request for electronic recording is made, a party shall have until the date of the formal hearing on the record, if such hearing date is pending at the time of the prehearing conference, or 100 days following the prehearing conference, whichever is shorter, within which to request that the prehearing conference unit prepare a transcript. The cost of preparing such transcripts shall be paid by the requesting party directly to the vendor providing the service who shall be designated by the administrative law judge.

e. The prehearing administrative law judge may require a party to provide available vocational, medical, hospital and employment records, or reports to the other parties.

4. Arbitration. Parties to a dispute may consent to submit any dispute to binding arbitration by written agreement. Binding arbitration pursuant to the provisions of this Rule VIII and section 8-43-206.5, 3B C.R.S., shall be conducted by an administrative law judge of the parties' mutual choice from the Division of Administrative Hearings, or pursuant to arbitration procedures as provided by the Colorado Rules of Civil Procedure. Unless otherwise provided by the administrative law judge or upon mutual consent of the parties and/or upon the order of the arbitrator(s), proceedings in any such arbitration shall be conducted in a manner consistent with the Colorado Rules of Civil Procedure.

H. SUBPOENAS

A subpoena to compel the attendance of witnesses or parties and the production of books, papers or records at a scheduled deposition or formal hearing may be issued on behalf of the Division of Administrative Hearings by an attorney who has entered an appearance in the case.

I. SUBMISSION OF REPORTS, OTHER DOCUMENTARY EVIDENCE, DEPOSITIONS, POSITION STATEMENTS FOR FORMAL HEARING BEFORE THE DIVISION OF ADMINISTRATIVE HEARINGS

1. All reports without limitation including medical and hospital reports, physicians' reports, vocational reports, and records of the employer shall be provided to the opposing party or counsel if represented at least 20 days prior to the formal hearing. If not so disclosed, the reports shall not be introduced into evidence at hearing, absent a showing of good cause. Reports and records previously provided to opposing parties do not have to be provided again. When provided, such reports and records do not have to be identified as potential formal hearing exhibits.

2. An evidentiary deposition may be filed before or at the formal hearing.

3. After a hearing is set and at least 3 days prior to the formal hearing, the claimant shall file a copy of the Worker's Claim for Compensation that has been filed with the Division of Workers' Compensation, and the respondent shall file a copy of the employer's First Report of Accident and the most recent Admission or Notice of Contest that has been filed with the Division of Workers' Compensation; the party applying for the hearing shall file a copy of any order previously entered in the claim granting or denying a benefit which is the same or similar to an issue designated for hearing.

4. Copies of interlocutory orders previously issued in the case that a party intends to raise on appeal shall be filed and identified at the formal hearing.

5. Oral argument at the conclusion of the formal hearing may be allowed in the discretion of the administrative law judge. A party may file a position statement and/or proposed order upon approval of the administrative law judge.

6. Only reports and records filed and identified at the formal hearing which are relevant to an issue set for hearing will be considered as evidence.

7. Testimony presented by reports, records, deposition, or telephone is presumed to be equivalent of in person hearing testimony.

J. TRANSCRIPTS OF HEARING

1. All testimony and argument of each hearing held pursuant to section 8-43-207, C.R.S. may be taken by a hearing reporter provided by the Division of Administrative Hearings, or electronically recorded by the Division of Administrative Hearings, or a private court reporter provided by any party. If the hearing is recorded by more than one method, the administrative law judge shall designate, at the time of the hearing, which will be the source for the transcript on appeal. That source will be the source for the transcript on appeal unless the administrative law judge determines that a transcript from a different source is more accurate.

2. The Division of Administrative Hearings shall provide parties and their counsel with as current information as possible regarding the availability of hearing reporters for particular hearings. However, if any party deems live reporting services to be essential, such party should make arrangements for a private court reporter in order to ensure coverage.

K. CANCELLATIONS

A formal hearing on the record may be cancelled by the agreement of all parties. The parties may stipulate that the cancellation will not result in a waiver of any issues. One party or counsel shall contact the clerk of the Division of Administrative Hearings Office where the hearing is set to be held and advise that all parties have agreed to a cancellation of the hearing. A new hearing can then only be set by filing a new application for hearing. A formal hearing may also be cancelled by written motion made pursuant to section D. of this rule, or oral motion made at the time of the prehearing conference or the formal hearing.

L. CONSOLIDATION

1. A motion to consolidate two or more claims for formal hearing shall be filed no later than the time the response to the application for hearing is due, unless the moving party verified that any new party has waived this requirement.

2. The motion shall contain a statement of any additional issues the moving party wishes to have determined at the formal hearing, and the names and addresses of any witnesses the moving party wishes to present at the hearing.

3. The moving party is responsible for appropriate notices to all interested parties.

M. PLACE OF FILING

1. All matters for the director's determination shall be filed with the Division of Workers' Compensation at 1515 Arapahoe Street, Tower 2, 5th Floor, Customer Service Unit, Denver, Colorado. Matters for the Director's determination include:

(a) Show cause orders as set forth in subsection O of this rule;

(b) Requests for penalties for a violation of rules as set forth in subsection N of this rule;

(d) Matters regarding claims handling or administration, for example, benefit distribution, petitions to modify, terminate or suspend temporary benefits, lump sum requests;

(e) Requests for payment of costs of a transcript pursuant to section 8-43-213(3), C.R.S.;

(f) Closure orders pursuant to Rule X. A.;

(g) Petition to Reopen pursuant to rule X B.;

(h) Matters involving uninsured employers pursuant to section 8-43-409, C.R.S.;

(i) Utilization reviews, unless the Director has referred the matter on appeal;

(j) Application for admission to the major medical or medical disaster funds;

(k) Settlement documents in which all parties are represented by counsel, unless settlement was finalized before an administrative law judge, in which case an administrative law judge may approve the settlement documents; and, (l) Intent to practice forms and entries of appearance under subsection Q of this rule.

2. To avoid duplication, and unnecessary expense to all parties and the Division of Workers' Compensation and the Division of Administrative Hearings, copies of matters for the determination of the Director shall not be filed with the Division of Administrative Hearings. However, copies of these documents may be filed if required as attachments, evidence submissions, and other instances to complete the record at the Division of Administrative Hearings.

3. All other motions and responses shall be filed, unless otherwise specifically ordered, with the Division of Administrative Hearings office closest to the claimant's residence.

4. To avoid duplication, and unnecessary expense to all parties and the Division of Workers' Compensation and the Division of Administrative Hearings, copies of these motions and responses shall not be filed with the Division of Workers' Compensation. However, copies of these documents may be filed if required as attachments, evidence submissions, and other instances to complete the record for determination of a matter before the Director.

N. REQUESTS FOR ATTORNEY FEES

When the claim is based upon an injury or illness which occurred on or after July 1, 1991, attorney fees may be requested by a Motion for Attorney Fees filed within 20 days after an order has become final or 20 days after a formal hearing has been cancelled, or, if the motion is made pursuant to section 8-43-408(4), at such time as may be designated by the director or the administrative law judge. The motion shall be accompanied by a detailed itemization of the time spent on the matter for which attorney fees are sought, and an affidavit from the attorney that such time was reasonably necessary to prepare for or attend the formal hearing or other matter, and stating the reasonable hourly rate. If no objection is filed by another party within 10 days of the motion, it will be presumed that there is no objection to the number of hours or the hourly rate, and the director or the administrative law judge shall enter an order awarding the amount requested or denying the entire request. If an objection is filed, the director or the administrative law judge may enter an order based upon the motion and objection, or may refer the matter for a mediation conference, a prehearing conference, or a formal hearing on the record to resolve the disputed issues.

O. PENALTY PROCEDURES UNDER SECTION 8-43-304, 3B C.R.S.

1. A person requesting the assessment of penalties pursuant to section 8-43-304, 3B C.R.S. shall proceed as follows:

a. When there are other issues pending hearing, by moving to add the issue of penalties to the application or response. Thereafter the provisions of section 8-43-304(4), 3B C.R.S. shall control.

b. When there are no other issues pending hearing, a party may request the imposition of penalties by:

(1) Filing an application for hearing requesting assessment of penalties; or

(2) Filing a written motion with the director requesting the assessment of penalties wherein the grounds therefore are stated with specificity.

2. When a motion is filed with the director pursuant to paragraph 1.b.(2) of this section N and the alleged violator has not timely filed a written response to the motion pursuant to the provisions of section D.2. of this Rule VIII, or when the director otherwise becomes aware of any alleged violation contemplated by section 8-43-304(1), 3B C.R.S., the director may issue an order to show cause pursuant to the provisions of section O. of this Rule VIII. 3. When a Motion is filed with the director pursuant to paragraph 1.b.(2) of this section N and the alleged violator timely files a written response pursuant to the provisions of section D.2. of this Rule VIII, the director shall issue a notice advising the alleged violator that unless the matter is set for a formal hearing on the record within 20 days from the date of the notice, the director may:

a. Make a determination regarding the assessment of penalties as provided for in the Act; or

b. Refer the matter to an administrative law judge in the Division of Administrative Hearings to conduct a hearing on the alleged violation, whereupon the administrative law judge shall issue an order on the matter.

P. ORDERS TO SHOW CAUSE

Where the director determines that action shall be taken unless a person shows good cause, the following procedures shall apply:

1. Unless otherwise specifically set forth in the order, a show cause order shall direct the respondent to either set the matter for a formal hearing on the record within 20 days from the date of the show cause order, or show cause in writing within twenty 20 days from the date of the show cause order why the director should not take the action identified in the order.

Q. TRUST DEPOSITS AND SURETY BONDS UNDER 8-43-408(2)

1. The trustee for all funds held in trust under the provisions of section 8-43-408(2), 3B C.R.S. may be the Colorado State Treasurer. If the Colorado State Treasurer is designated as trustee, an employer depositing funds into the trust shall transmit such funds by check payable to the Colorado State Treasurer as trustee for the employer.

2. If the Colorado State Treasurer is designated as trustee, the employer shall deliver the check for funds to be deposited in trust or a surety bond to the Division within 10 days after the date of the order.

3. Interest on funds deposited in trust shall accrue for the benefit of the person(s) determined to be entitled to such funds in the final order. If the trust funds are ordered to be distributed to more than one person, each person shall receive the interest that has accrued on the principal amount he or she is entitled to receive.

4. A person seeking distribution of a trust deposit, or enforcement of release of a surety bond, shall file a written motion in accordance with the requirements of Rule VIII D., setting forth the reasons justifying distribution, the person(s) to whom the distribution shall be made, and the amount(s) to be distributed. The motion may be filed with the Division or with an administrative law judge.

5. Nothing set forth herein shall otherwise limit the authority and duties of the State Controller as provided by section 24-30-202.4, 10A C.R.S.

R. PRACTICE BEFORE THE DIVISION

1. An attorney who wishes to practice before the Division or the Division of Administrative Hearings shall file a notice of intent to practice on the prescribed form. Such form shall be filed with the Division of Workers' Compensation.

2. To enter an appearance in a specific case, an attorney shall file an entry of appearance on the prescribed form, or complete the entry of appearance section on the application for hearing or response form, or file a notice of substitution of counsel containing the following:

a. The name of each party the attorney is representing, and b. The attorney's address, telephone number, registration number and office code, if applicable.

c. Such form shall be filed with the Division of Workers' Compensation.

3. All pleadings shall contain the information required in section 2.b. above.

4. When the case has been closed by order or final admission, An attorney may withdraw from a specific case by filing a notice of substitution of counsel signed by both attorneys, by providing notice to all parties and filing a copy of the notice with the Division of Workers' Compensation or, when the case is not closed, by filing a motion and obtaining an order authorizing withdrawal.

5. An attorney who wishes to request an order allowing withdrawal from a case that is not closed, shall file a motion together with a copy of the notice of request to withdraw mailed to the client. The notice to the client shall contain the following:

a. A statement that the attorney wishes to withdraw;

b. A statement that the client is responsible for keeping the Division informed of the client's current address and telephone number and that a claim may be dismissed if the claim is not pursued;

c. The date scheduled for any future hearing, the dates by which any legal pleadings or briefs are to be filed and a statement that these dates will not be affected by the withdrawal of counsel; and

d. A statement that the client may object to the request to withdraw by filing a written objection within 10 days of the date on the certificate of mailing of the notice, and mailing a copy of the objection to the attorney.

6. A motion to withdraw should be filed with the Division of Administrative Hearings.

7. Any attorney in good standing from any other jurisdiction in the United States may in the discretion of the Director of the Division of Administrative Hearings, or an administrative law judge, be admitted to practice before the Division of Administrative Hearings in a specific case when the attorney has been employed by one of the parties in the case.

S. DISFIGUREMENT AWARD

A party may have an administrative law judge determine the amount of additional compensation due to a claimant for disfigurement as follows:

1. By photograph: a party may submit a request for a disfigurement award to the Division of Administrative Hearings. The request shall be accompanied by a photograph or photographs clearly showing the disfigurement and the face of the claimant. The back of the photographs shall be signed by the claimant and state the date the photograph was taken. The date the photograph was taken must be at least six months after the date of the injury or surgery, or after the date of maximum medical improvement. The signature of the claimant is the claimant's certification that the photograph accurately depicts the disfigurement on the date the photograph was taken. A copy of the request, and a copy of the photographs, shall be provided to all opposing parties. Any party may request reconsideration of a disfigurement award by photograph by filing, within twenty days of the date of the certificate of mailing of the disfigurement award, an application for hearing listing disfigurement as an issue. If such an application is filed the disfigurement award will be withdrawn and vacated.

2. At a hearing: a party may file an application for hearing with the Division of Administrative Hearings listing disfigurement as an issue. If disfigurement is the only issue listed, the hearing shall be set 30 to 60 days after the date of the setting.

3. The employer or insurer may credit any disfigurement award by any amount previously paid for disfigurement, unless provided otherwise in the disfigurement award. If the amount of the credit exceeds the disfigurement award, the employer or insurer may credit any permanent disability benefits not yet paid to the claimant.

RULE IX MODIFICATION, TERMINATION OR SUSPENSION OF TEMPORARY DISABILITY BENEFITS

A. Termination of Temporary Disability Benefits by an Admission of Liability in Claims Arising Prior to July 2, 1987, at 4:16 p.m.

1. In all claims based upon an injury or disease which occurred prior to July 2, 1987, at 4:16 p.m., an insurance carrier may terminate temporary disability benefits without a hearing by filing an admission of liability form with:

a. a report from the authorized treating physician who has provided the primary care stating the claimant has reached maximum medical improvement and is released to return to an occupation which the claimant regularly performed at the time of injury.

b. a report from the authorized treating physician who has provided the primary care stating the claimant has reached maximum medical improvement and a director's determination that the claimant is not eligible for vocational rehabilitation services.

c. a written report from the employer or the claimant stating the claimant has returned to work and setting forth the wages paid for the work to which the claimant has returned; provided such admission shall admit for temporary partial disability benefits, if any.

d. a letter or death certificate advising of the death of the claimant along with a statement by the carrier as to its liability for death benefits.

e. a report from the authorized treating physician who has provided the primary care stating the claimant has reached maximum medical improvement and documentation the claimant has completed an approved vocational rehabilitation plan.

B. Termination of Temporary Disability Benefits by an Admission of Liability in Claims Arising After July 2, 1987, at 4:16 p.m. and Before July 1, 1991

1. In all claims based upon an injury or disease which occurred after July 2, 1987, at 4:16 p.m., an insurance carrier may terminate temporary disability benefits without a hearing by filing an admission of liability form with:

a. a medical report from the authorized treating physician who has provided the primary care stating the claimant has reached maximum medical improvement; provided such admission of liability shall state a position on permanent disability benefits as provided in Rule IV, G. This paragraph shall not apply in cases where vocational rehabilitation has been offered and accepted.

b. a medical report from the authorized treating physician who has provided the primary care stating the claimant is able to return to regular employment provided such admission of liability shall state a position on permanent partial disability benefits as provided in Rule IV, G. c. a written report from the employer or the claimant stating the claimant has returned to work and setting forth the wages paid for the work to which the claimant has returned; provided that such admission of liability shall admit for temporary partial disability benefits, if any.

d. a letter or death certificate advising of the death of the claimant with a statement by the carrier as to its liability for death benefits.

C. Termination of Temporary Disability Benefits in Claims Arising From Injuries Arising On or After July 1, 1991

1. In all claims based upon an injury or disease occurring on or after July 1, 1991, an insurance carrier may terminate temporary disability benefits without a hearing by filing an admission of liability form with:

a. a medical report from an authorized treating physician stating the claimant has reached maximum medical improvement; provided such admission of liability shall state a position on permanent disability benefits as provided in Rule IV(G). This paragraph shall not apply in cases where vocational rehabilitation has been offered and accepted.

b. a medical report from the authorized treating physician who has provided the primary care, stating the claimant is able to return to regular employment.

c. a written report from an employer or the claimant stating the claimant has returned to work and setting forth the wages paid for the work to which the claimant has returned provided that such admission of liability shall admit for temporary partial disability benefits, if any, or

d. a certified letter to the claimant or copy of a written offer delivered to the claimant with a signed certificate of service, containing both an offer of modified employment, setting forth duties, wages and hours and a statement from an authorized treating physician that the employment offered is within the claimant's physical restrictions, or

(e) a copy of a certified letter to the claimant or a copy of a written notice delivered to the claimant with a signed certificate of service, advising that temporary disability benefits will be suspended for failure to appear at a rescheduled medical appointment, and a statement from the authorized treating physician documenting the claimant's failure to appear.

f. a letter or death certificate advising or the death of the claimant with a statement by the carrier as to its liability for death benefits.

D. Suspension, Modification or Termination of Temporary Disability Benefits by a Petition

1. When an insurance carrier seeks to suspend, modify or ter-minate temporary disability benefits pursuant to a provision of the act, but is not able to proceed under sections A, B, C, E, F or G herein, the insurance carrier may file a petition to suspend, modify or terminate temporary disability benefits on a form prescribed by the Division. All documentation upon which the petition is based shall be attached to the petition. The petition shall indicate the type, amount and time period of compensation for which the petition has been filed and shall set forth the facts and law upon which the petitioner relies.

2. A copy of a response form prescribed by the Division shall be mailed with a copy of the petition to the claimant and claimant's attorney. Certification of this mailing shall be filed with the petition.

3. If the claimant does not file a written objection with the Division within twenty (20) days of the date of mailing of the petition and response form, the insurance carrier may suspend, modify or terminate disability benefits as of the date of the petition.

4. When a claimant files a timely objection to a petition, the insurance carrier shall continue temporary disability benefits at the previously admitted rate until an application for hearing is filed pursuant to Rule VIII, and the matter is resolved by order. The director finds that good cause exists to expedite a hearing to be held within forty (40) days from the date of the setting, because overpayment of benefits may result if the suspension, modification or termination is granted.

5. When a hearing is continued at the request of the claimant, the administrative law judge shall temporarily grant the relief requested in the petition, pending the continued hearing, if the reports and evidence attached to the petition and objection indicate a reasonable probability of success by the petitioner. The continued hearing shall be held no later than 30 days from the date of the request for continuance.

6. When a hearing is continued at the request of the insurance carrier, temporary disability benefits shall continue pending the continued hearing, subject to the provision of the administrative law judge's order.

E. Modification of Temporary Disability Benefits Pursuant to Statutory Offset

An insurance carrier may modify temporary disability benefits to offset social security, disability pension or similar benefits pursuant to statute by filing an admission of liability form with the Division, with documentation which substantiates the offset and figures showing how the amount of the offset was calculated pursuant to statute.

F. Termination or Modification of Temporary Disability Benefits Due to Confinement

An insurance carrier may terminate or modify temporary disability benefits pursuant to statute, by filing an admission of liability form with the Division with a certified copy of a mittimus, or other document issued by a court of criminal jurisdiction, which establishes that the claimant is confined in a jail, prison, or any department of corrections facility as the result of a criminal conviction.

G. Termination of Temporary Disability Benefits Pursuant to Third-Party Settlement

An insurance carrier may terminate temporary disability benefits pursuant to statute, by filing an admission of liability form with the Division with a copy of a fully executed third-party settlement agreement which establishes that the claimant has agreed to a monetary settlement for damages from a third party in an action based upon the same injury/illness that is the basis of the worker's compensation claim.

H. Failure to Comply With Requirements of Rule IX

1. Temporary disability benefits may not be suspended, modified or terminated except pursuant to the provisions of this rule or pursuant to an order of the Division following a hearing.

2. If a claimant alleges the insurance carrier has modified or terminated temporary disability benefits without following the provisions of this rule, the claimant may file an objection with the director within 60 days of the date the claimant's benefits were terminated or modified. If the director concludes the insurance carrier has not met the applicable requirements of this rule, the director may set the matter for hearing to be held within 60 days of the filing of the objection, or the director may order the insurance carrier to continue payment of temporary disability benefits, pursuant to §§8-42-105(3) and 8-42-106(2), C.R.S., until the requirements of this rule are followed or until a hearing is held and further order entered. The director's review of a claimant's objection to a termination of benefits is not a prerequisite to an administrative law judge's ruling upon such objection. I. Termination of Temporary Disability Benefits Due to Refusal to Return to Colorado for Permanent Impairment Evaluation

When a claimant has elected to proceed under C.R.S. Section 8-42-107(8) (b.5) (I) (B) and subsequently refuses to return to Colorado for examination and rating, an insurance carrier may terminate temporary disability benefits by filing an admission of liability with a copy of the claimant's written refusal to return to Colorado for examination.

J. Termination of Temporary Disability Benefits Due to Failure to Respond to an Offer of Modified Employment From a Temporary Help Contracting Firm in Claims for Injuries Occurring on or After July 1, 1996

1. An insurance carrier may terminate temporary disability benefits by filing an admission of liability with:

a. a copy of the initial written offer of modified employment provided to the claimant, which clearly states that future offers of employment need not be in writing, a description of the policy of the temporary help contracting firm regarding how and when employees are expected to learn of such future offers, and a statement that benefits shall be terminated if an employee fails to timely respond to an offer of modified employment;

b. a written statement from the employer representative giving the date, time, and method of notification which forms the basis for the termination of temporary disability benefits; and

c. a statement from the attending physician that the employment offered is within the claimant's restrictions.

RULE X CLOSURE OF CLAIMS AND PETITIONS TO REOPEN

A. Closure of Claims

1. A claim may be closed by final order, final admission, or pursuant to paragraph 2 of this section.

2. When no action in furtherance of prosecution has occurred in a claim for at least 6 months, any of the parties may file a petition to close the claim for lack of prosecution.

a. Following receipt of a request to close the claim for lack of prosecution, the director will issue an order requiring the parties to show cause why the request should not be granted. A response to such order shall be filed within 30 days of the date the order was mailed.

b. If no response is filed within 30 days of the date the order was mailed, the claim shall be automatically closed, subject to the reopening provisions of the statute. If a response is filed within 30 days of the date the order was mailed, the director will determine whether the claim should remain open.

B. Petitions to Reopen

1. A petition to reopen filed pursuant to statute shall be filed with the Division and copied to the opposing party on the form prescribed by the Division.

2. A petition to reopen based upon a change of medical condition shall be filed with a medical report containing a description of the claimant's present condition and how the claimant's condition has deteriorated or improved.

3. A petition to reopen based upon an error, mistake, fraud, or overpayment shall identify specifically the error or mistake to be corrected or the basis for the alleged fraud or overpayment. 4. For those injuries arising after July 2, 1987 at 4:16 p.m. and prior to July 1, 1991, a Petition to Reopen shall be filed when a claimant is requesting a redetermination of the original permanent partial disability award pursuant to Section 8-42-110(3), C.R.S. (Repealed 7/1/91). The petition shall be filed with a statement outlining the circumstances of termination from employment.

5. Response to the Petition to Reopen shall be sent to the opposing party and the Division of Workers' Compensation.

6. For those injuries arising on or after July 1, 1991, resulting in permanent total disability, a petition to reopen based upon a request to terminate permanent total disability benefits shall contain a statement of the basis for the petition.

a. If within thirty (30) days of the date of mailing of the petition the claimant does not file a written objection with the Division, the insurance carrier or self-insured employer may terminate disability benefits as of the date of the petition.

b. Objection to the petition filed in a timely manner shall cause the case to be set for hearing to be held within sixty (60) days of the mailing of the petition.

RULE XI GENERAL RULES

A. Completion of Division Forms

Information required on Division forms shall be typed, or legibly written in black or blue ink, and completed in full, in accordance with Division requirements as to form and content. Forms, other than position statements relative to liability, which do not comply with this rule may not be accepted for filing. Position statements relative to liability which do not meet Division requirements, will be returned to the carrier.

B. Service of Documents

1. Whenever a document is filed with the Division, a copy of the document shall be mailed to each party to the claim and attorney(s) of record, if any.

2. A copy of every medical report not filed with the Division shall be exchanged with all parties within fifteen (15) working days of receipt,

a. For claims which are not required to be reported to the division, the parties shall exchange medical information immediately upon request for such information by any interested party. Five (5) working days is considered to be a reasonable time within which to exchange information.

3. When mailing or serving any documents or correspondence on a party, whether it is filed with the Division, a copy shall be mailed to the attorney(s) of record.

4. The claimant or any other person or entity shall have fifteen (15) days from the date of mailing to complete and return any requests for release of medical, financial or other information as allowed by law.

C. Lump Sum Payment of an Award

1. A request for a lump sum payment of permanent partial, permanent total, or dependents benefits shall be made by submitting an application to the insurance carrier on the form prescribed by the Division. Within fifteen (15) days of the date the application was mailed, the insurance carrier shall file the required benefit payment information with the Division, with any objection the insurance carrier may have to the request for a lump sum payment. A copy of this filing shall be mailed to the claimant, or, if represented, to the claimant's attorney.

2. The claimant shall have ten (10) days from receipt of the benefit payment information provided by the insurance carrier to object to the accuracy of this information. In the absence of an objection, a lump sum order issued by the Division will be based upon such information and the insurance carrier shall pay the lump sum in the amount set forth in the order.

3. When the permanent partial disability award results from the application of C.R.S. 8-42-107(8) where the injury or illness occurred on or after July 1, 1991, the following applies:

a. where the injury or illness occurred on or after July 1, 1991, but prior to April 29, 1992, a lump sum of $10,000.00 or the remainder, if less, may be paid on the injured employees written request to the carrier. The insurance carrier shall respond within fifteen (15) days from the date of the mailing of the request as to whether they will grant the lump sum.

b. where the injury or illness occurred on or after April 29, 1992, a lump sum of $10,000.00 or the remainder, if less, shall automatically be paid, less discount, on the injured employees request to the carrier.

The carrier shall calculate the sum certain and issue payment taking applicable offsets (i.e. disability benefits, incarceration, garnishments) within fifteen (15) days from the date of the mailing of the request by the claimant.

c. when a claimant requests the initial $10,000.00 or less, the request shall be directed to the carrier. The director may consider an application for lump sum on the remaining benefits if the claimant has indicated that the admission will be accepted as filed, relative to permanency. Where the claimant is asserting a claim for permanent total disability, the Director may consider an application for lump sum on benefits awarded by final admission.

4. The Director may consider an application for lump sum on awards for scheduled impairment. The claimant is not limited to payment of the initial $10,000.00 but may request a lump sum payment for the entire award, up to the maximum as pursuant to section 8-43-406(2), C.R.S.

5. The insurance carrier shall issue payment within fifteen (15) days from the date of the mailing of the order by the Director.

D. Approval of Settlement Agreements

1. A request for approval of a settlement agreement shall be made by filing the following documents:

a. Original settlement agreement signed by all parties to the agreement. The agreement shall be signed and sworn to by the claimant. Where the parties do not request an appearance before the director to review the terms of the settlement, this right must be expressly waived in the agreement.

b. A proposed order in the form prescribed by the Division.

2. Whenever a pro se claimant requests approval of a settlement agreement, or whenever a party requests the right to an appearance before the director to review the terms of the agreement, a settlement proceeding shall be scheduled.

3. A settlement proceeding shall be scheduled in the Division of Administrative Hearings at least two days in advance, except for good cause shown. All medical reports contained in the files of the insurance carrier shall be filed with the Division at least two days prior to the proceeding. E. Employer Credit for Wages Paid Under 8-42-124 (2), C.R.S.

1. An employer who wishes to pay salary or wages in lieu of temporary disability benefits may apply to the director for authorization to proceed pursuant to section 8-42-124 (2), C.R.S.

2. The application to the director shall contain the following information:

a. a reference to the contract, agreement, policy, rule or other plan under which the employer wishes to pay salary or wages in excess of the temporary disability benefits required by the act, and

b. a description of the employees covered by the application and a statement that these employees will not be charged with earned vacation leave, sick leave, or other similar benefits during the period the employer is seeking a credit or reimbursement.

3. An employer who has received authorization from the director to proceed under section 8-42-124(2), C.R.S., shall stamp every employer's first report of injury form involving an employee subject to the authorization with the words, “SUBJECT TO 8-42-124(2)”, in letters approximately 3/8 inches high.

F. Notarization of Authorization for Release of Information

The claimant's signature shall be notarized on all releases filed with the Division of Workers' Compensation pursuant to section 8-47-203(1) (e), C.R.S.

G. Penalties

Whenever any rule in the Workers' Compensation Rules of Procedure has been violated, the director may:

1. impose penalties pursuant to section 8-43-304, C.R.S.,

2. request that the commissioner of insurance revoke or suspend the insurance carrier's license, pursuant to section 8-44-106, C.R.S.,

3. request that the executive director revoke or suspend an employer's self-insurance permit or impose additional terms and conditions for the permit, or

4. impose penalties otherwise authorized by the act.

H. Notice of Third Party Action or Demand

When a third party action or demand is initiated as a result of an injury or death and the claimant is eligible for worker's compensation benefits, a notice shall be filed by the claimant with the Division as well as with all interested parties indicating what action is being taken. Such notice shall contain the following:

The name and address of the third party and the person and address upon which the demand was made.

The court or forum in which the action is filed, if any.

The case number of the action, if any.

The name and address of the claimant's attorney in the action. I. REPEALED AND RESERVED

J. REPEALED AND RESERVED

K. Requests for Orders under Section 8-47-203(2), 3B C.R.S.

1. Requests made to the Division of Workers' Compensation pursuant to section 8-47-203(2), 3B C.R.S. (1994 Supp.), for copies or inspection of orders entered by the Director or an Administrative Law Judge shall:

a. be made in writing and addressed to the Director of the Division of Workers' Compensation; and,

b. state the name of the person requesting the orders and include the person's mailing address and phone number; and,

c. specifically identify the criteria for orders being requested, for example, all orders on the merits from a specified time period or all orders involving specified issues or injuries, etc.; and,

d. state the purpose for reviewing the orders.

2. The person identified as the requestor shall provide to the Division, upon request, all information necessary to clarify the request. Within thirty days from receipt of the request, the Division shall acknowledge receipt of the request and provide an estimate of the time required to process the request. Processing the request includes development of a cost estimate. Based on the cost estimate for the request provided by the Division, the requestor shall accept or reject further processing of the request. Acceptance constitutes the requestor's agreement to pay the actual cost before or upon receipt of the orders.

3. To protect the confidentiality of the claimant and employer named in requested orders:

a. requests shall not be accepted for orders based on claimant or employer names, or other uniquely identifying claimant or employer information; and,

b. requests shall not be accepted for any criteria resulting in the inclusion of fewer than 3 claimants or employers in the group of orders inspected, unless approved by the Director or the Director's designee following an in-camera review of the request; and,

c. the names and other identifying information concerning the claimant and employer shall be excised from all orders requested prior to receipt.

4. Questions regarding the least expensive methods of retrieval may be directed to the Division.

RULE XII REQUESTS FOR BENEFITS FROM THE SUBSEQUENT INJURY FUND

A. Offset of Liability to Subsequent Injury Fund

1. Offset of liability to the Subsequent Injury Fund, shall be initiated by filing a request for offset with the Division upon the prescribed form and serving the director with a copy of the request for offset. The party filing the request for offset with the director shall also simultaneously file with the director a copy of all available relevant documents that support the request for offset.

2. A request pursuant to section 8-46-101, C.R.S., shall list, to the extent available by every reasonable effort by the movant, all prior or pending workers' compensation cases by name and number, a brief description of each injury and the award in each case. 3. A request pursuant to section 8-41-304(2), C.R.S., shall indicate the types of exposures alleged, the approximate dates of each exposure, and the location and the name of the employer in whose employ each exposure allegedly occurred.

4. A request for offset shall be filed no later than the date the party requesting offset files an application for hearing or response to application for hearing, unless an administrative law judge rules that good cause has been shown for filing later. However, in no event shall a request for offset be filed after a determination, by admission or order, that a claimant is permanently and totally disabled under 8-46-101 or disabled under 8-41-304(2).

5. The party requesting offset shall also file a proposed order joining the director as a party on behalf of the Subsequent Injury Fund. Sufficient copies of the order and pre-addressed envelopes for all parties shall also be filed.

6. The Subsequent Injury Fund shall file a response to a request for offset within 30 days of the date the director is served with a request for offset.

7. The administrative law judge shall consider the request and response and rule on whether to join the director as a party. The ruling shall be based on whether the procedural requirements of this Rule XII have been met and whether the request states a sufficient basis upon which offset could be granted. Until the director is joined, notices and orders are not binding on the Subsequent Injury Fund.

8. When the director is joined as a party and when an assistant attorney general has entered an appearance on behalf of the Subsequent Injury Fund, the party who filed the request for offset shall serve the Office of the Attorney General with copies of transcripts of proceedings prior to the date of the order joining the director in the pending workers' compensation cases.

9. When the director is joined as a party and when an assistant attorney general has entered an appearance on behalf of the Subsequent Injury Fund, copies of all reports, pleadings or other documents thereafter filed by any party shall be served on the Office of the Attorney General.

B. Status of Director, on Behalf of the Subsequent Injury Fund, in Fatal Cases

1. The director shall be deemed to be an interested party in all fatal cases and shall be served with all pleadings, notices, reports, and documents as required for any party. Where an assistant attorney general has entered an appearance for the director in a case, such service shall be made upon that attorney.

2. In the event a compensable injury results in a death which has not been reported to the Division, the director may initiate a claim for the death benefits provided by statute.

RULE XIII WORKERS' COMPENSATION PREMIUM SURCHARGES

A. PREMIUM REPORTING REQUIREMENTS

Every insurance carrier shall semi-annually file a surcharge return with the Division within the time period specified in section (D) of this rule. The return shall be verified by affidavits of its president and secretary or other chief officers or agents, and shall state the amount of premiums written, including any policy expense constants, membership fees, finance and service, or other administrative fees charged to the policyholder in connection with the issuance or renewal of a policy, as reported to the Division of Insurance in accordance with Section 10-3-208, C.R.S., and regulations promulgated thereunder, during the period covered by such return. With this filing the insurance carrier shall pay the surcharges required by statute. Forms for such returns shall be provided by the Division.

B. PAYROLL REPORTING REQUIREMENTS

Every self-insured employer shall semi-annually file a surcharge return with the Division, within the time period specified in section (D) of this rule. The return shall be verified by affidavits of its president and secretary or other chief officers or agents, and shall state the total amount of its payroll for the period covered by such return. With this filing the employer shall pay the surcharges required by statute. Forms for such return shall be provided by the Division.

C. COMPUTATION OF PAYROLL SURCHARGES PAID BY SELF-INSURED EMPLOYERS

1. Surcharges paid by self-insured employers shall be based upon the manual premium, discounted by the Colorado Compensation Insurance Authority rate discount applicable for the surcharge period covered. The discounted premium shall then be modified by the experience rating factor as calculated by the National Council on Compensation Insurance (N.C.C.I.). No other rating factor shall be allowable. The self-insured employer may elect not to provide such a rating factor; however, failure to submit the required rating factor will result in the premium surcharge being computed on the basis of manual premium only.

2. If the self-insured employer is unable to develop the experience rating factor due to the unavailability of reliable and adequate data, the employer may apply to the director for approval to use a 1.0 experience rating factor for the following two semiannual surcharge periods. If at the conclusion of the two semiannual surcharge periods that the 1.0 factor is used, the N.C.C.I. has been unable to develop an experience modification, the director may permit an extension of time for the 1.0 factor to be used.

3. In order that consideration be given to the experience modification, a completed N.C.C.I. form setting forth all of the information and methodology used in the calculation of the experience modification shall accompany each corresponding payroll report.

D. PAYMENT PERIODS AND CREDITS

1. The premium and payroll surcharges for the semiannual period beginning July 1, shall be based upon premiums written, including any policy expense constants, membership fees, finance and service, or other administrative fees charged to the policyholder in connection with the issuance or renewal of a policy, as reported to the Division of Insurance in accordance with Section 10-3-208, C.R.S., and regulations promulgated thereunder, for Colorado workers' compensation insurance or the self-insured employer's total payroll during the previous six months, and shall be paid to the Division on or before July 31 of that year, with a return form provided by the Division.

2. The premium and payroll surcharges for the semiannual period beginning January 1 shall be based upon premiums written, including any policy expense constants, membership fees, finance and service, or other administrative fees charged to the policyholder in connection with the issuance or renewal of a policy, as reported to the Division of Insurance in accordance with Section 10-3- 208, C.R.S., and regulations promulgated thereunder, for Colorado workers' compensation insurance or the self-insured employer's total payroll during the previous six months, and shall be paid to the Division on or before January 31 of that year, with a return form provided by the Division.

3. An insurance carrier is entitled to a credit for canceled or returned premiums, including any policy expense constants, membership fees, finance and service, or other administrative fees charged to the policyholder in connection with the issuance or renewal of a policy, as reported to the Division of Insurance in accordance with Section 10-3-208, C.R.S., and regulations promulgated thereunder, actually refunded. The credit must be taken as an offset against surcharges due within one year of the date the premium amount was refunded.

4. An insurance carrier or employer is not entitled to offset a credit of one subsidiary against the surcharge owed by another subsidiary.

E. SURCHARGE RATE

1. For the annual period beginning July 1, 2001 and continuing indefinitely with annual review by the director, the workers' compensation cash fund premium surcharge rate authorized under section 8-44-112(1)(a), C.R.S., shall be 1.47 percent of the amount of all premiums written, including any policy expense constants, membership fees, finance and service, or other administrative fees charged to the policyholder in connection with the issuance or renewal of a policy, as reported to the Division of Insurance in accordance with Section 10-3-208, C.R.S., and regulations promulgated thereunder, or the premium equivalent amount established in section (C) of this rule, for Colorado workers' compensation insurance during the period of January 1, 2001 continuing indefinitely.

2. For the purpose of funding the direct and indirect costs of the premium cost Containment program of the Division as authorized under section 8-44-112(1)(b)(I), C.R.S., there is added to the surcharge imposed pursuant to Section (E) of this rule, an additional increment for the annual period beginning July 1, 2001 and continuing indefinitely with annual review by the director, against workers' compensation insurance premiums written, including any policy expense constants, membership fees, finance and service, or other administrative fees charged to the policyholder in connection with the issuance or renewal of a policy, as reported to the Division of Insurance in accordance with Section 10-3-208, C.R.S., and regulations promulgated thereunder, during the period of January 1, 2001, continuing indefinitely. The amount of this assessment shall be 0.03 percent. No assessment shall be imposed upon self-insured employers under this subsection.

3. For the purposes of funding the financial liabilities of the Subsequent Injury Fund as authorized under Section 8-46-101(2)(A)(I) And the Major Medical Fund under Section 8-46-202, for the period beginning July 1, 2001, and continuing indefinitely with annual review by the director, the tax shall be assessed at 2.318 percent of the amount of Workers' Compensation premiums written, including any policy expense constants, membership fees, finance and service, or other administrative fees charged to the policyholder in connection with the issuance or renewal of a policy, as reported to the Division of Insurance in accordance with section 10-3-208, C.R.S., and regulations promulgated thereunder, or the premium equivalent amount established in Section (C) of this rule, for Colorado Workers' Compensation insurance during the period of January 1, 2001, continuing indefinitely.

RULE XIV MEDICAL COST CONTAINMENT

A. CROSS-REFERENCES TO MEDICAL COST CONTAINMENT RULES FORMERLY ADDRESSED IN RULE XIV.

1. Medical Treatment Guidelines

- See Rule XVII

2. Utilization Standards

- See Rule XVI

3. Reimbursement of all Medical Procedures and Services - See Rule XVIII, Medical Fee Schedule

4. Recognized Health Care Providers

- See Rule XVI, Utilization Standards

5. Utilization Review Program

- See Rule XV, Utilization Review

6. Timely Payment for Services

- See Rule XVI, Utilization Standards

7. Billing Rates, Fees, Procedures, Documentation Requirements

- See Rule XVI, Utilization Standards

8. Medical Fee Schedule Disputes

- See Rule XVI, Utilization Standards

9. Prior Authorization of Payment

- See Rule XVI, Utilization Standards

10. Review of Hospital Charges (Audit)

- See Rule XVI, Utilization Standards

11. Failure to Comply with Rules

- See Rule XVI, Utilization Standards

12. Physicians Accreditation Program

- See Rule XX, Accreditation of Physicians

PARTS B. THROUGH K. – REPEALED AND RESERVED

L. MEDICAL REVIEW PANEL – INDEPENDENT MEDICAL EXAMINATION (IME)

1. Qualifications

These rules apply to parties and physicians participating in the workers' compensation IME program pursuant to the authority of the Workers' Compensation Act.

A physician who seeks appointment to the Division's medical review panel for the purpose of performing IME's under the authority of the Workers' Compensation Act, Title 8, Articles 40 through 47 of the Colorado Revised Statutes, shall make application and meet the following qualifications:

a. Be licensed by the Board of Dental Examiners, the Board of Chiropractic Examiners, the Colorado Podiatry Board, the Board of Medical Examiners and board certified (or board eligible) by the American Board of Medical Specialties or the American Osteopathic Association or another organization acceptable to the Division;

b. For determination of maximum medical improvement (MMI), have attained at least level I accreditation and have 384 hours per year of direct patient care (excluding medical/legal evaluation); and

c. For purposes of determining permanent impairment have attained level II accreditation and either have 384 hours per year of direct patient care (excluding medical/legal evaluation) or demonstrated additional competency in the field of disability evaluation through certification by the American Board of Independent Medical Examiners or the American Academy of Disability Evaluation Physicians.

d. Shall have a license which is current, active and unrestricted.

e. A physician who has agreed to perform an IME as a result of negotiation and agreement by the parties, and who has not applied for appointment to the Division's IME panel, is not required to complete the application for appointment to the IME panel as set forth in subsection L.2. However, such physician shall comply with all other qualifications and procedures governing the conduct of IME proceedings as established by this rule.

2. Appointment Procedures

The physician shall complete the Division application form, certify to and, upon approval of the application, comply with the following:

a. Unless otherwise approved by both parties, or the Division, the physician shall conduct an IME no earlier than 35 calendar days, nor later than 50 calendar days from the telephone call requesting an appointment;

b. Within 20 calendar days of the examination submit the original report with all attachments to the Division and a copy to all parties;

c. Decline a request to conduct an IME only on the basis of good cause shown, as determined by the director;

d. Comply with the Workers' Compensation Rules of Procedure;

e. Conduct an IME pursuant to this section in an objective and impartial manner;

f. Not refer any ME claimant to another physician for treatment or testing;

g. Not become the treating physician for the IME claimant, unless approved by the director, ordered by an administrative law judge, or by both party written agreement;

h. Not evaluate an ME claimant if the appearance of or an actual conflict of interest exists for any reason; a conflict of interest includes, but is not limited to, instances where the physician or someone in the physician's office has treated the claimant. Further, a conflict may be presumed to exist when the IME physician and a physician that previously treated the claimant have a relationship which involves a direct or substantial financial interest. The following guidelines are to assist in determination of conflict:

i. direct or substantial financial interest is a substantial interest which is a business ownership interest, a creditor interest in an insolvent business, employment or prospective employment for which negotiations have begun, ownership interest in real or personal property, debtor interest or being an officer or director in a business.

ii. The relationship should be determined as of the time the IME is being requested. Relationships in existence before or after the review will have no bearing, unless a direct and substantial interest is present at the time of the IME.

iii. Being members of the same professional association, society or medical group, sharing office space or having practiced together in the past are not the types of relationships that will be considered a conflict, absent the present existence of a direct or substantial financial interest.

i. Not employ invasive diagnostic procedures unless approved as provided hi L.4.a., below;

j. Not substitute any other physician as the designated IME physician without written permission of the director;

k. In order to assure fair and unbiased IME's, not engage in communication regarding the IME with any person other than Division staff, except under the following circumstances: the claimant during the IME examination, the requesting party when setting the appointment, by approval of the director, both party written agreement, an order by an administrative law judge, by deposition or subpoena as approved by an administrative law judge;

l. No later than 30 calendar days after the cancellation of an examination, refund to the paying party part or all of the fee paid by that party as may be required by these rules or by the director.

m. For each IME case assigned, address the following issues and make findings if relevant: maximum medical improvement, permanent impairment, and apportionment of impairment. Also consider any issues presented on the “Application for IME” or as directed by an administrative law judge. If the IME is requested pursuant to section 8-42- 107(8)(b)(II)(A-D), C.R.S., the requesting party shall clearly note such on the IME application form.

3. Requests for an IME:

a. Application Process:

1) Either party that disputes the determination of MMI or impairment made by an authorized treating physician in a workers' compensation case may apply for an IME.

2) Requirement to Negotiate: Prior to Division intervention, the parties must attempt to negotiate the selection of a physician to conduct the ME. Parties that have agreed upon a physician to conduct the ME shall schedule the appointment pursuant to section L.2.a. of this rule and shall notify the Division on the ME application form. If despite the good faith efforts of the parties, an agreement that was reached fails, either party may apply to the Division for the selection of an IME physician, using the form required under L.3.b., below, within 30 days of such failure.

3) The requesting party shall submit an application for an ME according to L.3.b., below. If the parties did not agree on the physician, the insurance carrier shall notify the Division and the other party on a prescribed form regarding the failed negotiation within 30 calendar days of their failure to agree. The party disputing the determinations of the authorized treating physician, and seeking review of those determinations (“requesting party”) shall file an application for ME within 30 days of the date of the failure to agree upon an ME physician.

4) Insurance carriers are not designated the requesting party simply due to their obligation to submit the documents referenced above. The requesting party is the party disputing the determinations of the authorized treating physician and seeking review of those determinations. The requesting party must complete the application for ME.

5) The parties may agree to limit the issues addressed in an IME exam. Such agreement shall be reduced to writing, signed by both parties, and provided to the ME unit no later than five (5) days prior to the IME appointment date. An opinion from an ME examiner concerning MMI, impairment or apportionment in a case in which the parties agreed to limit such issue, is not entitled to any weight before an administrative law judge. b. Form Required: The prescribed form, “Application for a Division Independent Medical Examination” shall be used in all cases to request an IME. The Division requires that the party requesting the IME designate:

1) The preferred geographic location for the IME examination;

2) The body part(s) or medical conditions to be evaluated, including whether mental impairment shall be evaluated;

3) Other physicians that have previously evaluated, treated, or are currently treating the claimant.

The requesting party shall certify that all parties and the Division have been sent the application form at the same time by the same means. Only the Division application form or a materially substantial equivalent duplication approved by the Division is acceptable. c. IME Physician Selection: If the parties are unable to agree upon a physician to conduct the IME, the division will select via a revolving selection process a panel of three qualified physicians from its list of qualified physicians, from which one physician shall be designated to perform the IME. To obtain a pool of qualified physicians from which the Division shall make the selection of the three physician panel, the Division shall consider to the extent possible the criteria identified in the application for IME as set forth hi section L.3.b. of this rule. The Division will correlate the body parts or medical conditions on the IME application with the appropriate medical treatment guideline on the table designated in part Q of this rule XIV. The three-physician panel will be comprised of physicians based on their accreditation to perform impairment ratings on the body part(s) and/or medical conditions designated by the requesting party on the IME application. At the time a physician applies to join the IME panel of physicians, he/she shall designate the body parts or medical conditions that he/she is willing and able to evaluate. Physicians electing not to perform impairment ratings on certain body parts or conditions shall not be included in any three-doctor panel where those body parts or conditions are listed on the IME application pursuant to part L.3.b.2) of this rule. d. The Division will apply the same selection process for designation of the three-physician panel for injuries or conditions for which no Division medical treatment guideline exists. e. All potential candidate names will be kept confidential until the selection of the three physician panel is made. The Division will notify the parties in writing by mail or fax of the names and the medical specialties of the three physician panel within ten calendar days after receipt of the application. The physician names and related information will be listed on a form generated and provided by the Division. Should a party be contacted by telephone, and the party is unavailable, that information will be left on voice mail or with an answering person. Pro se claimants without telephone availability shall be notified by mail. f. Within seven (7) business days of issuance of the three-physician list by the Division, the requesting party shall strike one name and inform the other party. Within five (5) business days of receiving that information from the requesting party, the other party shall strike one of the two remaining physicians and inform the Division's IME Unit, with confirmation to the requesting party, of the name of the remaining physician. That information shall be provided to the Division via fax or telephone. The parties may exchange information under this rule via fax, e-mail or telephone.

If the division is not notified of the selected physician within fifteen (15) business days of the date the Division issued the three-physician panel, the Division shall randomly select one name from the three-physician list. If one party fails to timely strike a physician from the list, the other party shall notify the Division and at the same time provide to the Division the name of the physician that party wishes to strike. In that situation the Division will randomly select one name from the remaining two physicians. The Division shall confirm to the parties by telephone and/or in writing the name of the selected physician.

If the selected physician declines or is unable to perform the IME, the Division shall provide one replacement name to the original list of three physicians, and present that revised list to the parties where each shall strike one name according to the procedures set forth in this section.

Additionally, if a physician is removed from the three-physician panel for any reason other than having been struck by one of the parties, the Division will issue one replacement name using the same criteria and process set forth in subsection 3.c.., above. g. When a physician is selected from the three-physician panel to perform the IME, the Division will remove his/her name from the revolving list of physicians for a period of time so that he/she is not available for assignment to another three-physician panel. This period of time may be adjusted by the Division as necessary to balance the mandate to reduce over utilization of individual physicians, yet ensure that an adequate pool of physicians is available in each geographic area. This procedure shall not preclude the parties from agreeing-upon such physicians to perform division IMEs. h. Appointment Date: The date of the examination shall be set in accordance with Subsection L.2.a. of Rule XIV. The requesting party shall call the IME physician within five business days after providing and/or receiving notice of the final IME physician selection to schedule the examination, and shall immediately notify the Division and the opposing party by telephone, and confirm in writing, the date and time of the examination. Absent good cause as determined by the director or an administrative law judge, failure to make the appointment and advise all parties within five business days permits the opposing party, after notifying the Division of such failure, to either schedule the IME appointment or to request cancellation of the IME. i. Submission of Medical Records: The insurance carrier shall concurrently provide to the IME physician and all other parties, a complete copy of all medical records in their possession pertaining to the subject injury, postmarked or hand-delivered no fewer than 14 calendar days prior to the IME examination. If the insurance carrier or its representative fails to timely submit medical records to the designated IME physician, the claimant may request the Division cancel the IME; or the claimant may submit all medical records he/she has available no later than 10 calendar days prior to the IME examination; or as otherwise arranged by the Division with the IME physician. This rule does not prohibit the rescheduling of the IME. The defaulting party may supplement the records pursuant to subsection L.3.k. of Rule XIV.

j. Form/Content of Medical Records Package: Pertinent medical records shall include all medical reports and medical records reflecting the diagnosis and treatment of the claimant's work- related injury, and shall include available medical records regarding relevant pre-existing condition(s) or work-related injury(ies). The medical file shall be two-hole punched at the top center of each page and clipped at the top with paper fasteners. A dated cover sheet shall be included listing the claimant's name, IME physician's name, date and time of the appointment, and the workers' compensation number. The medical file shall be in chronological order and tabbed by year. It shall include a written summary of medical providers with the range of dates of treatment. Medical records not meeting these requirements shall be resubmitted to the IME physician and all other parties in the correct format within three business days of notification by the Division. Failure to timely and properly resubmit such records may result in cancellation of the IME by the director, at the cost of the submitting party. Penalties otherwise available under these rules and the Act may be determined by the Director.

Medical bills, adjustor notes, surveillance tapes, admissions, denials, vocational rehabilitation reports, non-treating case manager records or commentaries to the IME physician shall not be submitted without written agreement of all parties, order of an administrative law judge, or prior permission of the Division.

k. Submission of Supplemental Medical Records: Supplemental medical records shall be prepared according to subsection L.3.J., above, and may be mailed or hand-delivered by any party concurrently to the IME physician and all other parties no later than seven calendar days prior to the IME examination.

l. Depositions: Medical depositions may be submitted as part of the medical records package only by written agreement of all parties or pursuant to an order issued by the director or an administrative law judge. The ME physician shall be reimbursed for time spent reviewing medical depositions at the rate set forth in Rule XVIII, Testimony Fees. The party submitting the medical deposition shall be responsible for payment of the additional fees.

m. Interpreter: The claimant shall be responsible for notifying the insurance carrier of the necessity for a language interpreter, a minimum of 14 calendar days before the examination. The paying party shall be responsible for arranging for the services of and paying for such language interpreter. The language interpreter shall be impartial and independent, and have no professional or personal affiliation with any party to the claim or the IME physician.

n. IME Proceedings Held in Abeyance: If a party files a motion involving a pending IME proceeding, the moving party shall provide a copy of the motion directly to the Division's IME section. The IME proceeding shall be held in abeyance until the Division IME section is notified of the disposition as provided in this rule. When the motion is disposed of by written order or other means, the moving party shall provide a copy of the order or other dispositive document to the Division's IME section.

4. Payments/Fees: Unless the party requesting the IME is determined indigent pursuant to part P of this rule, the following shall apply to payments and fees:

a. The physician performing the IME shall be prepaid a total fee of $675.00 for each ME by the requesting party unless otherwise stipulated or ordered by the director or an administrative law judge. If the record review is unusually extensive and requires longer than an hour for review, the physician shall contact the Division and request additional payment. This request should be made no later than three calendar days prior to the IME examination. The Division will transmit the request to the requesting party. If the requesting party declines to pay, the IME physician shall complete the IME process to the best of his/her ability without expending the additional time on record review. If additional file review charges are approved, the physician shall bill at the rate set forth in Rule XVIII F.7.C The same process described in this paragraph shall apply with regard to any clinical or diagnostic testing requested by physicians performing IMEs

It is expected that a test essential under the AMA Guides, 3 rd Edition (revised) or the level II accreditation curriculum for an impairment rating to be rendered will have been performed prior to the IME. Routine tests necessary for a complete IME should be performed as part of the IME with no additional cost. If an essential test is non-routine or requires special facilities or equipment, and such test was not previously performed, or was previously performed but the findings are not usable at the time of the IME, the physician performing the IME shall notify the Division, who will notify the parties. Unless extraordinary circumstances exist that result in an ALJ issuing a ruling to the contrary, the physician performing the IME will either perform the essential test or refer out the essential test for completion, and the insurer or self-insured employer shall be responsible for paying for the essential test.

b. Payment for an ME shall be made at least 10 calendar days prior to the scheduled examination. Failure of the requesting party to timely submit the IME examination fee shall allow the physician to charge up to an additional $100.00 for the IME review which the requesting party shall pay.

c. An IME examination may be canceled only by the requesting party, or the Division, no later than three (3) business days prior to the examination. The non-canceling party may contact the Division to determine whether the IME may be rescheduled. If the IME is not timely canceled or the claimant fails to keep the IME appointment, or the medical records are not submitted in a timely manner, the IME physician shall be entitled to retain $150.00 from the total fee when the IME was requested by the defaulting party. If the fee has not yet been paid, or the party responsible for the untimely cancellation is not the requesting party, the physician shall be entitled to collect from the defaulting party a $150.00 cancellation/penalty fee. The insurance carrier may be entitled to offset the cancellation fee against any future permanent or temporary benefits if the claimant fails to appear for the IME examination without good cause as determined by the director or an administrative law judge.

d. Services rendered by an ME physician shall conclude upon acceptance by the Division of the final ME report. An IME report is final for the purpose of this subsection L.4.d. of this rule, when it includes the requested determination regarding MMI and/or final impairment rating worksheets. A party who seeks the presence of an IME physician as a witness at a proceeding for any purpose, by subpoena or otherwise, shall be responsible for payment to the ME physician pursuant to Rule XVIII, Testimony Fees.

5. Multiple Impairment Rating IMEs

Only one IME impairment rating per case shall be administered by the Division's IME Section, pursuant to 8-42-107 (8), C.R.S., unless otherwise directed by written agreement of the parties, by order of an administrative law judge or the director, or by request of the originally designated impairment rating IME physician.

6. Communication with an IME Physician

a. During the IME process, there shall be no communication allowed between the parties and the IME physician unless approved by the director, or an administrative law judge. Any violation may result in cancellation of the IME.

b. After acceptance by the Division of the final report, no communication with the IME physician shall be allowed by any party or their representative except under the following circumstances: approval by the director, both party written agreement, an order by an administrative law judge, by deposition or subpoena as approved by an administrative law judge. The parties shall provide the Division IME section with copies of any correspondence permitted under this section with the IME physician. See Rule XIV L.4.d. for fee information.

7. IME Follow-Up

Sections of this Rule XIV apply to follow-up procedures, as appropriate. If a Level n IME physician determines a claimant has not reached MMI and recommends further treatment or return for range of motion validation, a follow-up IME examination shall to the extent possible be scheduled with the original ME physician. The party requesting the follow-up appointment shall provide written notification of such request to the Division's IME section, with a copy to the other party.

A new IME physician may be selected only if agreed upon by both parties. The parties shall have reached prior agreement on who shall pay the $675.00 to the new IME physician prior to the patient visit. Upon good cause shown, an administrative law judge may also order a new physician and designate which party shall pay the examination fee.

Absent both party agreement or an order from an administrative law judge, the party requesting the follow-up shall pay any additional examination expense according to the Relative Value for Physicians Fee Schedule, incorporated by reference in Rule XVIII, set forth in the RVP's Evaluation & Management Section, “Consultations.”

99241 Follow-up for repeat Range of Motion measurements.

99242 Follow-up evaluation is within six months of the original evaluation.

99243 Follow-up for evaluation on cases that are older than six months and less than one year from the original evaluation.

Follow-up for evaluation on cases older than one year from the original evaluation. These follow- ups may be charged at the full fee of $675.00. Charges described above are allowed due to the need for additional history-taking.

8. Removal of a Physician from the Medical Review Panel Complaints regarding an IME physician may be submitted to the director or to the medical director. A physician under consideration for removal from the medical review panel shall be notified by the director and provided an opportunity to respond. The director, in consultation with the medical director, may remove a physician from the medical review panel on the following grounds:

a. A misrepresentation on the application for appointment to the panel;

b. Refusal and/or substantial failure to comply or two or more incidents of failure to comply with the provisions of these Workers' Compensation Rules of Procedure and any statutes relevant to physicians;

c. Loss of Level I and/or Level II accreditation; or d. Any other reason for good cause as determined by the director.

After six months from the date of removal, a physician may apply to the director for reinstatement on the panel for good cause.

9. Failure to comply with any of the ME rules for which no penalty has been specified shall subject the entity or party to the penalty provided in Rule XIG.

10. Members of the medical review panel and any person acting as a consultant, witness, or complainant shall be immune from liability in any civil action brought against said person for acts occurring while the person was acting as a panel member, consultant, witness, or complainant, respectively, if such person was acting in good faith within the scope of the respective capacity, made a reasonable effort to obtain the facts of the matter as to which action was taken, and acted in the reasonable belief that the action taken by such person was warranted by the facts. Such grant of immunity from liability is necessary to ensure that the purposes of the IME provisions are met and participating physicians can exercise their professional knowledge, skills and judgment.

11. Disputes concerning the division IME process that arise in individual cases that cannot be resolved by agreement of the parties, may be taken to an administrative law judge for resolution.

PARTS M. AND N.- REPEALED AND RESERVED

O. Task Forces Under the Division

1. The Division may develop task forces as needed for development of utilization standards, medical treatment guidelines, impairment ratings, and/or other specific needs.

2. The MCAC may recommend the composition of these task forces to the director.

3. The director, with advice from the medical director, may appoint the members to the task force.

4. The task force shall be under the guidance of a Division representative.

5. A final deadline for completion of the task force objectives may be set by the director with advice from the MCAC.

6. The appropriate draft document shall be returned to the Division from the task force and shall include outcome criteria to assess the effect of its recommendations.

7. The Division with input from the Medical Director and MCAC shall review this document and may make any appropriate revisions, which, if requested, shall be considered and acted upon by the designated task force.

8. Public input shall be solicited by the MCAC from local and regional medical providers, legal community, risk management departments, business community, claimants, and other entities as appropriate.

9. The Division shall review and consider all comments from the public, MCAC, and medical director prior to adoption. The Division may utilize the designated task force for consideration of public input and revisions.

P. Indigent claimant

1. When a claimant applying for an IME pursuant to section L.3.a. of this Rule asserts indigence, this process shall be followed: a. At the same time the “Notice and Proposal to Select an Independent Medical Examiner” form is submitted, the claimant may also indicate on the form whether indigence is asserted.

b. Within twenty (20) days following submission of the Notice and Proposal to Select an Independent Medical Examiner and statement asserting indigence, the claimant wishing to assert indigent status shall file an “Application for Indigent Determination (IME)” form at the Division of Administrative Hearings, and provide a copy to the other parties. A blank Application for Indigent Determination (IME) form may be obtained at the Division of Workers' Compensation Customer Service Unit, at the IME unit, on the Division's website, or at the Division of Administrative Hearings.

c. The IME process will not be held in abeyance during the pendency of indigent application except that an IME physician will not be selected by the Division until a determination is made as to whether the claimant is indigent.

d. Within eight (8) days after the date of mailing of the Application for Indigent Determination (IME) form, any other party to the claim may file a response at the Division of Administrative Hearings. Any such response shall state with specificity the grounds for objection.

e. Within twenty (20) days after the Application for Indigent Determination (IME) is filed, an Administrative Law Judge shall issue an order based on the written submissions determining whether or not the claimant is indigent for purposes of paying for the ME. A hearing will be held only if the Administrative Law Judge determines that one is necessary because a timely submitted response raises genuine issues of disputed material fact that must be resolved. In the event no response is filed but an Administrative Law Judge determines there is a lack of sufficient information in the Application for Indigent Determination (IME), the Administrative Law Judge may hold a hearing to obtain additional information. Any such hearing shall be held as expeditiously as possible, and if a hearing is held a determination must be issued within thirty (30) days of the date of filing of the Application for Indigent Determination (ME).

f. The determination regarding indigence shall be based on the claimant's financial status as of the date the Application for Indigent Determination (IME) is filed. In making the determination on the Application for Indigent Determination (IME), the ALJ shall apply the following standard. A person shall be found to be indigent only if income is at or below the eligibility guidelines with liquid assets of $1,500 or less; or, income is up to 25% above the eligibility guidelines, liquid assets equal $1,500 or less, and the claimant's monthly expenses equal or exceed monthly income; or, if “extraordinary circumstances” exist which merit a determination of indigence. The following definitions shall apply in making the determination:

Income eligibility guidelines Family size Monthly income Monthly income Yearly income guideline guidelines guideline plus 25% 1 $935 $1,169 $11,225 2 $1,263 $1,578 $15,150 3 $1,590 $1,987 $19,057 4 $1,917 $2,396 $23,000 5 $2,244 $2,805 $26,925 6 $2,571 $3,214 $30,850 7 $2,898 $3,622 $34,775 8 $3,225 $4,031 $38,700 For family units with more than eight members, add $327 per month for “monthly income” or $3,925 per year for “yearly income” for each additional family member.

i. Income is gross income from all members of the household who contribute monetarily to the common support of the household.

ii. Liquid assets include cash on hand or in accounts, stocks, bonds, certificates of deposit, equity and personal property or investments which could readily be converted into cash without jeopardizing the applicant's ability to maintain home and employment; “Liquid assets” exclude any equity in any vehicle which the injured worker or his/her family must use for essential transportation unless the ALJ makes an affirmative finding of fact that the worker is credit worthy, can borrow against the equity in this vehicle, and can afford to pay back a loan without compromising his/her needs for food, clothing, shelter, and transportation.

iii. Expenses for nonessential items such as cable television, club memberships, entertainment, dining out, alcohol, cigarettes, etc. shall not be included.

iv. “Extraordinary circumstances” are deemed to be those which cause extraordinary financial hardship by depriving the claimant of the ability to provide for basic necessities that cannot be deferred, such as food, shelter, clothing, utilities, and medical costs not covered by insurance.

g. The Administrative Law Judge shall provide the determination regarding indigence in writing to all the parties. The determination shall include discussion sufficient to explain the basis of determination.

2. Payment for the IME

a. If an Administrative Law Judge determines that the claimant is not indigent, the claimant shall be responsible for payment of the ME. The process for selection of the physician and completion of the IME shall be as set forth in this rule.

b. If an Administrative Law Judge determines that the claimant is indigent, the insurer or employer shall advance payment for the cost of the IME. Such a payment must be made to the doctor no later than ten (10) days prior to the date of the scheduled IME appointment. The insurer or employer shall also pay for any additional costs as identified in parts L.3., L.4., and L.7. of this Rule.

c. The IME will proceed as set forth in section L.3. of this Rule. The claimant shall be considered the requesting party.

d. After a final order is issued, a final admission of liability is uncontested, or the parties have settled the case on a full and final basis, claimant shall reimburse the cost of the IME to the insurer or employer who paid initially. The obligation to reimburse the cost does not arise until a final order or order approving the settlement is issued. Any reimbursement shall be taken as an offset against permanent indemnity benefits.

Q. TABLE OF DIAGNOSES OR MEDICAL CONDITIONS -INDEPENDENT MEDICAL EXAMINATIONS PROGRAMMedical Treatment Guidelines - List of Specified Diagnoses or Conditions Guideline Conditions Body Part or System Accreditation Units Lower Extremity Ankle Sprain/Fracture Ankle Lower Extremity

Talar fracture Calcaneal fractures Midfoot (Lisfranc's) Fracture Dislocation Metatarsal-Phalangeal, Tarsal-Metatarsal, and Interphalangeal Joint Arthropathy Pilon Fracture Puncture wounds of the foot Achilles Tendon Injury/Rupture Ankle Osteoarthropathy Ankle or Subtalar Joint Dislocation Heel Spur Foot Syndrome/Plantar Fasciitis Tarsal Tunnel Syndrome Neuroma Knee - Chondral Defects Knee Aggravated Osteoarthritis Anterior Cruciate Ligament Injury Posterior Cruciate Injuries Meniscus Injury Patellar Subluxation Retropatellar Pain Syndrome Tendonitis/Tenosynovitis Bursitis of the Lower Extremity Hip fracture Hip Acetabulum Fracture Hamstring Tendon Rupture Hip Dislocation Trochanteric Fracture Hip, leg, pelvis Femur Fracture Leg Pelvis Tibia Fracture Pelvic Fracture Leg Pelvis Spine Lower Extremity

Cervical Spine Injury Incomplete Spinal Cord Cervical Spine Neuro/Spine Injury Syndrome:Anterior Cord SyndromeBrown- Sequard SyndromeCentral Cord SyndromePosterior Cord Syndrome Soft Tissue Injury, Quebec Classification, Grades I-IV Disc Herniation Low Back Pain No diagnoses other than Lumbar Spine Spine Low Back Pain given.

Traumatic Brain Injury Mild TBI (MTBI) HeadSkullBrain Neuro

Moderate-Severe TBI Cumulative Trauma DeQuervain's Arm Upper Extremity Disorder Tenosynovitis

Extensor Tendinous Disorders Flexor Tendinous Disorders Lateral Epicondylitis Medial Epicondylitis Cubital tunnel syndrome Hand-Arm Vibration Syndrome Guyon Canal (Tunnel) Syndrome Pronator Syndrome Radial Tunnel Syndrome Elbow Musculoskeletal Elbow Disorders (Epicondylitis) Wrist Tendonitis, Wrist including DeQuervain's Tenosynovitis Trigger Finger Hand, finger Upper Extremity Elbow, shoulder Tendonitis or bursitis Chronic Pain Disorder Chronic Pain N/A Not rated separately - refer to initial injury Reflex Sympathetic CRPS-I (RSD), Stages 1- Neurologic system; also Neuro; also check to see Dystrophy/Complex 3CRPS-II (Causalgia) match specialty to body if the initial injury Regional Pain Syndrome part, e.g., upper/lower requires rating extremity

Occupational Carpal Carpal Tunnel Syndrome Hand Wrist Upper Extremity Tunnel Syndrome

Thoracic Outlet Definite Thoracic Outlet Thoracic spineThoracic Neuro Syndrome SyndromeProbable nerves Thoracic Outlet SyndromePossible Thoracic Outlet Syndrome Shoulder Acromioclavicular Joint Shoulder Upper Extremity (Spine if Sprains/DislocationsAdhe cervical spine sive Capsulation/Frozen involvement) Shoulder DisordersBicipital Tendon DisordersBrachioplexus InjuriesBursitis of the ShoulderImpingement SyndromeRotator Cuff TearRotator Cuff TendinitisShoulder FracturesShoulder Instability

Other Conditions Condition Specialty Body Part or System Dermatological Fully Accredited Skin Specialists (Level II); Limited-Accredited Specialist: Dermatology Ophthalmic Fully Accredited Eye, visual system Specialists (Level II); Limited-Accredited Specialist: Ophthalmology Ear, Nose & Throat Fully Accredited Ear, nose & throat; deformities Specialists (Level II) deformities Limited-Accredited Specialists: Allergist, Otolaryngology, Plastic surgery Hearing or vestibular Fully Accredited Ear, middle ear problems Specialists (Level II) Limited-Accredited Specialist: Otolaryngology Cardiac Fully Accredited Heart, cardiopulmonary Specialists (Level II) system Limited-Accredited Specialist: Cardiac Surgery Allergies (not isolated to Fully Accredited Sinus skin or lungs) Specialists (Level II) Limited-Accredited Specialists: Allergist, Otolaryngology Pulmonary Fully Accredited Lungs, cardiopulmonary Specialists (Level II) system Limited-Accredited Specialists: Allergist, Pulmonology Hernia Fully Accredited Gastrointestinal Specialists (Level II) Surgery Go to specific condition N/A and choose surgical specialty accordingly Mental/Psychological Fully Accredited Mental/Behavioral Disorders Specialists (Level II) Limited-Accredited Specialists: Psychiatry, Neurology/Neurosurgery

RULE XV MEDICAL UTILIZATION REVIEW

A. Statement of Purpose

1. This rule is promulgated to implement and establish procedures for the medical utilization review program, by which the treatment rendered by a health care provider to a workers' compensation claimant may be professionally reviewed on issues of whether such treatment is reasonable, necessary and/or appropriate according to accepted professional standards.

B. Requests for Utilization Review

1. A party shall request a utilization review on a case-by-case basis by filing the Request for Utilization Review form (request form) prescribed by the Division. In order to reduce costs, the request form may be photocopied/duplicated or reproduced using computer type devices as long as either process results in an exact reproduction of the form in both appearance and content.

2. The provider under review shall remain as an authorized provider for the associated claimant until the director or an administrative law judge issues an order to the contrary as a result of the utilization review process. The provider shall continue to submit bills for services rendered to the associated claimant during the review period and the insurance carrier shall continue to pay the provider's bills as provided in these rules of procedure.

3. As provided in section C., below, an information package and medical records package shall be filed with the request form.

C. Filing a Request for Utilization Review

1. One copy of an information package shall be filed and shall contain the following items:

a. A completed and signed Division prescribed request form,

b. Copies of all admissions filed or orders entered in the case,

c. A list containing the full names and medical degrees of all providers, including the provider under review, other treating providers, and individuals who are considered as referrals or who performed consultations, independent medical examinations and/or second opinions, and d. The minimum filing fee as provided in section C.6.

2. Seven (7) identical copies of a medical records package shall be filed with the request form and each copy shall contain the following items:

a. A case report which shall be prepared, signed and dated by a licensed medical professional. This report shall be dated within thirty (30) days prior to the date of filing with the Division. The case report shall be limited to the following:

(1) Name, discipline of care and specialty of the provider under review,

(2) Claimant's standard demographic information (age, sex, marital status, etc.),

(3) Claimant's employer and occupation/job title,

(4) Date(s) of claimant's work-related injury/exposure(s), and

(5) Date of initial treatment, a brief chronological history of treatment to the present date, and any significant contributing factors which may have had a direct effect on the length of treatment (e.g., diabetes).

b. Table of contents

c. The following sections:

Section 1 – a copy of the Employer's First Report of Injury and/or the Worker's Claim for Compensation form.

Section 2 – all reports, notes, etc., from the provider under review as submitted to the requesting party.

Section 3 – all reports, notes, etc., of other treating providers as submitted to the requesting party.

Section 4 – all reports resulting from referrals, consultations, independent medical examinations and second opinions as submitted to the requesting party.

Section 5 – all diagnostic test results as submitted to the requesting party.

Section 6 – all medical management reports as submitted to the requesting party.

Section 7 – all hospital/clinic records related to the injury as submitted to the requesting party.

3. The medical records package shall not contain billing statements, adjustor notes, vocational rehabilitation records, surveillance tapes or reports, admissions, denials or comments directed to the utilization review committee.

4. In order to reduce costs, all material contained in the medical records package shall be presented in identified sections, each section's contents presented in chronological order.

5. In order to reduce costs, the presentation of the medical records package shall be as follows:

a. Seven (7) separate and identical copies. b. Each copy two-hole punched at the top center of each page and securely fastened. Notebooks and plastic type covers and binders shall not be used.

c. A blank sheet of paper shall be placed and bound to the front and back of each copy of the submitted material.

d. If tabs are used to divide sections, they shall be positioned to the right side of the document.

6. A minimum filing fee of $1,250.00 shall be paid at the time of filing by the requesting party. The Division shall notify the requesting party of additional costs incurred which require a supplemental fee.

D. Official Notification of Utilization Review

1. The Division shall notify in writing the provider under review of the review request. Each party to the case shall receive a copy of the written notification as their official notification of the review request.

2. The provider under review shall receive, as an attachment to the written notification, one copy of the medical records package as filed by the requesting party. Each party to the case shall receive one copy of the medical records package as filed by the requesting party.

E. Adding Medical Records to the Utilization Review File

1. The Division shall not accept additional medical records filed by any individual who has not been identified as a party to the case.

2. The Division shall incorporate all properly and timely filed additional medical records into the review file as provided in sections E.3. through E.5., below.

3. Parties filing additional medical records should not duplicate records already submitted for review.

4. Each party has thirty (30) days from the mailing of the review notification to file additional medical records. Absent a timely showing of good cause, any additional medical records shall not be filed after the specified time.

5. The presentation of additional medical records shall be as follows:

a. The first item in each copy shall be a dated and signed transmittal letter which contains the following information:

(1) The UR# and claimant's name,

(2) Submitting party name and position in the case,

(3) A certification stating the seven (7) copies of additional medical records contain the same documents, and

(4) An index of the attached material.

b. The presentation of the additional medical records is identical to those provided in section C.5., above.

6. Each party to the case shall receive from the Division a copy of all properly filed additional medical records. F. Selection Of Utilization Review Committee Members

1. The director, with input from the medical director, shall appoint appropriate peer professionals to serve on the utilization review committees for three years.

2. A committee member may be suspended from participation if the member has been the subject of a utilization review which resulted in an order for change of provider, retroactive denial of payment and/or revocation of accreditation.

3. Committee members shall be paid a fee of $225 per hour for their time incurred in preparing and completing their reports and recommendations to the director. Services rendered by the committee members on behalf of the Division shall be concluded upon acceptance by the Division of their final reports and recommendations. Any party to a claim for benefits or any party to a urilization review proceeding who requests the presence as a witness of one or more committee members at a proceeding for any purpose, by subpoena or otherwise, shall be responsible for payment to said committee member(s) pursuant to the fee schedule set forth in these rules of procedure.

4. A provider may not serve on a UR Committee unless his or her professional license or certification, if applicable, is current, active and unrestricted.

5. Members of UR Committees shall not engage in communication regarding the Utilization Review with any person other than Division staff, except under the following circumstances: by approval of the director; by written agreement of the parties to the case, including the provider under review; by order of an administrative law judge; or by deposition or subpoena as approved by an administrative law judge.

G. Composition of Utlization Review Committees

1. The composition of the utilization review committees shall reflect a fair balance of interests. Committees shall be established to review cases submitted for utilization review. Membership of the committees will include the following:

a. Joints/Musculoskeletal Committee – Two practitioners licensed in the same discipline of care as the provider under review and one occupational medicine practitioner (M.D. or D.O.) with a minimum of 2 years experience in occupational medicine where 30% of practice time is in occupational medicine cases or a minimum of 5 years of experience with a minimum of 15% of practice time in occupational medicine cases;

b. Dental Committee (Teeth only) – Three dentists;

c. Psychiatry Committee – One occupational medicine practitioner (M.D. or D.O) and two psychiatrists;

d. Other – Committee shall be determined by the director to meet the specific circumstances of the utilization review case.

H. Responsibilities of Utilization Review Committee Members

1. Each committee member shall work independently while performing his/her review. The review shall be a paper review only unless a specialist opinion is requested by a majority of the committee members. The specialist's opinion may require a physical examination of the claimant.

2. When performing a utilization review, the members of the medical utilization review committee shall consider all applicable medical treatment guidelines under these rules of procedure. The Division shall provide copies of the appropriate guidelines to the committee upon request.

3. Report of the Utilization Review Committee

a. The report of each member of the utilization review committee shall be restricted to specific questions submitted by the Division.

b. Each committee member shall prepare and submit a written narrative demonstrating how the answers were determined for each of the questions as provided in section H.3.a., above.

I. Change of Medical Provider

1. If the director orders that a change of provider be made, the claimant and insurer or self-insured employer shall notify the Division, on the prescribed form, as to whether the parties have agreed upon a new provider. The parties may request mediation or pre-hearing services from the Division to assist them in this matter.

2. If the claimant chooses to remain under the care of the provider under review during the period of appeal resolution, the payor shall be responsible for payment of medical bills to the provider until an order on appeal is issued. If the insurance carrier, employer or self-insured employer prevails on appeal, the claimant may be held liable by the prevailing party for such medical costs paid during the appeal period.

3. A provider who wishes to participate in the UR Program as a new treating provider candidate shall not be eligible unless his or her professional license or certification, if applicable, is current, active and unrestricted.

J. Utilization Review Appeals

1. The appealing party shall complete the appeal form prescribed by the Division. The form shall be filed with the Medical Utilization Review coordinator.

2. Should the appealing party be entitled to a de novo hearing, the hearing shall be scheduled according to the instructions on the appeal form.

RULE XVI UTILIZATION STANDARDS

A. STATEMENT OF PURPOSE

1. In an effort to comply with its legislative charge to assure appropriate and timely medical care at a reasonable cost, the Director of the Division of Workers' Compensation (Division) has promulgated these “Utilization Standards.” This rule defines the standard terminology, administrative procedures and dispute resolution procedures required to implement the Division's “Medical Treatment Guidelines” and “Medical Fee Schedule.”All providers and payers shall use the “Medical Treatment Guidelines,” Rule XVII, and the “Medical Fee Schedule,” Rule XVIII, as incorporated and defined in the Workers' Compensation Rules of Procedure, 7 C.C.R. 1101-3.

B. STANDARD TERMINOLOGY FOR THIS RULE

The following terms are used throughout this rule and are defined as indicated:

1. Authorized Treating Provider (ATP) – (may be any of the following):

a. the initial treating physician chosen by either the employer or insurer, or, in the absence of choice, the health care provider chosen by the injured worker; b. a health care provider to whom an authorized treating physician refers the injured worker for treatment, consultation, or impairment rating;

c. a provider who is designated by agreement of the injured worker and the payer; or

d. a provider selected by the injured worker with permission from the payer, the Division, or after a hearing with an administrative law judge.

2. Billed Service(s) – any billed service, procedure, equipment or supply provided to an injured worker by a provider.

3. Billing Party – a service provider or an injured worker who has incurred authorized medical costs.

4. Certificate of Mailing – a signed and dated statement containing the names and mailing addresses of all persons receiving copies of attached or referenced document(s), certifying the documents were placed in the U.S. Mail, postage pre-paid, to those persons.

5. Day – for the purpose of Rule XVI, day is defined as a calendar day unless otherwise noted.

6. Medical Fee Schedule – Division's RULE XVIII and the documents incorporated by reference in that rule.

7. Hospital – the Division incorporates the definition established by the Colorado Department of Public Health and Environment in its Rules of Procedure, 6 C.C.R. 1011-1, Chapter 1, Definitions.

8. MCAC – Medical Care Advisory Committee to the Director.

9. Medical Treatment Guidelines – the medical treatment guidelines as incorporated into Rule XVII, “Medical Treatment Guidelines.”

10. Payer – an insurer, employer, or their designated agent(s) who is responsible for payment of medical expenses.

11. Provider – a person or entity providing authorized healthcare service to an injured worker in connection with an injury or occupational disease.

C. REQUIRED USE OF THE MEDICAL TREATMENT GUIDELINES

1. When an injury or occupational disease falls within the purview of Rule XVII “Medical Treatment Guidelines”and the date of injury occurs on or after July 1, 1991, providers shall use the medical treatment guidelines, in effect, to prepare their treatment plan(s) for the injured worker.

D. REQUIRED USE OF THE MEDICAL FEE SCHEDULE

When services provided to an injured worker fall within the purview of the fee schedule, all payers shall use the fee schedule to determine maximum allowable fees.

E. RECOGNIZED HEALTH CARE PROVIDERS

1. Physician and Non-Physician Providers

a. For the purpose of this rule, recognized health care providers are divided into the major categories of “physician” and “non-physician”. Recognized providers are defined as follows: 1) “Physician providers” are those individuals who are licensed by the State of Colorado through one of the following state boards:

(1) Colorado State Board of Medical Examiners;

(2) Colorado State Board of Chiropractic Examiners;

(3) Colorado Podiatry Board; and

(4) Colorado State Board of Dental Examiners.

2) “Non-physician providers”are those individuals who are registered or licensed by the State of Colorado Department of Regulatory Agencies, or certified by a national entity recognized by the State of Colorado as follows:

(1) Audiologist (CCC-AUD) – certified by the American Speech and Hearing Association;

(2) Acupuncturist (RAc) – registered by the Office of Acupuncturist Registration, Colorado Department of Regulatory Agencies;

(3) Licensed Clinical Social Worker (LCSW) – licensed by the Colorado State Board of Social Work Examiners;

(4) Licensed Practical Nurse (LPN) – licensed by the Colorado State Board of Nursing;

(5) Licensed Professional Counselor (LPC) – licensed by the Colorado State Board of Professional Counselor Examiners;

(6) Marriage and Family Therapist (LMFT) – licensed by the Colorado State Board of Marriage and Family Therapist Examiners;

(7) Nurse Practitioner (NP) – licensed by the Colorado State Board of Nursing;

(8) Occupational Therapist (OTR) – certified by the National Occupational Therapy Certification Board;

(9) Optometrist (OD) – licensed by the Colorado State Board of Optometric Examiners;

(10) Orthopedic Technologist (OTC) – certified by the Board for Certification of Orthopedic Technologists, National Association of Orthopedic Technologists;

(11) Psychologist (PsyD, PhD, EdD) – licensed by the Colorado State Board of Psychologist Examiners;

(12) Physical Therapist (LPT) – licensed by the Colorado State Board of Physical Therapy;

(13) Physician Assistant (PA) – licensed by the Colorado State Board of Medical Examiners;

(14) Registered Nurse (RN) – licensed by the Colorado State Board of Nursing; (15) Respiratory Therapist (RT, LRT) – certified by the National Board of Respiratory Care;

(16) Speech Language Pathologist (CCC-SLP) – certified by the American Speech and Hearing Association; and

(17) Surgical Technologist (CST) – certified under direction of the Association of Surgical Technologists.

b. Any provider not listed in Rule XVI.E.1. a.1) or 2) must comply with Rule XVI.I., Prior Authorization when providing all services.

c. All non-physician providers must have a referral from an authorized treating physician. An authorized physician making the referral to any listed or unlisted non-physician provider is required to clarify any questions concerning the scope of the referral, prescription, or the reasonableness or necessity of the care.

d. Any listed or non-listed non-physician provider is required to clarify any questions concerning the scope of the referral, prescription, or the reasonableness or necessity of the care with the referring authorized treating physician.

e. Any healthcare provider must be an “authorized treating provider (ATP) ”in each specific workers' compensation case to obtain payment. An authorized provider is defined in this Rule XVI.B.1.

2. Upon request, healthcare providers must provide copies of license, registration, certification or evidence of healthcare training for billed services.

3. Out-of-State Provider – Injured Worker Relocated

a. Upon receipt of the “Employer's First Report of Injury” or the “Worker's Claim for Compensation ”form, the payer shall notify the injured worker that the procedures for change-of-provider, should s/he relocate out-of-state, can be obtained from the payer.

b. A change of provider must be made:

1) Through referral by the injured worker's authorized provider; or

2) In accordance with Section 8-43-404(5)(a), C.R.S.

4. Out-of-State Provider – Injured Worker Referred

a. In the event an injured worker has not relocated out-of-state but is referred to an out-of-state provider for treatment or services not available within Colorado, the referring provider shall obtain prior authorization from the payer as set forth in Rule XVI.I. Prior Authorization, and J. Contest of a request for Prior Authorization. The referring provider's written request for out-of-state treatment shall include the following information:

1) Medical justification prepared by the referring provider;

2) Written explanation as to why the requested treatment/services cannot be obtained within Colorado;

3) Name, complete mailing address and telephone number of the out-of-state provider; 4) Description of the treatment/services requested, including the estimated length of time and frequency of the treatment/service, and all associated medical expenses; and

5) Out-of-state provider's qualifications to provide the requested treatment or services.

5. The Colorado fee schedule should govern reimbursement for out-of-state providers.

F. BILLING RATES/FEES

1. Payment for billed services identified in the fee schedule shall not exceed those scheduled rates/fees or the provider's actual billed charges, whichever is less.

2. Payment for billed services not identified in the fee schedule shall require prior authorization from the payer as set forth in this Rule XVI.I. Prior Authorization and Rule XVI.J. Contest of a Request for Prior Authorization. Determination of the payment amount shall be made by the payer and reflect the complexity, time, level of training and expertise required to perform the service or procedure, but shall at no time exceed the amount billed. The methodology for determination of payment used by the payer shall be made available to the provider upon request. Rule XVI.K. Payment of Medical Benefits, sets forth the procedures for contesting any portion of a bill. If there are no reasonable methods to determine a fee, the payer shall pay the billed charges.

G. REQUIRED BILLING FORMS AND ACCOMPANYING DOCUMENTATION

1. Providers may use electronic reproductions of any required form(s) referenced in this section; however, any such reproduction shall be an exact duplication of such form(s) in content and appearance.

2. Required Billing Forms

a. All health care providers shall use only the following billing forms or electronically produced formats when billing for services:

1) HCFA 1500 – shall be used by all providers billing for professional services with the exception of those providers billing for dental services or procedures; hospitals are required to use the HCFA 1500 when billing for professional services.

2) UB-92 – shall be used by all hospitals and facilities, meeting the definition of “hospital” as found in section (B) “Standard Terminology” of this Rule XVI, when billing for hospital services; or any facility fees billed by any other provider, such as ambulatory surgery centers.

3) American Dental Association's Dental Claim Form, Version 2000 – shall be used by all providers billing for dental services or procedures.

4) With the agreement of the payer, a nationally recognized electronic billing transaction containing the same information as in 1), 2), or 3) in this subsection may be used.

3. Required Billing Codes

a. All billed services shall be itemized on the appropriate billing form as set forth in this Rule XVI.G.1 and 2, and shall include applicable billing codes and modifiers from the fee schedule. b. Outpatient services billed by a hospital on a UB-92 require CPT coding for the following revenue codes:

30X – Laboratory

31X – Laboratory, Pathological

32X – Radiology – Diagnostic

33X – Radiology – Therapeutic

34X – Nuclear Medicine

35X – CT Scan

40X – Other imaging Services

42X – Physical Therapy

43X – Occupational Therapy

44X – Speech Language Pathology

51X – Clinic

52X – Free-standing Clinic

53X – Osteopathic Services

57X – Home Health – Home Health Aide

58X – Home Health – Other Visits

59X – Home Health – Units of Service

61X –Magnetic Resonance Technology (MRI)

64X – Home IV Therapy Services

73X – EKG/ECGT

74X – EEG

90X – Psychiatric/Psychological Treatments

91X – Psychiatric/Psychological Services

92X – Other Diagnostic Services

94X – Other Therapeutic Services

96X – Professional Fees

97X – Professional Fees 98X – Professional Fees

4. Inaccurate Billing Forms or Codes

a. Payment for any services not billed on the forms identified and/or not itemized as instructed in this Rule XVI.G.2 and 3, may be contested until the provider complies. However, when payment is contested, the payer shall comply with the applicable provisions set forth in Rule XVI.K. “Payment of Medical Benefits”.

5. Accompanying Documentation:

a. Authorized treating physicians submit to the payer, with their initial and final visit billings, a completed “Physician's Report of Workers' Compensation Injury” (Form WC164) specifying:

1) The report type as “initial” when the injured worker has their initial visit with the authorized treating physician for this workers' compensation injury. This form includes a treatment plan and may require the attachment of additional materials;

2) The report type as “closing” when the physician determines the injured worker has reached maximum medical improvement (MMI) for all injuries or diseases covered under this workers' compensation claim. If the injured worker has sustained a permanent impairment, the following additional information shall be attached to the bill at the time MMI is determined:

(1) All necessary permanent impairment rating reports when the authorized treating physician is Level II Accredited, or

(2) The name of the Level II Accredited physician designated to perform the permanent impairment rating when a rating is necessary and the authorized treating physician is not determining the permanent impairment rating.

b. The physician shall supply the injured worker with a copy of all completed Physician's Medical Report (WC164) forms. When the injured worker is represented, a copy of the completed form(s) shall be supplied to the injured worker for his/her representative.

c. The provider shall submit to the payer the completed WC164 form as specified in this Rule XVI.G.5, no later than fourteen (14) days from the date of service.

d. Providers, other than hospitals, shall provide the payer with all supporting documentation at the time of submission of the bill unless other agreements have been made between the payer and provider. This shall include copies of the examination, surgical, and/or treatment records.

e. Hospital documentation shall be available to the payer upon request. Payers shall specify what portion of a hospital record is being requested. (For example, only the emergency room (ER) chart notes, in-patient physician orders and chart notes, x-rays, pathology reports, etc.)

f. In accordance with this Rule XVI.K, the payer may contest payment for billed services until the provider completes and submits the required accompanying documentation as specified by this Rule XVI.G.5.

H. REQUIRED MEDICAL RECORD DOCUMENTATION 1. A provider shall maintain medical records for each injured worker when the provider intends to bill for the provided services.

2. All medical records shall contain legible documentation substantiating the services billed. The documentation shall itemize each contact with the injured worker and shall detail at least the following information per contact or, at a maximum, be summarized once per week:

a. Patient's name;

b. Date of contact, office visit or treatment;

c. Name and professional designation of person providing the billed service;

d. Assessment or diagnosis of current condition with appropriate objective findings;

e. Treatment status or patient's functional response to current treatment;

f. Treatment plan including specific therapy with time limits and measurable goals and detail of referrals;

g. If being completed by an authorized treating physician, all pertinent changes to work and/or activity restrictions which reflect lifting, standing, stooping, kneeling, hot or cold environment, repetitive motion or other appropriate physical considerations; and

h. All prior authorization(s) for payment received from the payer (i.e., who approved the prior authorization for payment, services authorized, dollar amount, length of time, etc.).

I. PRIOR AUTHORIZATION

1. Prior authorization for payment shall be requested by the provider when:

a. A prescribed service exceeds the recommended limitations set forth in the medical treatment guidelines;

b. The medical treatment guidelines otherwise require prior authorization for that specific service;

c. A prescribed service is identified within the medical fee schedule as requiring prior authorization for payment; or

d. A prescribed service is not identified in the fee schedule as referenced in Rule XVI.F.2.

2. All prior authorization for a prescribed service or procedure may be granted immediately and without medical review. However, the payer shall respond to all providers requesting prior authorization within seven (7) business days from receipt of the provider's completed request as defined in Rule XVI.I.5. To complete the contest, refer to procedures in Rule XVI.J.

3. The payer, upon receipt of the “Employer's First Report of Injury” or a “Worker's Claim for Compensation,” shall give written notice to the injured worker stating that the requirements for obtaining prior authorization for payment are available from the payer.

4. The payer, unless they have previously notified said provider, shall give notice to the provider of these procedures for obtaining prior authorization for payment upon receipt of the Division form titled “Physician's Report of Workers' Compensation Injury” (WC164).

5. To complete a prior authorization request, the provider shall concurrently explain the medical necessity of the services requested and provide relevant supporting medical documentation. Supporting medical documentation is defined as documents used in the provider's decision-making process to substantiate the need for the requested service or procedure.

6. To contest a request for prior authorization, the payer is required to comply with the provisions outlined in Rule XVI.J.

7. The Division recommends payers confirm in writing, to providers and all parties, when a request for prior authorization is approved.

8. If, after the service was provided, the payer agrees the service provided was reasonable and necessary, lack of prior authorization for payment does not warrant denial of payment.

J. CONTEST OF A REQUEST FOR PRIOR AUTHORIZATION

1. If the payer contests a request for prior authorization for non-medical reasons as defined under this Rule XVI.K.2.a, the payer shall notify the provider and parties, in writing, of the basis for the contest within seven (7) business days. A certificate of mailing of the written contest must be sent to the provider and parties.

2. If the payer is contesting a request for prior authorization for medical reasons, the payer shall, within seven (7) business days of the completed request:

a. Have the request reviewed by a Physician or other health care professional, as defined in Rule XVI.E.1.a.1, who holds a license and is in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review; and

b. The reviewing provider may call the requesting provider to expedite communication and processing of prior authorization requests. However, the written contest or approval still needs to be completed within the specified seven (7) days under this Rule XVI.J.2.

c. Furnish the provider and the parties with either a verbal or written approval, or a written contest that sets forth the following information:

1) An explanation of the specific medical reasons for the contest, including the name and professional credentials of the person performing the medical review and a copy of the medical reviewer's opinion;

2) The specific cite from the division's Medical Treatment Guidelines exhibits to Rule XVII, when applicable;

3) Identification of the information deemed most likely to influence the reconsideration of the contest when applicable; and

4) A certificate of mailing to the provider and parties.

3. Prior Authorization Disputes

a. The requesting party or provider shall have seven (7) business days from the date of the certificate of mailing on the written contest to provide a written response to the payer, including a certificate of mailing. The response is not considered a “special report” when prepared by the provider of the requested service.

b. The payer shall have seven (7) business days from the date of the certificate of mailing of the response to issue a final decision, including a certificate of mailing to the provider and parties.

c. In the event of continued disagreement, the parties should follow dispute resolution and adjudication procedures under Rule VIII.

4. An urgent need for prior authorization of health care services, as recommended in writing by an authorized treating provider, shall be deemed good cause for an expedited hearing under Rule VIII.

5. Failure of the payer to timely comply in full with the requirements of Rule XVI.J.1 or Rule XVI.J.2, shall be deemed authorization for payment of the requested treatment unless a hearing is requested within the time prescribed for responding as set forth in Rule XVI.J.1 or Rule XVI.J.2.

6. Unreasonable delay or denial of prior authorization, as determined by the director or an administrative law judge, may subject the payer to penalties under the Workers' Compensation Act.

K. PAYMENT OF MEDICAL BENEFITS

1. Uncontested Payment For Billed Services

a. Providers shall submit their bills for services rendered within one hundred twenty (120) days of the date of service. Bills first received later than one hundred twenty (120) days may be denied unless extenuating circumstances exist.

b. Unless contested in accordance with the provisions set forth in this section K. 2. and 3., all bills submitted by a provider are due and payable in accordance with the Medical Fee Schedule within thirty (30) days after receipt of the bill by the payer. Date of receipt may be established by the payer's date stamp or electronic acknowledgement date; otherwise, receipt is presumed to occur three (3) days after the date the bill was mailed to the payer's correct address. The payer shall notify the billing provider that the injured worker shall not be balance-billed for services related to a compensable work-related injury or occupational disease.

c. In the event the injured worker has directly paid a medical provider for uncontested medical services, the payer shall reimburse the injured worker for actual costs incurred for authorized services within thirty (30) days after receipt of the bill by the payer. If the actual costs exceed the maximum fee allowed by the medical fee schedule (rule XVIII), the payer may seek a refund from the medical provider for the difference between the amount charged to the injured worker and the maximum fee. Each request for a refund shall indicate the service provided and the date of service(s) involved.

d. When the payer fails to make timely payment of uncontested billed services, the billing party shall first attempt to resolve payment with the payer. Where such attempt is unsuccessful, the billing party may request assistance from the Division's Carrier Practices Unit.

2. Contested Payment for Billed Services Based on Non-Medical Issues.

a. Non-medical reasons for contesting payment may include, but are not limited to: compensability has not been established; the billed services are not related to the admitted injury; the provider is not authorized to treat; the insurance coverage is at issue; or the billed code does not appear to be accurate based upon the information submitted.

b. In all cases where a billed service is contested by the payer, the payer shall, within thirty (30) days of receipt of the bill, submit to the billing party a written notification of contest. The written non-medical notification of contest shall include the following information:

1) Name of the injured worker;

2) Date of service(s) being contested;

3) Payer's accident number and/or Division's workers' compensation claim number;

4) If applicable, acknowledgement of specific uncontested and paid items submitted on the same bill as contested services;

5) Reference to the bill and each item of the bill being contested;

6) Reason(s) for contesting the payment of any item. The explanation shall include the citing of appropriate statutes, rules and /or documents supporting the payer's reasons for contesting payment; and

7) Notice that the billing party may resubmit the bill or corrected bill within sixty (60) days.

c. Prior to modifying a billed code, the payer must contact the billing provider and determine if the modified code is accurate

1) If the billing provider agrees with the payer, then the payer shall process the service with the agreed upon code and shall document on their explanation of benefits (EOB), the agreement with the provider. The EOB shall include the name of the person at the provider's office who made the agreement.

2) If the provider is in disagreement, then the payer shall proceed according to this Rule XVI.K.2.b or K.3, as appropriate.

d. If the payer agrees a service or procedure was reasonable and necessary, the provider's lack of prior authorization for payment does not warrant denial of liability for payment.

3. Contested Payment for Billed Services Based on Medical Issues:

a. The payer shall within thirty (30) days of receipt of the medical bill and supporting medical documentation do the following:

1) Have the request reviewed by a physician or other healthcare professional as defined in Rule XVI.E.1.a.1, who holds a license and is in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review. This reviewing provider may call the billing provider to expedite communication and timely processing of the contested or paid medical bill. However, the written contest or payment still needs to be completed within the specified thirty (30) days under this Rule XVI.K.

2) Furnish the provider and the parties with a written contest setting forth the following information:

(1) An explanation of the specific medical reasons for the decision, including the name and professional credentials of the person performing the medical review and a copy of the medical reviewer's opinion;

(2) The specific cite from the division's Medical Treatment Guidelines exhibits to Rule XVII, when applicable;

(3) Identification of the information deemed most likely to influence the reconsideration of the contest, when applicable; and

(4) A certificate of mailing to the provider and parties.

4. Medical Bill Disputes

a. The billing party shall have sixty (60) days to respond to the payer's written notification of contest. If a dispute occurs between the billing party and the payer in relation to the Medical Fee Schedule, the parties shall attempt to resolve the dispute themselves. If the parties are unable to resolve the dispute, either party may contact the Medical Policy Unit (MPU) at the Division.

b. When seeking clarification or dispute resolution from the MPU, the requesting party must provide:

1) A copy of the bill with the contested codes and dates of services in dispute;

2) A copy of the payer's explanation as to why the billed services are being contested; and

3) A copy of any applicable medical record documentation.

The MPU will try to provide a written analysis and opinion to the parties regarding the appropriate application of the Medical Fee Schedule within thirty (30) days of receipt of the complete documentation and the written request for assistance; or as soon thereafter as possible.

c. In the event of continued disagreement, the parties should follow dispute resolution and adjudication procedures under Rule VIII.

L. REVIEW OF HOSPITAL CHARGES

1. The payer may conduct a review of billed and non-billed hospital charges related to a specific worker's compensation claim.

2. The payer shall comply with the following procedures:

a. Make payment to the hospital of at least 80 percent of the maximum allowed under the fee schedule for the discharge billing prior to the start of the review; and

b. Within thirty (30) days of receipt of the discharge billing, notify the hospital of its intent to conduct a review. Notification shall be in writing and shall set forth the following information:

1) Name of the injured worker;

2) Claim and/or hospital I.D. number associated with the injured worker's discharge bill;

3) An outline of the items to be reviewed; and

4) If applicable, the name, address and telephone number of any person who has been designated by the payer to conduct the review (reviewer). 3. The hospital shall comply with the following procedures:

a. Allow the review to begin within thirty (30) days of the payer's notification, provided, prior to the start of the review, the hospital has received payment related to the discharge billing of at least 80 percent of the maximum allowed under the fee schedule;

b. Upon receipt of the patient's signed release of information form, allow the reviewer access to all items identified on the injured worker's signed release of information form;

c. Designate an individual(s) to serve as the primary liaison(s) between the hospital and the reviewer who will acquaint the reviewer with the documentation and charging practices of the hospital;

d. Provide a written response to each of the preliminary review findings within ten (10) days of receipt of those findings; and

e. Participate in the exit conference in an effort to resolve discrepancies.

4. The reviewer shall comply with the following procedures:

a. Obtain from the injured worker a signed information release form;

b. Negotiate the starting date for the review;

c. Assign staff members who are familiar with medical terminology, general hospital charging and medical records documentation procedures or have a level of knowledge equivalent at least to that of an LPN;

d. Establish the schedule for the review which shall include, at a minimum, the dates for the delivery of preliminary findings to the hospital, a 10-day response period for the hospital, and the delivery of an itemized listing of discrepancies at an exit conference upon the completion of the review; and

e. Provide the payer and hospital with a written summary of the review within twenty (20) working days of the exit conference.

RULE XVII MEDICAL TREATMENT GUIDELINES

A. STATEMENT OF PURPOSE

1. In an effort to comply with its legislative charge to assure appropriate medical care at a reasonable cost, the director of the Division has promulgated these “Medical Treatment guidelines.” This rule provides a system of evaluation and treatment guidelines for high cost or high frequency categories of occupational injury or disease to assure appropriate medical care at a reasonable cost.

2. Pursuant to section 8-42-101(3)(a)(I), C.R.S., prior to July 1 of each year the Division Director shall review all medical treatment guidelines. Written comments which have been submitted by the public to the director or the Division's medical director will be considered during such reviews.

B. USE OF THE MEDICAL TREATMENT GUIDELINES

1. All health care providers shall use the medical treatment guidelines adopted by the Division.

2. Payers shall routinely and regularly review claims to ensure that care is consistent with the Division's medical treatment guidelines.

C. STANDARD TERMINOLOGY FOR THIS RULE

1. See Rule XVI, Utilization Standards, Section B.

D. PROVIDER'S RESPONSIBILITIES

1. The health care provider shall prepare a diagnosis-based treatment plan that includes specific treatment goals with expected time frames for completion in all cases where treatment falling within the purview of the medical treatment guidelines continues beyond 6 weeks.

2. Within 14 days of request by any party, the provider shall supply a copy of the treatment plan both to the patient and to the payer. Should the patient otherwise require care that deviates from the medical treatment guidelines, the provider shall supply the patient and the payer with a written explanation of the medical necessity for such care.

E. PROCEDURE FOR QUESTIONING CARE

1. In cases where treatment falls within the purview of a medical treatment guideline, prior authorization for payment is unnecessary unless the guideline specifies otherwise, or Rule XVI.I.1.a - d apply.

a. If prior authorization is required by the Medical Treatment Guidelines or a provider requests prior authorization then the procedure for contesting a request for prior authorization for payment is under Rule XVI.J.

b. If the payer questions whether treatment is consistent with the medical treatment guidelines then the procedure for contesting payment of a billed service is covered under Rule XVI.K.2 and 3.

F. FAILURE TO COMPLY

1. See Rule XI, General Rules, Section G

G. EXHIBITS TO RULE XVII

1. Exhibit A – Low Back Pain Medical Treatment Guidelines

2. Exhibit B – Upper Extremity Medical Treatment Guidelines

3. Exhibit C – Lower Extremity Medical Treatment Guidelines

4. Exhibit D – Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome Medical Treatment Guidelines

5. Exhibit E – Cervical Spine Injury Medical Treatment Guidelines

6. Exhibit F – Chronic Pain Disorder (Evaluation and Management) Medical Treatment Guidelines

7. Exhibit G – Traumatic Brain Injury Medical Treatment Guidelines

RULE XVII, EXHIBIT A Low Back Pain Medical Treatment Guidelines December 1, 2001

(Previously Adopted April 1993, revised April 30, 1994, March 2, 1995 & March 15, 1998) Presented By:

State of Colorado Department of Labor and Employment DIVISION OF WORKERS' COMPENSATION

TABLE OF CONTENTS

Low Back Pain Medical Treatment Guideline SECTION DESCRIPTION

A. INTRODUCTION B. GENERAL GUIDELINE PRINCIPLES 1. APPLICATION OF GUIDELINES 2. EDUCATION 3. TREATMENT PARAMATER DURATION 4. ACTIVE INTERVENTIONS 5. ACTIVE THERAPEUTIC EXERCISE PROGRAM 6. POSITIVE PATIENT RESPONSE 7. RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS 8. SURGICAL INTERVENTIONS 9. SIX-MONTH TIME FRAME 10. RETURN-TO-WORK 11. DELAYED RECOVERY 12. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE 13. CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI) C. INITIAL DIAGNOSTIC PROCEDURES 1. HISTORY-TAKING AND PHYSICAL EXAMINATION (HX & PE) a. History of Present Injury: b. Past History: c. Physical Examination 2. RADIOGRAPHIC IMAGING 3. LABORATORY TESTING D. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES 1. IMAGING STUDIES a. Magnetic Resonance Imaging (MRI) b. Computerized Axial Tomography (CT) c. Lineal Tomography d. Bone Scan (Radioisotope Bone Scanning) e. Myelography f. CT Myelogram g. Electrodiagnostic Studies (EMG/NCV) h. Other Radionuclide Scanning 2. OTHER TESTS a. Personality/Psychological /Psychosocial/Evaluation b. Electrodiagnostic Testing c. Injections — Diagnostic d. Discography e. Thermography 3. SPECIAL TESTS a. Computer-Enhanced Evaluations b. Functional Capacity Evaluation (FCE) c. Jobsite Evaluation d. Vocational Assessment e. Work Tolerance Screening E. THERAPEUTIC PROCEDURES — NON-OPERATIVE 1. ACUPUNCTURE a. Acupuncture b. Acupuncture with Electrical Stimulation c. Other Acupuncture Modalities 2. BIOFEEDBACK 3. INJECTIONS — THERAPEUTIC a. Therapeutic Spinal Injections b. Facet Rhizotomy (Radio Frequency Medial Branch Neurotomy) c. Sacroiliac Joint Injection d. Trigger Point Injections e. Prolotherapy f. Sympathetic Injections 4. MEDICATIONS a. Acetaminophen b. Minor Tranquilizer/Muscle Relaxants c. Narcotics d. Nonsteroidal Anti- Inflammatory Drugs (NSAIDs) e. Oral Steroids f. Psychotropic/Anti- anxiety/Hypnotic Agents g. Tramadol h. Topical Drug Delivery 5. OCCUPATIONAL REHABILITATION PROGRAMS a. Non-Interdisciplinary b. Interdisciplinary 6. ORTHOTICS a. Foot Orthoses b. Lumbosacral Bracing 7. PATIENT EDUCATION 8. PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCI AL INTERVENTION 9. RESTRICTION OF ACTIVITIES 10. RETURN-TO-WORK a. Establishment of a Return-To-Work Status b. Establishment of Activity Level Restrictions c. Compliance with Activity Restrictions 11. THERAPY — ACTIVE a. Activities of Daily Living (ADL) b. Aquatic Therapy c. Functional Activities d. Functional Electrical Stimulation e. Lumbar Stabilization f. Neuromuscular Re- Education g. Therapeutic Exercise 12. THERAPY — PASSIVE a. Electrical Stimulation (Unattended) b. Infrared Therapy c. Iontophoresis d. Manipulation e. Massage — Manual or Mechanical f. Mobilization (Joint) g. Mobilization (Soft Tissue) h. Superficial Heat and Cold Therapy i. Short-Wave Diathermy j. Traction — Manual k. Traction — Mechanical l. Transcutaneous Electrical Nerve Stimulation (TENS) m. Ultrasound n. Vertebral Axial Decompression (VAX-D) o. Whirlpool/Hubbard Tank 13. VOCATIONAL REHABILITATION F. THERAPEUTIC PROCEDURES — OPERATIVE 1. DISCECTOMY 2. CHEMONUCLEOLYSIS 3. PERCUTANEOUS DISCECTOMY (NUCLECTOMY) OR LASER DISCECTOMY 4. LAMINOTOMY/LAMINECTOMY/FORAMENOTO MY/FACETECTOMY 5. SPINAL FUSION 6. SACROILIAC JOINT FUSION 7. IMPLANTABLE SPINAL CORD STIMULATORS 8. INTRADISCAL ELECTROTHERMAL ANNULOPLASTY (IDEA)

A. INTRODUCTION

Although the primary purpose of this document is advisory and educational, these guidelines are enforceable under the Workers' Compensation rules of Procedure, 7 CCR 1101-3. The Division recognizes that acceptable medical practice may include deviations from these guidelines, as individual cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of professional care.

To properly utilize this document, the reader should not skip nor overlook any sections.

B. GENERAL GUIDELINE PRINCIPLES

The principles summarized in this section are key to the intended implementation of all Division of Workers' Compensation guidelines and critical to the reader's application of the guidelines in this document.

1. Application of Guidelines

The Division provides procedures to implement medical treatment guidelines and to foster communication to resolve disputes among the provider, payer and patient through the Worker's Compensation Rules of Procedure, Rule XVII and Rule VIII. In lieu of more costly litigation, parties may wish to seek administrative dispute resolution services through the Division.

2. Education

Education of the patient and family, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of low back pain and disability. Currently, practitioners often think of education last, after medications, manual therapy and surgery. Practitioners must develop and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers and the community as a whole. An education-based paradigm should always start with inexpensive communication providing reassuring information to the patient. More in-depth education currently exists within a treatment regime employing functional restorative and innovative programs of prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of facilitating self-management of symptoms and prevention.

3. Treatment Paramater Duration

Time frames for specific interventions commence once treatments have been initiated, not on the date of injury. Obviously, duration will be impacted by patient compliance, as well as availability of services. Clinical judgment may substantiate the need to accelerate or decelerate the time frames discussed in this document.

4. Active Interventions

Interventions emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment, are generally emphasized over passive modalities, especially as treatment progresses. Generally, passive interventions are viewed as a means to facilitate progress in an active rehabilitation program with concomitant attainment of objective functional gains.

5. Active Therapeutic Exercise Program

Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and education. This includes functional application in vocational or community settings.

6. Positive Patient Response

Positive results are defined primarily as functional gains that can be objectively measured. Objective functional gains include, but are not limited to, positional tolerances, range-of-motion, strength, endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures that can be quantified. Subjective reports of pain and function should be considered and given relative weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on objective findings.

7. Re-Evaluate Treatment Every 3 to 4 Weeks

If a given treatment or modality is not producing positive results within 3 to 4 weeks, the treatment should be either modified or discontinued.

Reconsideration of diagnosis should also occur in the event of poor response to a seemingly rational intervention.

8. Surgical Interventions

Surgery should be contemplated within the context of expected functional outcome and not purely for the purpose of pain relief. The concept of “cure” with respect to surgical treatment by itself is generally a misnomer. All operative interventions must be based upon positive correlation of clinical findings, clinical course and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with positive identification of pathologic conditions.

9. Six-Month Time Frame

The prognosis drops precipitously for returning an injured worker to work once he/she has been temporarily totally disabled for more than six months. The emphasis within these guidelines is to move patients along a continuum of care and return-to-work within a six-month time frame, whenever possible. It is important to note that time frames may not be pertinent to injuries that do not involve work-time loss or are not occupationally related.

10. Return-to-Work

Return-to-work is therapeutic, assuming the work is not likely to aggravate the basic problem or increase long-term pain. The practitioner must provide specific physical limitations and the patient should never be released to “sedentary” or “light duty.” The following physical limitations should be considered and modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, bending at the waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors. Even if there is residual chronic pain, return-to-work is not necessarily contraindicated.

The practitioner should understand all of the physical demands of the patient's job position before returning the patient to full duty and should request clarification of the patient's job duties. Clarification should be obtained from the employer or, if necessary, including, but not limited to, an occupational health nurse, occupational therapist, vocational rehabilitation specialist, or an industrial hygienist.

11. Delaved Recoverv

Strongly consider a psychological evaluation, if not previously provided, as well as initiating interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to make expected progress 6 to 12 weeks after an injury. The Division recognizes that 3 to 10% of all industrially injured patients will not recover within the timelines outlined in this document despite optimal care. Such individuals may require treatments beyond the limits discussed within this document, but such treatment will require clear documentation by the authorized treating practitioner focusing on objective functional gains afforded by further treatment and impact upon prognosis.

12. Guideline Recommendations and Inclusion of Medical Evidence

Guidelines are recommendations based on available evidence and/or consensus recommendations. When possible, guideline recommendations will note the level of evidence supporting the treatment recommendation. When interpreting medical evidence statements in the guideline, the following apply:

“Some” means the recommendation considered at least one adequate scientific study, which reported that a treatment was effective.

“Strong” means the recommendation considered the availability of multiple relevant and high quality scientific studies, which arrived at similar conclusions about the effectiveness of a treatment.

All recommendations in the guideline are considered to represent reasonable care in appropriately selected cases, regardless of the level of evidence or consensus statement attached to it. Those procedures considered inappropriate, unreasonable, or unnecessary are designated in the guideline as being “not recommended.”

13. Care Beyond Maximum Medical Improvement (MMI)

MMI should be declared when a patient's condition has plateaued to the point where the authorized treating physician no longer believes further medical intervention is likely to result in improved function. However, some patients may require treatment after MMI has been declared in order to maintain their functional state. The recommendations in this guideline are for pre-MMI care and are not intended to limit post-MMI treatment.

The remainder of this document should be interpreted within the parameters of these guideline principles that may lead to more optimal medical and functional outcomes for injured workers.

C. INITIAL DIAGNOSTIC PROCEDURES

The Division recommends the following diagnostic procedures be considered, at least initially, the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Standard procedures, that should be utilized when initially diagnosing a work- related low back pain complaint, are listed below.

1. History-Taking and Physical Examination (Hx & PE)

History taking and physical examinations are generally accepted, well established and widely used procedures that establish the foundation/basis for and dictates subsequent stages of diagnostic and therapeutic procedures. When findings of clinical evaluations and those of other diagnostic procedures are not complementing each other, the objective clinical findings should have preference. The medical records should reasonably document the following. a. History of Present Injury:

1) Mechanism of injury. This includes details of symptom onset and progression;

2) Relationship to work. This includes a statement of the probability that the illness or injury is work- related;

3) Location of pain, nature of symptoms, and alleviating/exacerbating factors (e.g., sitting tolerance);

4) Presence of lower extremity numbness, weakness, or paresthesias, especially if precipitated by coughing or sneezing;

5) Alteration in bowel, bladder, or sexual function;

6) Prior occupational and non-occupational injuries to the same area including specific prior treatment, chronic or recurrent symptoms, and any functional limitations; and

7) Ability to perform job duties and activities of daily living. b. Past History:

1) Past medical includes neoplasm, gout, arthritis, hypertension, kidney stones, and diabetes; 2) Review of systems includes symptoms of rheumatologic, neurologic, endocrine, neoplastic, infectious, and other systemic diseases;

3) Smoking history; and

4) Vocational and recreational pursuits. c. Physical Examination

Physical examinations should include accepted tests and exam techniques applicable to the area being examined, including:

1) General inspection, including stance and gait;

2) Visual inspection;

3) Palpation;

4) Lumber range of motion, quality of motion, and presence of muscle spasm. Motion evaluation of specific joints may be indicated;

5) Nerve tension testing;

6) Sensory and motor examination of the lower extremities with specific nerve root focus;

7) Deep tendon reflexes with or without Babinski's;

8) If applicable to injury, anal sphincter tone and/or perianal sensation; and

9) If applicable, abdominal examination, vascular examination, circumferential lower extremity measurements, or evaluation of hip or other lower extremity abnormalities.

2. Radiographic Imaging

Radiographic imaging of the lumbosacral spine is a generally accepted, well-established and widely used diagnostic procedure when specific indications based on history and/or physical examination are present. It should not be routinely performed. The mechanism of injury and specific indications for the radiograph should be listed on the request form to aid the radiologist and x-ray technician. Suggested indications include:

1) History of significant trauma, especially blunt trauma or fall from a height;

2) Age over 55 years;

3) Unexplained or persistent low back pain for at least 6 weeks or that is worse with rest;

4) Localized pain, fever, constitutional symptoms, or history or exam suggestive of intravenous drug abuse, prolonged steroid use, or osteomyelitis;

5) Suspected lesion in the lumbosacral spine as a part of a systemic illness such as a rheumatic/rheumatoid disorder or endocrinopathy. Suspected lesions may require special views;

6) Past medical history suggestive of pre-existing spinal disease, spinal instrumentation, or tumor; and

7) Roentgenographic evaluation may be appropriate before high-velocity/low amplitude manipulation or Grade IV to V mobilization.

3. Laboratory Testing

Laboratory tests are generally accepted well established and widely used procedures. They are, however, rarely indicated at the time of initial evaluation, unless there is suspicion of systemic illness, infection, neoplasia, or underlying rheumatologic disorder, connective tissue disorder, or based on history and/or physical examination. Laboratory tests can provide useful diagnostic information. Tests include, but are not limited to:

1) CBC with differential can detect infection, blood dyscrasias, and medication side effects;

2) Erythrocyte sedimentation rate, rheumatoid factor, ANA, HLA, and C-reactive protein can be used to detect evidence of a rheumatologic, infection, or connective tissue disorder;

3) Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease;

4) Urinalysis for bacteria (usually with culture and sensitivity), calcium, phosphorus, hydroxyproline, or hematuria; and

5) Liver and kidney function may be performed for prolonged anti-inflammatory use or other medications requiring monitoring.

D. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES

One diagnostic imaging procedure may provide the same or distinctive information as obtained by other procedures. Therefore, prudent choice of procedure(s) for a single diagnostic procedure, a complementary procedure in combination with other procedures(s), or a proper sequential order in multiple procedures will ensure maximum diagnostic accuracy; minimize adverse effect to patients and cost effectiveness by avoiding duplication or redundancy.

Magnetic resonance imaging (MRI), myelography, or CT scanning following myelography may provide useful information for many spinal disorders. When a diagnostic procedure, in conjunction with clinical information, can provide sufficient information to establish an accurate diagnosis, the second diagnostic procedure will become a redundant procedure. At the same time, a subsequent diagnostic procedure can be a complementary diagnostic procedure if the first or preceding procedures, in conjunction with clinical information, cannot provide an accurate diagnosis. Usually, preference of a procedure over others depends upon availability, a patient's tolerance and/or the treating practitioner's familiarity with the procedure.

1. Imaging Studies

Imaging studies are generally accepted, well established and widely used diagnostic procedures. When indicated, imaging studies can be utilized for further evaluation of the low back, based upon the mechanism of injury, symptoms, and patient history. Prudent choice of a single diagnostic procedure, a complementary combination of procedures, or a proper sequential order of complementary procedures will help ensure maximum diagnostic accuracy and minimize adverse effect to the patient. When the findings of the diagnostic imaging and testing procedures are not consistent with the clinical examination, the clinical findings should have preference. The studies below are listed in frequency of use, not importance: a. Magnetic Resonance Imaging (MRI)

MRI is rarely indicated in patients with non-traumatic acute low back pain with no neuropathic signs or symptoms. It is generally the first follow-up imaging study in individuals who respond poorly to proper initial conservative care. MRI is useful in suspected nerve root compression, myelopathy, masses, infections, metastatic disease, disc herniation, annular tear, and cord contusion. It is contraindicated in patients with certain implants.

In general, the high field, conventional, MRI provides better resolution. A lower field scan may be indicated when a patient cannot fit into a high field scanner or who is too claustrophobic despite sedation. Inadequate resolution on the first scan may require a second MRI using a different technique. All questions in this regard should be discussed with the MRI center and/or radiologist. b. Computerized Axial Tomography (CT)

Lineal tomography is infrequently used, yet may be helpful in the evaluation of bone surfaces, bony fusion, or pseudoarthrosis. d. Bone Scan (Radioisotope Bone Scanning)

Myelography is the injection of radiopaque material into the spinal subarachnoid space with x-rays then taken to define anatomy. It may be used as a pre-surgical diagnostic procedure to obtain accurate information of characteristics, location, and spatial relationships among soft tissue and bony structures. Myelography is an invasive procedure with complications including nausea, vomiting, headache, convulsion, arachnoiditis, CSF leakage, allergic reactions, bleeding, and infection. Therefore, myelography should only be considered when CT and MRI are unavailable, for morbidly obese or multiple-operated patients, and when other tests prove non-diagnostic in the surgical candidate. The use of small needles and a less toxic, water-soluble, nonionic contrast is preferred. f. CT Myelogram

CT myelogram provides more detailed information about relationships between neural elements and surrounding anatomy and is appropriate in patients with multiple prior operations or tumorous conditions. g. Electrodiagnostic Studies (EMG/NCV)

Electrodiagnostic studies include, but are not limited to, electromyography (EMG) and nerve conduction studies (NCS). These are generally accepted, well established, and widely used diagnostic procedures. Electrodiagnostic studies may be useful in the evaluation of patients with suspected radiculopathy. h. Other Radionuclide Scanning

Indium and gallium scans are generally accepted, well established, and widely used procedures usually to help diagnose lesions seen on other diagnostic imaging studies. 67Gallium citrate scans are used to localize tumor, infection, and abcesses. 111Indium-labeled leukocyte scanning is utilized for localization of infection or inflammation.

2. Other Tests

The following studies are listed by frequency of use, not importance: a. Personality/Psychological/Psychosocial/Evaluation

Personality/psychological/psychosocial evaluations are generally accepted and well-established diagnostic procedures with selective use in the acute low back pain population, but have more widespread use in sub-acute and chronic low back pain populations.

Diagnostic testing procedures may be useful for patients with symptoms of depression, delayed recovery, chronic pain, recurrent painful conditions, disability problems, and for pre-operative evaluation as well as a possible predictive value for post-operative response. Psychological testing should provide differentiation between pre-existing depression versus injury-caused depression, as well as post- traumatic stress disorder.

Formal psychological or psychosocial evaluation should be performed on patients not making expected progress within 6–12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests. In addition to the customary initial exam, the evaluation of the injured worker should specifically address the following areas:

1) Employment history;

2) Interpersonal relationships — both social and work;

3) Leisure activities;

4) Current perception of the medical system;

5) Results of current treatment;

6) Perceived locus of control; and

7) Childhood history, including abuse and family history of disability.

An individual with a PhD, PsyD, or Psychiatric MD/DO credentials may perform initial evaluations, which are generally completed within one to two hours. When issues of chronic pain are identified, the evaluation should be more extensive and follow testing procedures as outlined in Division Rule XVII, Exhibit F, Chronic Pain Disorder Medical Treatment Guideline.

(1) Frequency: One time visit for evaluation. If psychometric testing is indicated as a portion of the initial evaluation, time for such testing should not exceed an additional two hours of professional time. b. Electrodiagnostic Testing Electrodiagnostic tests include, but are not limited to, Electromyography (EMG), Nerve Conduction Studies (NCS), and Somatosensory Evoked Potentials (SSEP). These are generally accepted, well- established and widely used diagnostic procedures. The SSEP study, although it is generally accepted, has limited use. Electrodiagnostic studies may be useful for patients with suspected neural involvement whose symptoms are persistent or unresponsive to initial conservative treatments. They are used to differentiate peripheral neural deficits from radicular and spinal cord neural deficits and to rule out concomitant myopathy. Current Perception Threshold Evaluation (CPT) may be useful as a screening tool, but its diagnostic efficacy in the evaluation of industrial low back pain has not been determined.

1) Description — Diagnostic spinal injections are generally accepted, well-established procedures. These injections may be useful for localizing the source of pain, and may have added therapeutic value when combined with injection of therapeutic medication(s). Each diagnostic injection has inherent risk and risk versus benefit should always be evaluated when considering injection therapy. Since these procedures are invasive, less invasive or non-invasive procedures should be considered first. Selection of patients, choice of procedure, and localization of the level for injection should be determined by clinical information indicating strong suspicion for pathologic condition(s) and the source of pain symptoms.

The interpretation of the test result is primarily based upon pain response. The diagnostic significance of the test result should be evaluated in conjunction with clinical information and the results of other diagnostic procedures. Injections with local anesthetics of differing duration are required to confirm the diagnosis of pain. In some cases, injections at multiple levels may be required to accurately diagnose low back pain. Refer to “Injections – Therapeutic” for information on specific injections.

2) Special Requirements for Diagnostic Injections — Since fluoroscopic, arthrographic and/or CT guidance during procedures is required to document technique and needle placement, an experienced physician should perform the procedure. The subspecialty disciplines of the physicians may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry. The practitioner should have experience in ongoing injection training workshops provided by organizations such as the International Spinal Injection Society (ISIS) and be knowledgeable in radiation safety. In addition, practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments of Radiology, as applicable.

3) Complications — General complications of diagnostic injections may include transient neurapraxia, nerve injury, infection, headache, urinary retention, and vasovagal effects, as well as epidural hematoma, permanent neurologic damage, dural perforation and CSF leakage, and spinal meningeal abscess. Permanent paresis, anaphylaxis and arachnoiditis have been rarely reported with the use of epidural steroids.

4) Contraindications — Absolute contraindications of diagnostic injections include: (a) bacterial infection – systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d) possible pregnancy. Relative contraindications of diagnostic injections may include: (a) allergy to contrast, (b) poorly controlled Diabetes Mellitus or hypertension, (c) ASA/antiplatelet therapy (drug may be held for 3 days prior to injection), and (d) shellfish allergy, if contrast to be used.

5) Specific Diagnostic Injections — In general, relief should last for at least the duration of the local anesthetic used and give significant relief of pain. Refer to “Injections – Therapeutic” for information on specific therapeutic injections. (a) Medial Branch Blocks are primarily diagnostic injections, used to determine whether a patient is a candidate for facet rhizotomy.

(b) Transforaminal injections are useful in identifying spinal pathology and can require repeat injections at multiple levels. When used for diagnosis, small amounts of local anesthetic (with or without steroid) up to a total volume of 1.0 to 1.5 cc should be used to determine the level of nerve root irritation. The relief should last for at least the duration of the local anesthetic used and give significant relief of pain. d. Discography

1) Description — Discography is a generally accepted, wellestablished invasive diagnostic procedure to identify a discogenic source of pain for patients who are surgical candidates. Discography should only be performed by physicians who are experienced and have been proctored in the technique.

2) Indications — Discography may be indicated when a patient has a history of unremitting low back pain of greater than three months duration, with or without leg pain, which has been unresponsive to all conservative interventions. A patient who does not desire surgical intervention is not a candidate for an invasive non-therapeutic intervention, such as provocative discography.

Discography may prove useful for the evaluation of the presurgical spine, such as pseudoarthrosis, discogenic pain at levels above or below a prior spinal fusion, annular tear, or internal disc disruption. Discography is not useful in previously operated discs. In addition, discography may prove useful in evaluation of the number of lumbar spine levels that might require fusion. It has also been utilized to differentiate organic from psychogenic factors. CT- Discography provides further detailed information about morphological abnormalities of the disc and possible lateral disc herniations.

3) Preconditions for provocative discography include:

(a) A patient with unremitting back and/or leg pain greater than 3 months duration in whom conservative treatment has been unsuccessful and in whom the specific diagnosis of the pain generator has not been made apparent on the basis of other noninvasive imaging studies (e.g., MRI, CT, plain films, etc.) and in whom a psychosocial evaluation has been considered.

(b) Patients who are considered surgical candidates (e.g., symptoms are of sufficient magnitude and the patient has been informed of the possible surgical options that may be available based upon the results of discography). Discography should never be the sole indication for surgery.

4) Complications — Complications include, but are not limited to, discitis, nerve damage, chemical meningitis, pain exacerbation and anaphylaxis may occur with discography. Therefore, prior to consideration of discography, the patient should undergo other diagnostic modalities in an effort to define the etiology of the patient's complaint including psychological screening, myelography, CT and MRI.

5) Contraindications — Contraindications for provocative discography may include: (a) active infection of any type or continuing antibiotic treatment for infection; and/or (b) bleeding diathesis or pharmaceutical anticoagulation with warfarin, etc.; and/or (c) significant spinal stenosis at the level being studied as visualized by MRI, myelography or CT scan; and/or (d) presence of clinical myelopathy; and/or (e) effacement of the cord, thecal sac or circumferential absence of epidural fat; and (f) known allergic reactions.

6) Special Considerations:

(a) Discography should not be done by the treating surgeon, and the procedure should be carried out by an experienced individual who has received specialized training in the technique of provocative discography.

(d) Judicious use of sedation during the procedure is acceptable and represents the most common practice nationally at the current time and is recommended by most experts in the field.

(e) CT or MRI must have established spinal dimensions and ruled out spinal stenosis.

(f) Intradiscal injection of local anesthetic should be carried out after the provocative portion of the examination and the patient's response.

(g) It is recommended that a post-discogram CT be considered as it frequently provides additional useful information about disc morphology or other pathology.

7) Reporting of Discography—In addition to a narrative report, the discography report should contain a standardized classification of (a) disc morphology and (b) the pain response. Both results should be clearly separated in the report from the narrative portion. Asymptomatic annular tears are common and the concordant pain response is an essential finding for a positive discogram. Alternative reporting techniques using pressure monitors are being investigated and may prove useful in identifying patients with discogenic pain.

Caution should be used when interpreting results from discography. In one study of patients without lumbar pathology, 10 percent of pain free patients experienced pain with discography and 83 percent of patients with somatization disorder experienced pain with lumbar discography.

(a) Reporting disc morphology as visualized by the postinjection CT scan (when available) should follow the Modified Dallas Discogram Scale where:

Grade 0 = Normal Nucleus

Grade 1 = Annular tear confined to inner one-third of annulus fibrosis.

Grade 2 = Annular tear extending to the middle third of the annulus fibrosis.

Grade 3 = Annular tear extending to the outer one-third of the annulus fibrosis.

Grade 4 = A grade 3 tear plus dissection within the outer annulus to involve more than 30 degrees of the disc circumference.

Grade 5 = Full thickness tear with extra-annular leakage of contrast, either focal or diffuse. (b) Reporting of pain response should be according to the modified Aprill Scheme. In this scheme, codes are assigned a response during the initial injection (“P” provocative response) and the response to an injection of the local anesthetic (“R” response) where:

P0 = No Pain

P1 = Procedural pain, or pain that is nonconcordant with the patient's familiar pain

P2 = Concordant pain

R0 = No pain relief with injection of local anesthetic

R1 = Partial relief

R2 = Complete relief

N = Nondiagnostic, nonphysiologic injection. The final category of “N” is suggested when the discographer concludes that the provocative portion of the injection is nondiagnostic. For example, a patient with a morphologically normal disc who responds when typical pain is reproduced is considered to have a nondiagnostic or nonphysiologic response. Other circumstances may occur that cause the discographer to conclude that the provocative portion of the injection is invalid. The category “N” should be used for these situations.

(1) Time to produce effect: Immediate

(2) Frequency: One time only

(3) Optimal duration: One time

(4) Maximum duration: Repeat discography is rarely indicated. e. Thermography

Thermography is an accepted and established procedure, but has limited use as a diagnostic test for low back pain. It may be used to diagnose regional pain disorders and in these cases, refer to Division Rule XVII, Exhibit D, Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome Medical Treatment Guidelines.

3. Special Tests

Special tests are generally well-accepted tests and are performed as part of a skilled assessment of the patients' capacity to return to work, his/her strength capacities, and physical work demand classifications and tolerance. a. Computer-Enhanced Evaluations

Computer-enhanced evaluations may include isotonic, isometric, isokinetic and/or isoinertial measurement of movement, range of motion, endurance or strength. Values obtained can include degrees of motion, torque forces, pressures or resistance. Indications include determining validity of effort, effectiveness of treatment and demonstrated motivation. These evaluations should not be used alone to determine return to work restrictions.

(1) Frequency: One time for evaluation. Can monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations. b. Functional Capacity Evaluation (FCE)

Functional capacity evaluation is a comprehensive or modified evaluation of the various aspects of function as they relate to the worker's ability to return to work. Areas such as endurance, lifting (dynamic and static), postural tolerance, specific range of motion, coordination and strength, worker habits, employability and financial status, as well as psychosocial aspects of competitive employment may be evaluated. Components of this evaluation may include: (a) musculoskeletal screen; (b) cardiovascular profile/aerobic capacity; (c) coordination; (d) lift/carrying analysis; (e) job-specific activity tolerance; (f) maximum voluntary effort; (g) pain assessment/psychological screening; and (h) non-material and material handling activities.

(1) Frequency: Can be used initially to determine baseline status. Additional evaluations can be performed to monitor and assess progress and aid in determining the endpoint for treatment. c. Jobsite Evaluation

Jobsite evaluation is a comprehensive analysis of the physical, mental and sensory components of a specific job. These components may include, but are not limited to: (a) postural tolerance (static and dynamic); (b) aerobic requirements; (c) range of motion; (d) torque/force; (e) lifting/carrying; (f) cognitive demands; (g) social interactions; (h) visual perceptual; (i) environmental requirements of a job; (j) repetitiveness; and (k) essential functions of a job. Job descriptions provided by the employer are helpful but should not be used as a substitute for direct observation.

(1) Frequency: One time with additional visits as needed for follow-up per job site. d. Vocational Assessment

Once an authorized practitioner has reasonably determined and objectively documented that a patient will not be able to return to his/her former employment and can reasonably prognosticate final restrictions, implementation of a timely vocational assessment can be performed. The vocational assessment should provide valuable guidance in the determination of future rehabilitation program goals. It should clarify rehabilitation goals, which optimize both patient motivation and utilization of rehabilitation resources. If prognosis for return to former occupation is determined to be poor, except in the most extenuating circumstances, vocational assessment should be implemented within 3 to 12 months post-injury. Declaration of Maximum Medical Improvement should not be delayed solely due to lack of attainment of a vocational assessment.

(1) Frequency: One time with additional visits as needed for follow-up. e. Work Tolerance Screening

Work tolerance screening is a determination of an individual's tolerance for performing a specific job as based on a job activity or task. It may include a test or procedure to specifically identify and quantify work- relevant cardiovascular, physical fitness and postural tolerance. It may also address ergonomic issues affecting the patient's return-to-work potential. May be used when a full Functional Capacity Evaluation is not indicated.

(1) Frequency: One time for evaluation. May monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations.

E. THERAPEUTIC PROCEDURES — NON-OPERATIVE

Before initiation of any therapeutic procedure, the authorized treating provider, employer and insurer must consider these important issues in the care of the injured worker.

First, patients undergoing therapeutic procedure(s) should be released or returned to modified or restricted duty during their rehabilitation at the earliest appropriate time. Refer to “Return-to-Work” in this section for detailed information.

Second, cessation and/or review of treatment modalities should be undertaken when no further significant subjective or objective improvement in the patient's condition is noted. If patients are not responding within the recommended duration periods, alternative treatment interventions, further diagnostic studies or consultations should be pursued.

Third, providers should provide and document education to the patient. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of facilitating self- management of symptoms.

Lastly, formal psychological or psychosocial screening should be performed on patients not making expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests.

In cases where a patient is unable to attend an outpatient center, home therapy may be necessary. Home therapy may include active and passive therapeutic procedures as well as other modalities to assist in alleviating pain, swelling, and abnormal muscle tone. Home therapy is usually of short duration and continues until the patient is able to tolerate coming to an outpatient center.

Non-operative treatment procedures for low back pain can be divided into two groups: conservative care and rehabilitation. Conservative care is treatment applied to a problem in which spontaneous improvement is expected in 90% of the cases within three months. It is usually provided during the tissue- healing phase and lasts no more than six months, and often considerably less. Rehabilitation is treatment applied to a more chronic and complex problem in a patient with deconditioning and disability. It is provided during the period after tissue healing to obtain maximal medical recovery. Treatment modalities may be utilized sequentially or concomitantly depending on chronicity and complexity of the problem, and treatment plans should always be based on a diagnosis utilizing appropriate diagnostic procedures.

The following procedures are listed in alphabetical order.

1. Acupuncture

Acupuncture is an accepted and widely used procedure for the relief of pain and inflammation and there is some scientific evidence to support its use. The exact mode of action is only partially understood. Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the brain, promotes deep relaxation, and affects the release of neurotransmitters. Acupuncture is commonly used as an alternative or in addition to traditional Western pharmaceuticals. While it is commonly used when pain medication is reduced or not tolerated, it may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten the return of functional activity. Acupuncture should be performed by credentialed practitioners. a. Acupuncture

Acupuncture is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points). Needles may be inserted, manipulated and retained for a period of time. Acupuncture can be used to reduce pain, reduce inflammation, increase blood flow, increase range of motion, decrease the side effect of medication-induced nausea, promote relaxation in an anxious patient, and reduce muscle spasm.

Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain. (1) Time to produce effect: 3 to 6 treatments

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 1 to 2 months

(4) Maximum duration: 14 treatments b. Acupuncture with Electrical Stimulation

Acupuncture with electrical stimulation is the use of electrical current (micro- amperage or milli-amperage) on the needles at the acupuncture site. It is used to increase effectiveness of the needles by continuous stimulation of the acupoint. Physiological effects (depending on location and settings) can include endorphin release for pain relief, reduction of inflammation, increased blood circulation, analgesia through interruption of pain stimulus, and muscle relaxation.

It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.

(1) Time to produce effect: 3 to 6 treatments

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 1 to 2 months

(4) Maximum duration: 14 treatments c. Other Acupuncture Modalities

Acupuncture treatment is based on individual patient needs and therefore treatment may include a combination of procedures to enhance treatment effect. Other procedures may include the use of heat, soft tissue manipulation/massage, and exercise. Refer to Active Therapy (Therapeutic Exercise) and Passive Therapy sections (Massage and Superficial Heat and Cold Therapy) for a description of these adjunctive acupuncture modalities.

(1) Time to produce effect: 3 to 6 treatments

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 1 to 2 months

(4) Maximum duration: 14 treatments

Any of the above acupuncture treatments may extend longer if objective functional gains can be documented or when symptomatic benefits facilitate progression in the patient's treatment program. Treatment beyond 14 treatments must be documented with respect to need and ability to facilitate positive symptomatic or functional gains. Such care should be re-evaluated and documented with each series of treatments.

2. Biofeedback

Biofeedback is a form of behavioral medicine that helps patients learn self-awareness and self-regulation skills for the purpose of gaining greater control of their physiology, such as muscle activity, brain waves, and measures of autonomic nervous system activity. Electronic instrumentation is used to monitor the targeted physiology and then displayed or fed back to the patient visually, auditorially, or tactilely, with coaching by a biofeedback specialist. Biofeedback is provided by clinicians certified in biofeedback and/or who have documented specialized education, advanced training, or direct or supervised experience qualifying them to provide the specialized treatment needed (e.g., surface EMG, EEG, or other).

(1) Time to produce effect: 3 to 4 sessions

(2) Frequency: 1 to 2 times per week

(3) Optimum duration: 5 to 6 sessions

(4) Maximum duration: 10 to 12 sessions. Treatment beyond 12 sessions must be documented with respect to need, expectation, and ability to facilitate positive symptomatic or functional gains.

3. Injections — Therapeutic a. Therapeutic Spinal Injections

Description — Therapeutic spinal injections, which include epidural steroid and facet injections, are generally accepted, well-established procedures. They may be used after initial conservative treatment, such as physical and occupational therapy, medication, manual therapy, exercise, acupuncture etc., has been undertaken. Therapeutic injections should be used only after pathology has been demonstrated. Injections are invasive procedures that can cause serious complications thus clinical indications and contraindications should be closely adhered to. It is recommended that all patients have an appropriate exercise program that may include a functionally directed rehabilitation program.

Special Considerations — For all injections (excluding trigger point) fluoroscopic, arthrographic and/or CT guidance during procedures is recommended to document technique and needle placement, and should be performed by a physician experienced in the procedure. The subspecialty disciplines of the physicians may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry. The practitioner should participation in ongoing injection training workshops such as those sponsored by International Society for Injection Studies (ISIS) and be knowledgeable in radiation safety. In addition, practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments of Radiology, as applicable.

Complications — General complications of spinal injections may include (a) transient neurapraxia, local pain, nerve injury, infection, headache, urinary retention and vasovagal effects; (b) epidural hematoma, permanent neuralgic damage, dural perforation and CSF leakage, spinal meningeal abscess; and or (c) suppression of the hypothalamic pituitary adrenal axis, which may be steroid dose dependent. Permanent paresis, anaphylaxis and arachnoiditis have been rarely reported with the use of epidural steroids.

Contraindications — Absolute contraindications of diagnostic injections include: (a) bacterial infection- systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d) possible pregnancy. Relative contraindications of diagnostic injections may include: (a) allergy to contrast, (b) poorly controlled Diabetes Mellitus or hypertension, (c) ASA/antiplatelet therapy (drug may be held for 3 days prior to injection), (d) shellfish allergy, if contrast to be used.

1) Epidural Steroid Injection (ESI)

(a) Description — Epidural steroid injections are injections of corticosteroid into the epidural space. The purpose of ESI is to reduce pain and inflammation, restoring range of motion and thereby facilitating progress in more active treatment programs. ESI use three approaches: transforminal, translaminar (midline), and caudal. There is good evidence to support a preference for a transforaminal approach. The evidence also suggests that the transforaminal approach can deliver medication to the target tissue with few complications and is therefore used to identify the specific site of pathology. This is also the preferred approach for post-surgical patients.

(b) Needle Placement — Spinal imaging is required for all transforaminal epidural steroid injections. Since injections performed without radiographic guidance result in an increased risk of incorrect needle placement, spinal imaging is recommended for caudal and translaminar injections if available within 30 miles of the patient's home. Contrast epidurograms allow one to verify the flow of medication into the epidural space.

(c) Indications — There is some evidence that epidural steroid injections are effective for patients with radicular pain or radiculopathy (sensory or motor loss in a specific dermatome or myotome). Although there is no evidence regarding the effectiveness of ESI for non-radicular pain, it is a generally accepted intervention. Selected cases of vertebral compression fracture may be helped by ESI.

(1) Time to produce effect: Local anesthetic, approximately 30 minutes; corticosteroid, 48 to 72 hours for 80% of patients and 2 weeks for 20%.

(2) Frequency: One or more divided levels can be injected in one session. Whether injections are repeated depends upon the patient's response to the previous injection session. Subsequent injection sessions may occur after 1 to 2 weeks if patient response has been favorable. Injections can be repeated after a hiatus of three months if the patient has demonstrated functional gain and pain returns or worsens. If ESIs are repeated in the future, there should be increasing duration of relief and continued functional gain.

(3) Optimum duration: Usually 1 to 3 sessions of injection(s), depending upon each patient's response and functional gain.

(4) Maximum duration: Up to 3 to 4 sessions of injections may be done as per the patient's response to pain and function. Patients should be reassessed after each injection session.

2) Zygoapophyseal (Facet) Injection

(a) Description — Intra-articular or pericapsular injection of local anesthetic and corticosteroid. Medial branch nerve blocks are diagnostic only. There is conflicting evidence to support a long-term therapeutic effect using facet injections.

(b) Indications — Facet injections may be considered in those patients whose history and examination are suggestive of a facet pain generator. Lumbar facet injections are primarily of diagnostic value. The therapeutic value of facet injections provides short-term pain relief for patients to progress through a functionally directed rehabilitation program. These injections are useful when used in conjunction with Manipulation Under Joint Anesthesia (MUJA). Facet injections determine level(s) of lumbar facet involvement and the degree of pain coming from the posterior elements. Facet injections may help determine the best therapeutic exercise approach (i.e., lumbar stabilization vs. sacroiliac stabilization).

(1) Time to produce effect: Approximately 30 minutes for local anesthetic; 48 to 72 hours for corticosteroid.

(2) Frequency: 1 to 3 sessions for each joint.

(3) Optimum duration: 1 to 3 sessions of injections for each joint.

(4) Maximum duration: 3 intra-synovial or medial branch nerve injections per joint can be done for facilitating a therapeutic exercise program. b. Facet Rhizotomy (Radio Frequency Medial Branch Neurotomy)

(a) Description — A procedure designed to denervate the facet joint by ablating the periarticular facet nerve branches. Percutaneous radiofrequency is the method generally used. There is good evidence to support this procedure in the cervical spine but benefits beyond one year are not yet established. Evidence in the lumbar spine is conflicting, however, the procedure is generally accepted.

(b) Indications — Pain of well-documented facet origin, unresponsive to active and/or passive therapy, unresponsive to manual therapy, and in which a psychosocial evaluation has been performed. This procedure is commonly used to provide a window of pain relief allowing for participation in active therapy. All patients must have a successful response to diagnostic medial nerve branch blocks. A successful response is considered to be a 90 percent or greater relief of pain for the length of time appropriate to the local anesthetic used (i.e., bupivacaine greater than lidocaine). Radio-frequency rhizotomy is the procedure of choice over alcohol, phenol, or cryoablation. Precise positioning of the probe using fluoroscopic guidance is recommended since the maximum effective radius of the device is 2 milimeters.

(c) Complications — Bleeding, infection, or neural injury. The clinician must be aware of the risk of developing a deafferentation centralized pain syndrome as a complication of this and other neuroablative procedures.

(d) Post-Procedure Therapy — Active active and/or passive therapy. Implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-procedure week, barring complications. Instruction and participation in a long-term home-based program of ROM, strengthening, endurance and stability exercises should be done 3 to 4 weeks post-procedure. c. Sacroiliac Joint Injection

(a) Description — Injection of local anesthetic in an intra-articular fashion into the sacroiliac joint under radiographic guidance. May include the use of corticosteroids. Long-term therapeutic effect has not yet been established.

(b) Indications — Primarily diagnostic to rule out sacroiliac joint dysfunction vs. other pain generators. Intra-articular injection can be of value in diagnosing the pain generator. There should be documented relief from previously painful maneuvers (e.g., Patrick's test) on post-injection physical exam. Therapeutic response varies. Sacroiliac joint blocks may facilitate functionally directed rehabilitation program.

(1) Time to produce effect: Approximately 30 minutes for local anesthetic; 48 to 72 hours for corticosteroid. (2) Frequency: 1 to 3 sessions of injections.

(3) Optimum duration: 1 to 3 sessions.

(4) Maximum duration: 3 sessions of injections. Once diagnosis has been documented by intrajoint injection, posterior ligament block may be as effective as intra-joint injection for therapeutic value unless the primary pain is coming from an anterior capsular pain generator. d. Trigger Point Injections

(a) Description — Trigger point injection consists of dry needling or injection of local anesthetic with or without corticosteroid into highly localized, extremely sensitive bands of skeletal muscle fibers that produce local and referred pain when activated. Medication is injected in a four-quadrant manner in the area of maximum tenderness. Injection efficacy can be enhanced if injections are immediately followed by myofascial therapeutic interventions, such as vapo-coolant spray and stretch, ischemic pressure massage (myotherapy), specific soft tissue mobilization and physical modalities. The effectiveness of trigger point injection is uncertain, in part due to the difficulty of demonstrating advantages of active medication over injection of saline. Needling alone may be responsible for some of the therapeutic response.

(b) Indications — Trigger point injections may be used to relieve myofascial pain and facilitate active therapy and stretching of the affected areas. They are to be used as an adjunctive treatment in combination with other treatment modalities such as functional restoration programs. Trigger point injections should be utilized primarily for the purpose of facilitating functional progress. Patients should continue in an aggressive aerobic and stretching therapeutic exercise program as tolerated throughout the time period they are undergoing intensive myofascial interventions. Myofascial pain is often associated with other underlying structural problems and any abnormalities need to be ruled out prior to injection.

Trigger point injections are indicated in those patients where well circumscribed trigger points have been consistently observed, demonstrating a local twitch response characteristic radiation of pain pattern and local autonomic reaction, such as persistent hyperemia following palpation. Generally, these injections are not necessary unless consistently observed trigger points are not responding to specific, noninvasive, myofascial interventions within approximately a 6 week time frame. However, trigger point injections may be occasionally effective when utilized in the patient with immediate, acute onset of low back pain.

(c) Complications — Potential but rare complications of trigger point injections include infection, pneumothorax, anaphylaxis, penetration of viscera, neurapraxia and neuropathy. If corticosteroids are injected in addition to local anesthetic, there is a risk of local myopathy developing. Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be immediately repositioned.

(1) Time to produce effect: Local anesthetic 30 minutes; 24 to 48 hours for no anesthesia.

(2) Frequency: Weekly. Suggest no more than 4 injection sites per session per week to avoid significant post-injection soreness.

(3) Optimum duration: 4 Weeks.

(4) Maximum duration: 8 weeks. Occasional patients may require 2 to 4 repetitions of trigger point injection series over a 1 to 2 year period. e. Prolotherapy Prolotherapy, also known as sclerotherapy, consists of a series of injections of hypertonic dextrose, with or without glycerine and phenol, into the ligamentous structures of the low back. Its proponents claim that the inflammatory response to the injections will recruit cytokine growth factors involved in the proliferation of connective tissue, stabilizing the ligaments of the low back when these structures have been damaged by mechanical insults.

There are conflicting studies concerning the effectiveness of prolotherapy in the low back. Lasting functional improvement has not been shown. The injections are invasive, may be painful to the patient, are not generally accepted or widely used. Therefore, the use of prolotherapy for low back pain is not recommended. f. Sympathetic Injections

Refer to Division Rule XVII, Exhibit D, Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome Medical Treatment Guideline for specific information regarding the use of these injections.

4. Medications

Medication use in the treatment of low back injuries is appropriate for controlling acute and chronic pain and inflammation. Use of medications will vary widely due to the spectrum of injuries from simple strains to post-surgical healing. All drugs should be used according to patient needs. A thorough medication history, including use of alternative and over the counter medications, should be performed at the time of the initial visit and updated periodically.

Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are useful in the treatment of inflammation. These same medications can be used for pain control.

Narcotic medications should be prescribed with strict time, quantity and duration guidelines, and with definitive cessation parameters. Pain is subjective in nature and should be evaluated using a scale to rate effectiveness of the narcotic prescribed. Other medications, including antidepressants, may be useful in selected patients with chronic pain. Tramadol, a centrally acting non-narcotic, can be useful to provide pain relief. Other medications, including antidepressants, may be useful in selected patients with chronic pain.

Topical agents may be beneficial in the management of localized low back pain.

The following are listed in alphabetical order: a. Acetaminophen

Acetaminophen is an effective analgesic with antipyretic but not anti-inflammatory activity. Acetaminophen is generally well tolerated, causes little or no gastrointestinal irritation and is not associated with ulcer formation. Acetaminophen has been associated with liver toxicity in overdose situations or in chronic alcohol use.

(1) Optimum duration: 7 to 10 days.

(2) Maximum duration: Chronic use as indicated on a case-by-case basis. b. Minor Tranquilizer/Muscle Relaxants

Minor tranquilizer/muscle relaxants are appropriate for muscle spasm, mild pain and sleep disorders.

(1) Optimum duration: 1 week. (2) Maximum duration: 4 weeks. c. Narcotics

Narcotics should be primarily reserved for the treatment of severe low back pain. There are circumstances where prolonged use of narcotics is justified based upon specific diagnosis, and in these cases, it should be documented and justified. In mild to moderate cases of low back pain, narcotic medication should be used cautiously on a case-by-case basis. Adverse effects include respiratory depression, the development of physical and psychological dependence, and impaired alertness.

(1) Optimum duration: 3 to 7 days.

(2) Maximum duration: 2 weeks. Use beyond two weeks is acceptable in appropriate cases. d. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs are useful for pain and inflammation. In mild cases, they may be the only drugs required for analgesia. There are several classes of NSAIDs, and the response of the individual injured worker to a specific medication is unpredictable. For this reason, a range of NSAIDs may be tried in each case with the most effective preparation being continued. Patients should be closely monitored for adverse reactions. Intervals for metabolic screening are dependent upon the patient's age, general health status and should be within parameters listed for each specific medication. Liver and renal function should be monitored at least every six months in patients on chronic NSAIDs.

1) Selective Nonsteroidal Anti-Inflammatory Drugs

Includes Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and acetylsalicylic acid (aspirin). Serious GI toxicity, such as bleeding, perforation, and ulceration can occur at any time, with or without warning symptoms in patients treated with traditional NSAIDs. Physicians should inform patients about the signs and/or symptoms of serious gastrointestinal toxicity and what steps to take if they occur. Anaphylactoid reactions may occur in patients taking NSAIDs. NSAIDs may interfere with platelet function. Fluid retention and edema have been observed in some patients taking NSAIDs.

Due to the cross-reactivity between aspirin and NSAIDs, NSAIDs should not be used in aspirin-sensitive patients, and should be used with caution in all asthma patients. NSAIDs are associated with abnormal renal function, including renal failure, as well as abnormal liver function. Certain NSAIDs may have interactions with various other medications. Individuals may have adverse events not listed above.

(1) Optimal duration: 1 week

(2) Maximum duration: 1 year

2) Selective Cyclo-oxygenase-2 (COX-2) Inhibitors

Selective cyclo-oxygenase-2 (COX-2) inhibitors are more recent NSAIDs and differ in adverse side effect profiles from the traditional NSAIDs. The major advantages of selective COX-2 inhibitors over traditional NSAIDs are that they have less gastrointestinal toxicity and no platelet effect. COX-2 inhibitors can worsen renal function in patients with renal insufficiency, thus renal function may need monitoring.

COX-2 inhibitors should not be first-line for low risk patients who will be using an NSAID short term but are indicated in select patients whom traditional NSAIDs are not tolerated or in certain high-risk patients. Patients most at risk of having a complication from traditional NSAIDs include patients with a prior history of peptic ulcer disease, gastrointestinal bleeding, gastrointestinal perforation, or hemophilia, as well as patients with thrombocytopenia or systemic anticoagulation. Celecoxib is FDA approved for osteoarthritis and rheumatoid arthritis. Rofecoxib is FDA approved for acute pain and osteoarthritis. Celecoxib is contraindicated in sulfonamide allergic patients.

(1) Optimal duration: 7 to 10 days

(2) Maximum duration: Chronic use is appropriate in individual cases. e. Oral Steroids

Oral steroids have limited use but are accepted in cases requiring potent anti-inflammatory drug effect. They have no proven benefit for patients with low back pain with or without radiculopathy and are not recommended unless spinal cord compression is suspected. The risks of permanent neurological damage from acute spinal cord compression generally outweigh the risks of pharmacologic side effects of steroids in an emergent situation. f. Psychotropic/Anti-anxiety/Hypnotic Agents

Psychotropic/anti-anxiety/hypnotic agents may be useful for treatment of mild and chronic pain, dysesthesias, sleep disorders, and depression. Antidepressant medications, such as tricyclics and Selective Serotonin Reuptake Inhibitors (SSRIs), are useful for affective disorder and chronic pain management. Tricyclic antidepressant agents, in low dose, are useful for chronic pain but have more frequent side effects.

Anti-anxiety medications are best used for short-term treatment (i.e., less than 6 months). Accompanying sleep disorders are best treated with sedating antidepressants prior to bedtime. Frequently, combinations of the above agents are useful. As a general rule, physicians should access the patient's prior history of substance abuse or depression prior to prescribing any of these agents.

(1) Optimum duration: 1 to 6 months.

(2) Maximum duration: 6 to 12 months, with monitoring. g. Tramadol

Tramadol is useful in relief of low back pain and has been shown to provide pain relief equivalent to that of commonly prescribed NSAIDs. Although Tramadol may cause impaired alertness, it is generally well tolerated, does not cause gastrointestinal ulceration, or exacerbate hypertension or congestive heart failure. Tramadol should be used cautiously in patients who have a history of seizures or who are taking medication that may lower the seizure threshold, such as MAO inhibiters, SSRIs, and tricyclic antidepressants. This medication has physically addictive properties and withdrawal may follow abrupt discontinuation and is not recommended for those with prior opoid addiction.

(1) Optimum duration: 3 to 7 days.

(2) Maximum duration: 2 weeks. Use beyond 2 weeks is acceptable in appropriate cases. h. Topical Drug Delivery

Topical drug delivery may be an alternative treatment for localized musculoskeletal disorders and is an acceptable form of treatment in selected patients although there is no scientific evidence to support its use in low back pain. It is necessary that all topical agents be used with strict instructions for application as well as maximum number of applications per day to obtain the desired benefit and avoid potential toxicity. As with all medications, patient selection must be rigorous to select those patients with the highest probability of compliance. Refer to “Iontophoresis” in the Passive Therapy section for information regarding topical iontophoretic agents. 5. Occupational Rehabilitation Programs a. Non-Interdisciplinary

These programs are work-related, outcome-focused, individualized treatment programs. Objectives of the program include, but are not limited to, improvement of cardiopulmonary and neuromusculoskeletal functions (strength, endurance, movement, flexibility, stability, and motor control functions), patient education, and symptom relief. The goal is for patients to gain full or optimal function and return to work. The service may include the time-limited use of passive modalities with progression to achieve treatment and/or simulated/real work.

1) Work Conditioning

These programs are usually initiated once reconditioning has been completed but may be offered at any time throughout the recovery phase. It should be initiated when imminent return of a patient to modified or full duty is not an option, but the prognosis for returning the patient to work at completion of the program is at least fair to good.

(1) Length of visit: 1 to 2 hours per day.

(2) Frequency: 2 to 5 visits per week

(3) Optimum duration: 2 to 4 weeks

(4) Maximum duration: 6 weeks. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.

2) Work Simulation

Work simulation is a program where an individual completes specific work-related tasks for a particular job and return to work. Use of this program is appropriate when modified duty can only be partially accommodated in the work place, when modified duty in the work place is unavailable, or when the patient requires more structured supervision. The need for work place simulation should be based upon the results of a Functional Capacity Evaluation and or Jobsite Analysis.

(1) Length of visit: 2 to 6 hours per day.

(2) Frequency: 2 to 5 visits per week

(3) Optimum duration: 2 to 4 weeks

(4) Maximum duration: 6 weeks. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains. b. Interdisciplinary

Interdisciplinary programs are characterized by a variety of disciplines that participate in the assessment, planning, and/or implementation of an injured workers program with the goal for patients to gain full or optimal function and return to work. There should be close interaction and integration among the disciplines to ensure that all members of the team interact to achieve team goals. These programs are for patients with greater levels of perceived disability, dysfunction, deconditioning and psychological involvement. For patients with chronic pain, refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder Medical Treatment Guideline.

1) Work Hardening Work Hardening is an interdisciplinary program addressing a patient's employability and return to work. It includes a progressive increase in the number of hours per day that a patient completes work simulation tasks until the patient can tolerate a full workday. This is accomplished by addressing the medical, psychological, behavioral, physical, functional, and vocational components of employability and return-to- work.

This can include a highly structured program involving a team approach or can involve any of the components thereof. The interdisciplinary team should, at a minimum, be comprised of a qualified medical director who is board certified with documented training in occupational rehabilitation, team physicians having experience in occupational rehabilitation, occupational therapy, physical therapy, case manager, and psychologist. As appropriate, the team may also include: chiropractor, RN, or vocational specialist.

(1) Length of visit: Up to 8 hours/day.

(2) Frequency: 2 to 5 visits per week

(3) Optimum duration: 2 to 4 weeks

(4) Maximum duration: 6 weeks. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.

2) Spinal Cord Programs

Spinal Cord Systems of Care provide coordinated, case-managed, and integrated service for people with spinal cord dysfunction, whether due to trauma or disease. The system includes an inpatient component in an organization licensed as a hospital and an outpatient component. Each component endorses the active participation and choice of the persons served throughout the entire program. The Spinal Cord System of Care also provides or formally links with key components of care that address the lifelong needs of the persons served.

This can include a highly structured program involving a team approach or can involve any of the components thereof. The interdisciplinary team should, at a minimum, be comprised of a qualified medical director who is board certified and trained in rehabilitation, a case manager, occupational therapy, physical therapy, psychologist, rehabilitation RN and MD, and therapeutic recreation specialist. As appropriate, the team may also include: rehabilitation counselor, respiratory therapist, social worker, or speech-language pathologist.

Timeframe durations for any spinal cord program should be determined based upon the extent of the patient's injury and at the discretion of the rehabilitation physician in charge.

6. Orthotics a. Foot Orthoses

Orthotics and inserts are a recognized and accepted intervention for spinal disorders that are due to aggravated mechanical abnormalities, such as leg length discrepancy, scoliosis, or lower extremity misalignment. Shoe insoles or inserts may be effective for patients with acute low back problems who stand for prolonged periods of time. b. Lumbosacral Bracing

Rigid Bracing Devices are well accepted and commonly used for post fusion, scoliosis, and vertebral fractures.

Lumbar Support Devices include backrests for chairs and car seats. Lumbar supports may provide symptomatic relief of pain and movement reduction in cases of chronic low back problems.

Lumbar Corsets and Back Belts may be useful in some cases. They are an accepted treatment with limited application yet there is insufficient evidence to support the effectiveness of their use. The injured worker should be advised of the potential harm from using a lumbar support for a period of time greater than that which is prescribed. Harmful effects include deconditioning of the trunk musculature, skin irritation and general discomfort.

7. Patient Education

No treatment plan is complete without addressing issues of individual and/or group patient education as a means of prolonging the beneficial effects of treatment, as well as facilitating self-management of symptoms and injury prevention. The patient should be encouraged to take an active role in the establishment of function outcome goals. They should be educated on their specific injury, assessment findings, and plan of treatment. Instruction on proper body mechanics and posture, positions to avoid, self-care for exacerbation of symptoms, and home exercise should also be addressed.

(1) Time to produce effect: Varies with individual patient.

(2) Frequency: Should occur at every visit.

8. Personalitv/Psychological/Psychosocial Intervention

Psychosocial Psychosocial treatment is generally accepted, widely used and well established intervention. This group of therapeutic and diagnostic modalities includes, but is not limited to, individual counseling, group therapy, stress management, psychosocial crises intervention, hypnosis and meditation. Any screening or diagnostic workup should clarify and distinguish between preexisting versus aggravated versus purely causative psychological conditions. Psychosocial intervention is recommended as an important component in the total management program that should be implemented as soon as the problem is identified. This can be used alone or in conjunction with other treatment modalities. Providers treating patients with chronic pain should refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder Medical Treatment Guideline.

(1) Time to produce effect: 2 to 4 weeks.

(2) Frequency: 1 to 3 times weekly for the first 4 weeks (excluding hospitalization, if required), decreasing to 1 to 2 times per week for the second month. Thereafter, 2 to 4 times monthly.

(3) Optimum duration: 6 weeks to 3 months

(4) Maximum duration: 3 to 12 months. Counseling is not intended to delay but to enhance functional recovery. For select patients, longer supervised treatment may required, and if further counseling beyond 3 months is indicated, documentation addressing which pertinent issues are preexisting versus aggravated versus causative, as well as projecting a realistic functional prognosis, should be provided by the authorized treating provider every 4 to 6 weeks during treatment.

9. Restriction of Activities

Continuation of normal daily activities is the recommendation for acute and chronic low back pain without neurologic symptoms. There is good evidence against the use of bed rest in cases without neurologic symptoms. Bed rest may lead to deconditioning and impair rehabilitation. Complete work cessation should be avoided, if possible, since it often further aggravates the pain presentation. Modified return-to- work is almost always more efficacious and rarely contraindicated in the vast majority of injured workers with low back pain. 10. Return-to-Work

Early return-to-work should be a prime goal in treating occupational injuries given the poor return-to-work prognosis for an injured worker who has been out of work for more than six months. It is imperative that the patient be educated regarding the benefits of return-to-work, restrictions, and follow-up if problems arise. When attempting to return a patient to work after a specific injury, clear objective restrictions of activity level should be made. An accurate job description may be necessary to assist the physician in making return-to-work recommendations.

Return-to-work is defined as any work or duty that the patient is able to perform safely, and it may not be the patient's regular work. Due to the large spectrum of injuries of varying severity and varying physical demands in the work place, it is not possible to make specific return-to-work guidelines for each injury. Therefore, the Division recommends the following: a. Establishment of a Return-To-Work Status

Communication is essential between the patient, employer and provider to determine appropriate restrictions and return-to-work dates. It is the responsibility of the physician to provide clear concise restrictions, and it the employer's responsibility to determine if temporary duties can be provided within the restrictions. For low back pain injuries, the following should be addressed when describing the patient's activity level:

1) Lower body postures such as squatting, kneeling, crawling, stooping, or climbing should include duration and frequency.

2) Ambulatory level for distance, frequency and terrain should be specified.

3) Standing duration and frequency with regard to balance issues.

4) Use of adaptive devices or equipment for proper office ergonomics to enhance capacities can be included. c. Compliance with Activity Restrictions.

In some cases, compliance with restriction of activity levels may require a complete jobsite evaluation, a functional capacity evaluation (FCE), or other special testing. Refer to the “Special Tests” section of this guideline.

11. Therapy — Active

The following active therapies have some evidence to support their use and are widely used and accepted methods of care for a variety of work-related injuries. They are based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion, and can alleviate discomfort. Active therapy requires an internal effort by the individual to complete a specific exercise or task. This form of therapy requires supervision from a therapist or medical provider such as verbal, visual and/or tactile instruction(s). At times, the provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is predominately executed by the patient.

Patients should be instructed to continue active therapies at home as an extension of the treatment process in order to maintain improvement levels. Home exercise can include exercise with or without mechanical assistance or resistance and functional activities with assistive devices.

The following active therapies are listed in alphabetical order: a. Activities of Daily Living (ADL)

Activities of daily living are instruction, active-assisted training and/or adaptation of activities or equipment to improve a person's capacity in normal daily activities such as self-care, work re-integration training, homemaking and driving.

(1) Time to produce effect: 4 to 5 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks b. Aquatic Therapy

Aquatic therapy is the implementation of active therapeutic procedures in a swimming or therapeutic pool. The water provides a buoyancy force that lessens the amount of force gravity applies to the body. The decreased gravity affect allows the patient to have a mechanical advantage and more likely have a successful trial of therapeutic exercise. Aquatic vests or belts can be used to provide stability and balance in the water. Indications are for individuals who cannot tolerate active land-based or full-weight bearing therapeutic procedures. The pool should be large enough to allow full extremity range of motion and fully erect posture. Aquatic vests, belts and other devices and be used to provide stability, balance, buoyancy, and resistance.

(1) Time to produce effect: 4 to 5 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks c. Functional Activities

Functional activities are the use of therapeutic activity to enhance mobility, body mechanics, employability, coordination, and sensory motor integration.

(1) Time to produce effect: 4 to 5 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks d. Functional Electrical Stimulation

(1) Time to produce effect: 2 to 6 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 8 weeks.

(4) Maximum duration: 8 weeks. If beneficial, provide with home unit. e. Lumbar Stabilization

Lumbar stabilization is a therapeutic program whose goal is to strengthen the spine in its neural and anatomic position. The stabilization is dynamic which allows whole body movements while maintaining a stabilized spine. It is the ability to move and function normally through postures and activities without creating undue vertebral stress.

(1) Time to produce effect: 4 to 8 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 8 weeks

(4) Maximum duration: 8 weeks f. Neuromuscular Re-Education

Neuromuscular re-education is the skilled application of exercise with manual, mechanical or electrical facilitation to enhance strength, movement patterns, neuromuscular response, proprioception, kinesthetic sense, coordination, education of movement, balance and posture. Indications include the need to promote neuromuscular responses through carefully timed proprioceptive stimuli, to elicit and improve motor activity in patterns similar to normal neurologically developed sequences, and improve neuromotor response with independent control.

(1) Time to produce effect: 2 to 6 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 4 to 8 weeks

(4) Maximum duration: 8 weeks g. Therapeutic Exercise

Therapeutic exercise, with or without mechanical assistance or resistance, may include isoinertial, isotonic, isometric and isokinetic types of exercises. Indications include the need for cardiovascular fitness, reduced edema, improved muscle strength, improved connective tissue strength and integrity, increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle recruitment, increased range-of-motion and are used to promote normal movement patterns. Can also include complementary/alternative exercise movement therapy. (1) Time to produce effect: 2 to 6 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 8 weeks

(4) Maximum duration: 8 weeks

12. Therapy — Passive

While protocols for specific diagnoses and post-surgical conditions may warrant durations of treatment beyond those listed as “maximum,” factors such as exacerbation of symptoms, re-injury, interrupted continuity of care, and comorbidities may extend durations of care. Having specific goals with objectively measured functional improvement during treatment can support extended durations of care. It is recommended that if after 6 to 8 visits no treatment effect is observed, alternative treatment interventions, further diagnostic studies or further consultations should be pursued.

The following passive therapies are listed in alphabetical order: a. Electrical Stimulation (Unattended)

Electrical stimulation, once applied, requires minimal on-site supervision by the physical or nonphysical provider. Indications include pain, inflammation, muscle spasm, atrophy, decreased circulation, and the need for osteogenic stimulation.

(1) Time to produce effect: 2 to 4 treatments

(2) Frequency: Varies, depending upon indication, between 2 to 3 times/day to 1 time/week. Provide home unit if frequent use.

(3) Optimum duration: 1 to 3 months

(4) Maximum duration: 3 months b. Infrared Therapy

Infrared therapy is a radiant form of heat application. Indications include the need to elevate the pain threshold before exercise and to alleviate muscle spasm to promote increased movement.

(1) Time to produce effect: 2 to 4 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 3 weeks as primary, or intermittently as an adjunct to other therapeutic procedures up to 2 months. (4) Maximum duration: 2 months c. Iontophoresis

Iontophoresis is the transfer of medication, including, but not limited to, steroidal anti-inflammatories and anesthetics, through the use of electrical stimulation. Indications include pain (Lidocaine), inflammation (hydrocortisone, salicylate), edema (mecholyl, hyaluronidase, salicylate), ischemia (magnesium, mecholyl, iodine), muscle spasm (magnesium, calcium), calcific deposits (acetate), scars and keloids (chlorine, iodine, acetate).

(1) Time to produce effect: 1 to 4 treatments

(2) Frequency: 3 times per week with at least 48 hours between treatments

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks d. Manipulation

Manipulation is a generally accepted, well-established and widely used therapeutic intervention for low back pain. Manipulation can include high velocity, low amplitude (HVLA) technique, chiropractic manipulation, osteopathic manipulation, muscle energy techniques and non-force techniques. It is performed by taking a joint to its end range of motion and moving the articulation into the zone of accessory joint movement, well within the limits of anatomical integrity.

There is good scientific evidence to suggest that manipulation can be helpful for patients with acute low back pain problems without radiculopathy when used within the first 4 to 6 weeks of symptoms. Although the evidence for sub-acute and chronic low back pain and low back pain with radiculopathy is less convincing, it is a generally accepted and well established intervention for these conditions. Indications for manipulation include joint pain, decreased joint motion and joint adhesions. Contraindications include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthridites, aortic aneurysm, and signs of progressive neurologic deficits.

(1) Time to produce effect: 1 to 6 treatments.

(2) Frequency: 1 to 5 times per week for the first 2 weeks as indicated by the severity of involvement and the desired effect, then 2 to 3 treatments per week for the next 4 weeks, then 1 to 2 treatments per week for the next 6 weeks.

(3) Optimum duration: 8 to 12 weeks

(4) Maximum duration: 3 months. Extended durations of care beyond what is considered “maximum” may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with comorbidities. Care beyond 3 months is indicated for certain chronic syndromes in which manipulation is helpful in improving function, decreasing pain and improving quality of life. Such care should be re-evaluated and documented on a monthly basis. Treatment may include visits 2 times a month through the 7th month postinjury, then on a monthly basis thereafter through the 10th month post-injury. Care beyond the 10th month should be reviewed and allowed on a case-by-case basis according to the unique needs of the patient with chronic and/or permanent injury. e. Massage — Manual or Mechanical

Massage is manipulation of soft tissue with broad ranging relaxation and circulatory benefits. This may include stimulation of acupuncture points and acupuncture channels (acupressure), application of suction cups and techniques that include pressing, lifting, rubbing, pinching of soft tissues by or with the practitioners hands. Indications include edema (peripheral or hard and non-pliable edema), muscle spasm, adhesions, the need to improve peripheral circulation and range-of-motion, or to increase muscle relaxation and flexibility prior to exercise.

(1) Time to produce effect: Immediate.

(2) Frequency: 1 to 2 times per week

(3) Optimum duration: 6 weeks

(4) Maximum duration: 2 months f. Mobilization (Joint)

Mobilization is passive movement involving oscillatory motions to the vertebral segment(s). The passive mobility is performed in a graded manner (I, II, III, IV, or V), which depicts the speed of the maneuver. It may include skilled manual joint tissue stretching. Indications include the need to improve joint play, segmental alignment, improve intracapsular arthrokinematics, or reduce pain associated with tissue impingement. Contraindications include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthridities, aortic aneurysm, and signs of progressive neurologic deficits.

(1) Time to produce effect: 6 to 9 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks g. Mobilization (Soft Tissue)

Mobilization of soft tissue is the skilled application of manual techniques designed to normalize movement patterns through the reduction of soft tissue pain and restrictions. Indications include muscle spasm around a joint, trigger points, adhesions, and neural compression.

(1) Time to produce effect: 2 to 3 weeks

(2) Frequency: 2 to 3 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks h. Superficial Heat and Cold Therapy

Superficial heat and cold are thermal agents applied in various manners that lowers or raises the body tissue temperature for the reduction of pain, inflammation, and/or effusion resulting from injury or induced by exercise. Includes application of heat just above the surface of the skin at acupuncture points. Indications include acute pain, edema and hemorrhage, need to increase pain threshold, reduce muscle spasm and promote stretching/flexibility. Cold and heat packs can be used at home as an_extension of therapy in the clinic setting. (1) Time to produce effect: Immediate

(2) Frequency: 2 to 5 times per week

(3) Optimum duration: 3 weeks as primary or intermittently as an adjunct to other therapeutic procedures up to 2 months

(4) Maximum duration: 2 months i. Short-Wave Diathermy

Short-wave diathermy involves the use of equipment that exposes soft tissue to a magnetic or electrical field. Indications include enhanced collagen extensibility before stretching, reduced muscle guarding, reduced inflammatory response and enhanced reabsorption of hemorrhage/hematoma or edema.

(1) Time to produce effect: 2 to 4 treatments

(2) Frequency: 2 to 3 times per week up to 3 weeks

(3) Optimum duration: 3 to 5 weeks

(4) Maximum duration: 5 weeks j. Traction — Manual

Manual traction is an integral part of manual manipulation or joint mobilization. Indications include decreased joint space, muscle spasm around joints, and the need for increased synovial nutrition and response. Manual traction is contraindicated in patients with tumor, infection, fracture, or fracture dislocation.

(1) Time to produce effect: 1 to 3 sessions

(2) Frequency: 2 to 3 times per week

(3) Optimum duration: 30 days

(4) Maximum duration: 1 month k. Traction — Mechanical

Mechanical traction is indicated for decreased joint space, muscle spasm around joints, and the need for increased synovial nutrition and response. Traction modalities are contraindicated in patients with tumor, infections, fracture or fracture dislocation. Nonoscillating inversion traction methods are contraindicated in patients with glaucoma or hypertension. A home lumbar traction unit can be purchased if therapy proves effective.

(1) Time to produce effect: 1 to 3 sessions up to 30 minutes. If response is negative after 3 treatments, discontinue this modality.

(2) Frequency: 2 to 3 times per week

(3) Optimum duration: 4 week

(4) Maximum duration: 1 month l. Transcutaneous Electrical Nerve Stimulation (TENS)

TENS should include least one instructional session for proper application and use. Indications include muscle spasm, atrophy, and decreased circulation and pain control. Minimal TENS unit parameters should include pulse rate, pulse width and amplitude modulation.

(1) Time to produce effect: Immedicate.

(2) Frequency: Variable.

(3) Optimum duration: 3 sessions

(4) Maximum duration: 3 sessions. If beneficial, provide with home unit or purchase if effective. m. Ultrasound

Ultrasound uses sonic generators to deliver acoustic energy for therapeutic thermal and/or nonthermal soft tissue effects. Indications include scar tissue, adhesions, collagen fiber and muscle spasm, and the need to extend muscle tissue or accelerate the soft tissue healing. Ultrasound with electrical stimulation is concurrent delivery of electrical energy that involves dispersive electrode placement. Indications include muscle spasm, scar tissue, pain modulation and muscle facilitation. Phonophoresis is the transfer of medication to the target tissue to control inflammation and pain through the use of sonic generators. These topical medications include, but are not limited to, steroidal antiinflammatory and anesthetics.

(1) Time to produce effect: 6 to 15 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 4 to 8 weeks

(4) Maximum duration: 2 months n. Vertebral Axial Decompression (VAX-D)

VAX-D, a registered trademark for a motorized traction table used to stretch the lower back, is an acronym for vertebral axial decompression. The patient lies prone on the table in a pelvic harness for 30 to 45 minutes while alternating cycles of stretching and relaxation are applied. The table has FDA approval as a traction device, but no studies have shown any advantage of vertebral axial decompression over ordinary manual therapy for low back pain and it has not been shown to treat conditions associated with herniated discs.

The evidence in support of vertebral axial decompression is insufficient to support its use in low back injuries. Proponents of this therapy may submit supporting evidence to the Division if they believe that claims of its effectiveness can be supported by well-designed studies. Vertebral axial decompression for treatment of low back injuries is not recommended. o. Whirlpool/Hubbard Tank

The whirlpool/Hubbard Tank is conductive exposure to water at temperatures that best elicits the desired effect (cold vs. heat). It generally includes massage by water propelled by a turbine or Jacuzzi jet system and has the same thermal effects as hot packs if higher than tissue temperature. It has the same thermal effects as cold application if comparable temperature water used. Indications include the need for analgesia, relaxing muscle spasm, reducing joint stiffness, and facilitating and preparing for exercise.

(1) Time to produce effect: 2 to 4 treatments (2) Frequency: 3 to 5 times per week

(3) Optimum duration: 3 weeks as primary, or intermittently as an adjunct to other therapeutic procedures up to 2 months.

(4) Maximum duration: 2 months

13. Vocational Rehabilitation

Vocational rehabilitation is a generally accepted intervention, but Colorado limits its use as a result of Senate Bill 87-79. Initiation of vocational rehabilitation requires adequate evaluation of patients for quantification highest functional level, motivation and achievement of maximum medical improvement. Vocational rehabilitation may be as simple as returning to the original job or as complicated as being retrained for a new occupation.

F. THERAPEUTIC PROCEDURES — OPERATIVE

All operative interventions must be based upon positive correlation of clinical findings, clinical course and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with positive identification of pathologic condition(s). It is imperative to rule out non-physiologic modifiers of pain presentation or non-operative conditions mimicking radiculopathy or instability (e.g., peripheral neuropathy, piriformis syndrome, myofascial pain, scleratogenous or sympathetically mediated pain syndromes, sacroiliac dysfunction, psychological conditions, etc.) prior to consideration of elective surgical intervention.

In addition, operative treatment is indicated when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions. All patients being considered for surgical intervention should first undergo a comprehensive neuromusculoskeletal examination to identify mechanical pain generators that may respond to non-surgical techniques or may be refractory to surgical intervention.

While sufficient time allowances for non-operative treatment are required to determine the natural cause and response to non-operative treatment of low back pain disorders, timely decision making for operative intervention is critical to avoid deconditioning and increased disability (exclusive of “emergent” or urgent pathology such as cauda equina syndrome or associated rapidly progressive neurologic loss).

In general, if the program of non-operative treatment fails, operative treatment is indicated when:

1. Improvement of the symptoms has plateaued and the residual symptoms of pain and functional disability are unacceptable at the end of 6 to 12 weeks of treatment, or at the end of longer duration of non-operative programs for debilitated patients with complex problems; and/or

2. Frequent recurrences of symptoms cause serious functional limitations even if a non-operative treatment program provides satisfactory relief of symptoms and restoration of function on each recurrence. Mere passage of time with poorly guided treatment is not considered an active treatment program.

Surgical workup and implementation for simple decompression of patients with herniated nucleus pulposus and sciatica should occur within 6 to 12 weeks after injury at the latest, within the above stated contingencies. For patients with true, refractory mechanical low back pain in whom fusion is being considered, it is recommended that a decisive commitment to surgical or non-surgical interventions occur within 5 months following injury, at the latest.

Re-operation is indicated only when the functional outcome following the reoperation is expected to be better, within a reasonable degree of certainty, than the outcome of other non-invasive or less invasive treatment procedures. “Functional outcomes” refers to the patient's ability to improve functional tolerances such as sitting, standing, walking, strength, endurance, and/or vocational status. While timely surgical decision-making is critical to avoid deconditioning and increased disability, a time limited trial of reconditioning should be tried prior to re-operation. Re-operation has a high rate of complications and failure and may lead to disproportionately increased disability.

Structured rehabilitation interventions should be strongly considered post-operative in any patient not making expected functional progress within three weeks post-operative.

Return to work restriction should be specific according to the recommendation in the section “Return to Work” under Therapeutic Procedures – Non-Operative. Most non-fusion surgical patient can return to a limited level of duty between 3 to 6 weeks. Full activity is generally achieved between 6 weeks to 6 months depending on the procedure and healing of the individual.

1. Discectomy a. Description — To enter into and partially remove the disc. b. Complications — Includes, but are not limited to, nerve damage, wrong level operation, spinal fluid leakage, infection and hemorrhage. c. Surgical Indications — To include all of the following: Primary radicular symptoms, radiculopathy on exam, correlating imaging study, and failure of non-surgical care. There is limited evidence that surgery provides initial improvement in symptoms although most lumbar discs resolve naturally with time. d. Operative Treatment — Laminotomy, partial discectomy, and root decompression. e. Post-Operative Therapy — Active and/or passive therapy. Implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-operative week, barring complications. Instruction and participation in a long-term home-based program of ROM, strengthening, endurance and stability exercises should be considered 3 to 4 weeks post-op.

2. Chemonucleolysis a. Description — Injection of a proteolytic enzyme into the disc to obtain an enzymatic degradation of the nucleus pulposus. b. Complications — Includes, but are not limited to, severe adverse reaction, neurologic complications including transverse myelitis, infection and back muscle spasm. c. Surgical Indications — To include all of the following: Primary radicular symptoms, radiculopathy on exam, correlating imaging study, and failure of non-surgical care. There is some evidence to support the use of chemonucleolysis over no treatment. However, more patients require second surgeries after this procedure than after a discectomy. The failure rate of chemonucleolysis is higher than the failure rate of discectomy. d. Operative Treatment — Injection of a proteolytic enzyme into the disc to obtain an enzymatic degradation of the nucleus pulposus. Physicians trained in chemonucleolysis and with extensive experience performing the procedure should only perform chemonucleolysis. e. Post-Operative Therapy — Active and/or passive therapy. Instruction and participation in a long-term home-based program of ROM, strengthening, endurance and stability exercises should be considered 3 to 4 weeks post-op. 3. Percutaneous Discectomy (Nuclectomy) or Laser Discectomy a. Description — An invasive operative procedure to accomplish partial removal of the disc through a trocar under imaging control. b. Complications — Include, but are not limited to, injuries to the nerve or vessel, infection and hematoma. c. Surgical Indications — Percutaneous discetomy is indicated in cases with suspected septic discitis in order to obtain diagnostic tissue. These procedures may be used in the presence of septic discitis for the following: Primary radicular symptoms, radiculopathy on exam, correlating imaging study, and failure of non-surgical care. The procedure has limited application for non-septic cases due to lack of evidence to support long-term improvement. d. Operative Treatment — Partial discectomy & root decompression. If unsuccessful, open laminectomy should be strongly considered within 2 weeks post-discectomy. e. Post-Operative Therapy — Active and/or passive therapy. Implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-operative week, barring complications. Instruction and participation in a long-term home-based program of ROM, strengthening, endurance and stability exercises should be considered 3 to 4 weeks post-op.

4. Laminotomy/Laminectomy/Foramenotomy/Facetectomy a. Description — They provide access to produce neural decompression by partial or total removal of various parts of vertebral bone. b. Complications — Include, but are not limited to, nerve injury, post-surgical instability, CSF leakage and infection. c. Surgical Indications — To include all of the following: Primary radicular symptoms, radiculopathy on exam, correlating imaging study, and failure of non-surgical care. d. Operative Treatment — Laminotomy, partial discectomy & root decompression. e. Post-Operative Therapy — Active and/or passive therapy. Implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-operative week, barring complications. Instruction and participation in a long-term home-based program of ROM, strengthening, endurance and stability exercises should be considered 3 to 4 weeks post-op.

5. Spinal Fusion a. Description — Use of bone grafts, sometimes combined with metal devices, to produce a rigid connection between two or more adjacent vertebrae. b. Complications — Instrumentation failure, bone graft donor site pain, in-hospital mortality, deep wound infection, superficial infection, graft extrusion. c. Surgical Indications — A timely decision-making process is recommended when considering patients for possible fusion. There is no good evidence from controlled trials that spinal fusion alone is effective for treatment of any type of acute low back problem, in the absence of spinal fracture or dislocation. For chronic low back problems, fusion should not be considered within the first 3 months of symptoms, except for fracture or dislocation. Indications for spinal fusion may include:

1) Neural arch defect – Spondylolytic spondylolisthesis, congenital unilateral neural arch hypoplasia.

2) Segmental Instability - Excessive motion, as in degenerative spondylolisthesis, surgically induced segmental instability.

3) Primary Mechanical Back Pain/ Functional Spinal Unit Failure - Multiple pain generators objectively involving two or more of the following: (a) Internal disc disruption (poor success rate if more than one disc involved), (b) Painful motion segment, as in annular tears, (c) Disc resorption, (d) Facet syndrome, and or (e) Ligamentous tear.

4) Revision surgery for failed previous operation(s) if significant functional gains are anticipated. Revision surgery for purposes of pain relief must be approached with extreme caution due to the less than 50% success rate reported in medical literature.

5) Infection, tumor, or deformity of the lumbosacral spine that cause intractable pain, neurological deficit and/or functional disability. d. Pre-Operative Surgical Indications — Required pre-operative clinical surgical indications for spinal fusion include all of the following:

1) All pain generators are identified and treated; and

2) All physical medicine and manual therapy interventions are completed; and

3) X-ray, MRI, or CT/Discography demonstrating disc pathology or spinal instability; and

4) Spine pathology limited to two levels; and

5) Psychosocial screen with confounding issues addressed.

6) For any potential fusion surgery, it is recommended that the injured worker refrain from smoking for at least six weeks prior to surgery and during the period of fusion healing. e. Operative Therapy — Operative procedures may include: a) Intertransverse Fusion; b) Anterior Fusion – generally used for component of discogenic pain where there is no significant radicular component requiring decompression; c) Posterior Interbody Fusion – generally used for componen: of discogenic pain where posterior decompression for radicular symptoms also performed; or d) Anterior/posterior (360°;) Fusion – most commonly seen in unstable or potentially unstable situations or non-union of a previous fusion. f. Post-Operative Therapy — Active and/or passive therapy. Implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-operative week, barring complications. Instruction and participation in a long-term home-based program of ROM, strengthening, endurance and stability exercises should be done once fusion is solid (generally 6 weeks to 6 months post-op). g. Return to Work — Barring complications, patients responding favorably to spinal fusion may be able to return to sedentary-to-light work within 6 to 12 weeks post-operatively, light-to-medium work within 6 to 9 months post-operatively and medium-to-medium/heavy work within 6 to 12 months post-operatively. Patients requiring fusion whose previous occupation involved heavy-to-very- heavy labor should be considered for vocational assessment as soon as reasonable restrictions can be predicted. As previously noted, the practitioner must release the patient with specific physical restrictions and should obtain a clear job description from the employer, if necessary. Once an injured worker is off work greater than 6 months, the functional prognosis with or without fusion becomes guarded for that individual. 6. Sacroiliac Joint Fusion a. Description — Use of bone grafts, sometimes combined with metal devices, to produce a rigid connection between two or more adjacent vertebrae providing symptomatic instability as a part of major pelvic ring disruption. b. Complications — Instrumentation failure, bone graft donor site pain, in-hospital mortality, deep infection, superficial infection, graft extrusion. c. Surgical Indications — This procedure has limited use in minor trauma and would be considered only on an individual case-by-case basis. In patients with typical mechanical low back pain, this procedure is considered to be under investigation in Colorado. Until the efficacy of this procedure for mechanical low back pain is determined by an independent valid prospective outcome study, this procedure is not recommended for mechanical low back pain.

7. Implantable Spinal Cord Stimulators

Implantable spinal cord stimulators are reserved for those low back pain patients with pain of greater than 6 months duration who have not responded to the standard non-operative or operative interventions previously discussed within this document. Refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder Medical Treatment Guideline.

8. Intradiscal Electrothermal Annuloplasty (IDEA) a. Description — An outpatient non-operative procedure. A wire is guided into the identified painful disc using fluoroscopy. The wire is then heated within the disc. The goal of the procedure is to burn the nerves and to tighten the injured tissue within the disc. Physicians performing this procedure must have been trained in the procedure and have performed at least 25 prior discograms. Prior authorization is required for IDEA. b. Complications — Complications include, but are not limited to, discitis, nerve damage, pain exacerbation and anaphylaxis. c. Surgical Indications — Failure of conservative therapy including physical therapy, medication management, or therapeutic injections. Indications may include those with chronic low back pain, disc related back pain, or pain lasting greater than 6 months. There is some evidence to support this procedure. It continues to be investigational and cannot be generally recommended. Controlled trials are currently in progress, but results will not be published in the immediate future so functional benefit beyond 12 months is unknown. Only patients who meet the following should be considered, including:

1) All pain generators are identified and treated; and

2) All physical medicine and manual therapy interventions are completed; and

3) X-ray, MRI, or CT/Discography demonstrating disc pathology; and

4) Spine pathology limited to two levels; and

5) Psychosocial screen with confounding issues addressed.

6) For any potential surgery, it is recommended that the injured worker refrain from smoking for at least six weeks prior to surgery and during the period of healing.

Additionally, the candidate must meet the following criteria: 1) Age not above 60 or under 18; and

2) Normal neurological exam; and

3) No evidence of nerve root compression on MRI; and

4) Concordant pain reproduction with provocative discography at less than 1ml dye volume (low pressure); and

5) Functionally limiting low back for at least 6 months; and

6) No evidence of inflammatory arthritis, spinal conditions mimicking low back pain, moderate to severe spinal stenosis, spinal instability, disc herniation, or medical or metabolic diseases precluding follow-up rehabilitation; and

7) The height of the disc must be sufficient to permit maneuvering of the thermal wire; and

8) Previous IDEA within the last 6 months. d. Operative Treatment — A wire is guided into the identified painful disc using fluoroscopy and then the wire is heated within the disc. e. Post-Procedure Therapy — Active and/or passive therapy. Some cases may require epidural injection after the procedure has been performed. Rehabilitation may take as long as 6 months and include stretching during the first month, floor exercises in the second month, 3 to 5 consecutive months of progressive exercise program, and sport activities in the 5th and 6th months as tolerated. f. Return to Work — Barring complications, may be able to return to limited duty after one week. Zero to 10 pounds lifting for first 6 weeks post-procedure. May return to medium work category (20 to 50 pounds per DOT standards) at 3 months or more.

RULE XVII, EXHIBIT B Upper Extremity Medical Treatment Guidelines 1995 (Revised March 15, 1998)

presented by:

State of Colorado Department of Labor and Employment DIVISION OF WORKERS' COMPENSATION

TABLE OF CONTENTS SECTION DESCRIPTION

INTRODUCTION I GENERAL GUIDELINE PRINCIPLES A. Application of Guidelines B. Education C. Treatment Parameter Duration D. Active Interventions E. Active Therapeutic Exercise Program F. Positive Patient Response G. Re-Evaluate Treatment Every 3-4 Weeks H. Surgical Intervention I. Six-Month Time Frame J. Return-to-Work K. Delayed Recovery II OCCUPATIONAL CARPAL TUNNEL SYNDROME III THORACIC OUTLET SYNDROME IV SHOULDER INJURY V CUMULATIVE TRAUMA DISORDER

INTRODUCTION

Although the primary purpose of this text is educational, these guidelines are enforceable under the Workers' Compensation Rules of Procedure, 7 CCR 1101-3. The Division recognizes that acceptable medical practice may include deviations from these guidelines. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of professional care.

To properly utilize this document, the reader should not skip nor overlook any sections.

J. RETURN-TO-WORK:

Even if there is residual chronic pain, return-to-work is not necessarily contraindicated. Return-to-work may be therapeutic, assuming the work is not likely to aggravate the basic problem or increase long-term pain. The practitioner must write detailed restrictions when returning a patient to limited duty. The following functions should be considered and modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, bending at the waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors. The patient should never be released to “sedentary or light duty” without specific physical limitations. The practitioner must understand all of the physical, demands of the patient's job position before returning the patient to full duty and should request clarification of the patient's job duties. Clarification should be obtained from the employer or, if necessary, including, but not limited to, an occupational health nurse, occupational therapist, vocational rehabilitation specialist, or an industrial hygienist.

K. DELAYED RECOVERY:

Strongly consider a psychological evaluation, if not previously provided, as well as initiating interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to make expected progress 6-12 weeks after an injury. The Division recognizes that 3-10% of all industrially injured patients will not recover within the timelines outlined in this document despite optimal care. Such individuals may require treatment beyond the limits discussed within this document, but such treatment will require clear documentation by the authorized treating practitioner focusing on objective functional gains afforded by further treatment and impact upon prognosis.

The remainder of this document should be interpreted within the parameters of these guideline principles which will hopefully lead to more optimal medical and functional outcomes for injured workers. I. GENERAL GUIDELINE PRINCIPLES

The principles summarized in this section are key to the intended implementation of these guidelines and critical to the reader's application of the guidelines in this document.

A. APPLICATION OF GUIDELINES:

The Division provides procedures to implement medical treatment guidelines and to foster communication to resolve disputes among the provider, payer and patient through the Workers' Compensation Rules of Procedure, Rule XVII and Rule VIII. In lieu of more costly litigation, parties may wish to seek administrative dispute resolution services through the Division.

B. EDUCATION:

Education of the patient and family, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of lower extremity pain and disability. Currently, practitioners often think of education last, after medications, manual therapy and surgery. Practitioners must develop and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers and the community as a whole. An education-based paradigm should always start with inexpensive communication providing reassuring information to the patient. More in-depth education currently exists within a treatment regime employing functional restorative and innovative programs of prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of facilitating self-management of symptoms and prevention.

C. TREATMENT PARAMETER DURATION:

Time frames for specific interventions commence once treatments have been initiated, not on the date of injury. Obviously, duration will be impacted by patient compliance, as well as availability of services. Clinical judgement may substantiate the need to accelerate or decelerate the time frames discussed in this document.

D. ACTIVE INTERVENTIONS:

Interventions emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment, are generally emphasized over passive modalities, especially as treatment progresses. Generally, passive and palliative interventions are viewed as a means to facilitate progress in an active rehabilitation program with concomitant attainment of objective functional gains.

E. ACTIVE THERAPEUTIC EXERCISE PROGRAM:

Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and education. This includes functional application in vocational or community settings.

F. POSITIVE PATIENT RESPONSE:

Positive results are defined primarily as functional gains which can be objectively measured. Objective functional gains include, but are not limited to, positional tolerances, range-of-motion, strength, endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures which can be quantified. Subjective reports of pain and function should be considered and given relative weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on objective findings.

G. RE-EVALUATE TREATMENT EVERY 3-4 WEEKS:

If a given treatment or modality is not producing positive results within 3-4 weeks, the treatment should be either modified or discontinued. Reconsideration of diagnosis should also occur in the event of poor response to a seemingly rational intervention.

H. SURGICAL INTERVENTIONS:

I. SIX-MONTH TIME FRAME:

Since the prognosis drops precipitously for returning an injured worker to work once he/she has been temporarily totally disabled for more than six months. The emphasis within these guidelines is to move patients along a continuum of care and return-to-work within a six-month time frame, whenever possible. It is important to note that time frames may not be pertinent to injuries which do not involve work-time loss or are not occupationally related.

RULE XVII, EXHIBIT B-II Carpal Tunnel Syndrome (CTS) Medical Treatment Guidelines July 30, 2003

(Previously Adopted March 2, 1995 and Revised December 30, 1996 and March 15, 1998)

Presented By:

State of Colorado Department of Labor and Employment DIVISION OF WORKERS' COMPENSATION

TABLE OF CONTENTS

A. INTRODUCTION

B. GENERAL GUIDELINE PRINCIPLES

1. APPLICATION OF GUIDELINES

2. EDUCATION

3. TREATMENT PARAMATER DURATION

4. ACTIVE INTERVENTIONS

5. ACTIVE THERAPEUTIC EXERCISE PROGRAM

6. POSITIVE PATIENT RESPONSE

7. RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS

8. SURGICAL INTERVENTIONS

9. SIX-MONTH TIME FRAME

10. RETURN-TO-WORK 11. DELAYED RECOVERY

12. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE

13. CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI)

C. DEFINITION

D. INITIAL DIAGNOSTIC PROCEDURES

1. INTRODUCTION

2. HISTORY

a. Description of symptoms - should address at least the following:

b. Identification of Occupational Risk Factors

c. Demographics

d. Past Medical History and Review of Systems

e. Activities of Daily Living (ADLs)

f. Avocational Activities

g. Social History

3. PHYSICAL EXAMINATION

4. RISK FACTORS

5. LABORATORY TESTS

E. FOLLOW-UP DIAGNOSTIC TESTING PROCEDURES

1. ELECTRODIAGNOSTIC (EDX) STUDIES

2. IMAGING STUDIES:

a. Radiographic Imaging

b. MRI

c. Sonography

3. ADJUNCTIVE TESTING

a. Electromyography

b. Electroneurometer

c. Portable Automated Electrodiagnostic Device

d. Quantitative Sensory Testing (QST) e. Pinch And Grip Strength Measurements

f. Laboratory Tests

4. SPECIAL TESTS

a. Personality/Psychological/Psychosocial Evaluations

b. Jobsite Evaluation

c. Functional Capacity Evaluation

d. Vocational Assessment

e. Work Tolerance Screening

F. THERAPEUTIC PROCEDURES – NON-OPERATIVE

1. ACUPUNCTURE

a. Definition

b. Acupuncture with Electrical Stimulation

c. Other Acupuncture Modalities

2. BIOFEEDBACK

3. INJECTIONS – THERAPEUTIC

4. JOB SITE ALTERATION

a. Ergonomic changes

b. Interventions

c. Seating Description

d. Job Hazard Checklist

5. MEDICATIONS

a. Vitamin B6

b. Oral Steroids

6. OCCUPATIONAL REHABILITATION PROGRAMS

a. Non-Interdisciplinary

b. Interdisciplinary

7. ORTHOTICS/IMMOBILIZATION WITH SPLINTING

8. PATIENT EDUCATION 9. PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION

10. RESTRICTION OF ACTIVITIES

11. RETURN TO WORK

a. Establishment of Return-To-Work

b. Establishment of Activity Level Restrictions

c. Compliance with Activity Level Restrictions

12. THERAPY - ACTIVE

a. Nerve Gliding

b. Instruction in Therapeutic Exercise

c. Proper Work Techniques

13. THERAPY - PASSIVE

a. Manual Therapy Techniques

b. Ultrasound

c. Microcurrent TENS

d. Other Passive Therapy

14. VOCATIONAL REHABILITATION

G. THERAPEUTIC PROCEDURES – OPERATIVE

1. SURGICAL DECOMPRESSION

2. NEUROLYSIS

3. TENOSYNOVECTOMY

4. CONSIDERATIONS FOR REPEAT SURGERY

5. POST-OPERATIVE TREATMENT

a. Immobilization

b. Home Program

c. Supervised Therapy Program

A. INTRODUCTION

To properly utilize this document, the reader should not skip nor overlook any sections.

B. GENERAL GUIDELINE PRINCIPLES

1. Application of Guidelines

2. Education

Education of the patient and family, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of CTS and disability. Currently, practitioners often think of education last, after medications, manual therapy and surgery. Practitioners must develop and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers and the community as a whole. An education-based paradigm should always start with inexpensive communication providing reassuring information to the patient. More in-depth education currently exists within a treatment regime employing functional restorative and innovative programs of prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of facilitating self-management of symptoms and prevention.

3. Treatment Paramater Duration

4. Active Interventions

5. Active Therapeutic Exercise Program

Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and education. This includes functional application in vocational or community settings.

6. Positive Patient Response Positive results are defined primarily as functional gains that can be objectively measured. Objective functional gains include, but are not limited to, positional tolerances, range-of-motion, strength, endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures that can be quantified. Subjective reports of pain and function should be considered and given relative weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on objective findings.

7. Re-Evaluate Treatment Every 3 to 4 Weeks

If a given treatment or modality is not producing positive results within 3 to 4 weeks, the treatment should be either modified or discontinued. Reconsideration of diagnosis should also occur in the event of poor response to a seemingly rational intervention.

8. Surgical Interventions

9. Six-Month Time Frame

10. Return-to-Work

11. Delayed Recovery

12. Guideline Recommendations and Inclusion of Medical Evidence Guidelines are recommendations based on available evidence and/or consensus recommendations. When possible, guideline recommendations will note the level of evidence supporting the treatment recommendation. When interpreting medical evidence statements in the guideline, the following apply:

“Some” means the recommendation considered at least one adequate scientific study, which reported that a treatment was effective.

13. Care Beyond Maximum Medical Improvement (MMI)

The remainder of this document should be interpreted within the parameters of these guideline principles that may lead to more optimal medical and functional outcomes for injured workers.

C. DEFINITION

Carpal tunnel syndrome (CTS) is one of the most common mononeuropathies (a disorder involving only a single nerve). The median nerve is extremely vulnerable to compression and injury in the region of the wrist and palm. In this area, the nerve is bounded by the wrist bones and the transverse carpal ligament. The most common site of compression is at the proximal edge of the flexor retinaculum (an area near the crease of the wrist). There is often a myofascial component in the patient's presentation. This should be considered when proceeding with the diagnostic workup and therapeutic intervention.

Studies have repeatedly confirmed that the diagnosis cannot be made based on any single historical factor or physical examination finding. Electrodiagnostic tests may be negative in surgically confirmed cases. Conversely, electrodiagnostic testing may be positive in asymptomatic individuals. The diagnosis of CTS, therefore, remains a clinical diagnosis based on a preponderance of supportive findings.

Classic findings of CTS include subjective numbness or dysesthesias confined to the median nerve distribution, worsening of symptoms at night, and positive exam findings. When the diagnosis is in question, steroid injection into the carpal tunnel is a strongly supportive test if it is followed by significant relief of symptoms.

Please refer to other appropriate upper extremity guidelines contained in this document (Exhibit B – Upper Extremity Medical Treatment Guidelines).

D. INITIAL DIAGNOSTIC PROCEDURES

1. Introduction

The two standard procedures that are to be utilized when initially evaluating a work-related carpal tunnel complaint are History Taking, and Physical Examination.

History-taking and Physical Examination are generally accepted, well-established, and widely used procedures which establish the foundation/basis for and dictate all ensuing stages of diagnostic and therapeutic procedures. When findings of clinical evaluation and those of other diagnostic procedures do not complement each other, the objective clinical findings should have preference.

2. History a. Description of symptoms - should address at least the following:

1) Numbness, tingling, and/or burning of the hand involving the distal median nerve distribution; however, distribution of the sensory symptoms may vary considerably between individuals. Although the classic median nerve distribution is to the palmar aspect of the thumb, the index finger, the middle finger and radial half of the ring finger, patients may report symptoms in any or all of the fingers. The Katz Hand diagram (see Fig. 1, page 7) may be useful in documenting the distribution of symptoms; the classic pattern of carpal tunnel affects at least two of the first three digits and does not involve dorsal and palmar aspects of the hand. A probable pattern involves the palmar but not dorsal aspect of the hand (excluding digits).

2) Nocturnal symptoms frequently disrupt sleep and consist of paresthesias and/or pain in the hand and/or arm.

3) Pain in the wrist occurs frequently and may even occur in the forearm, elbow or shoulder. While proximal pain is not uncommon, its presence warrants evaluation for other pathology in the cervical spine, shoulder and upper extremity.

4) The “flick sign,” or shaking the symptomatic hand to relieve symptoms may be reported.

5) Clumsiness of the hand or dropping objects is often reported, but may not be present early in the course. Used with permission. JAMA 2000; 283 (23): 3110-17. Copyrighted 2000, American Medical Association. b. Identification of Occupational Risk Factors

Job title alone is not sufficient information. The clinician is responsible for documenting specific information regarding repetition, force and other risk factors, as listed in the CTS Associations/Exposures Table. A job site evaluation may be required. c. Demographics

Age, hand dominance, gender, etc. d. Past Medical History and Review of Systems

A study of CTS patients showed a 33% prevalence of related disease. Risk factors for CTS include female gender; obesity; Native American, Hispanic, or Black heritage, and certain medical conditions:

1) Pregnancy,

2) Arthropathies including connective tissue disorders, rheumatoid arthritis, systemic lupus erythematosus, gout, osteoarthritis and spondyloarthropathy,

3) Colles' fracture or other acute trauma,

4) Amyloidosis,

5) Hypothyroidism, especially in older females,

6) Diabetes mellitus, including family history or gestational diabetes,

7) Acromegaly,

8) Use of corticosteroids or estrogens,

9) Vitamin B6 deficiency e. Activities of Daily Living (ADLs)

ADLs include such activities as self care and personal hygiene, communication, ambulation, attaining all normal living postures, travel, non-specialized hand activities, sexual function, sleep, and social and recreational activities. Specific movements in this category include pinching or grasping keys/pens/other small objects, grasping telephone receivers or cups or other similar-sized objects, and opening jars. The quality of these activities is judged by their independence, appropriateness, and effectiveness. Assess not simply the number of restricted activities but the overall degree of restriction or combination of restrictions. f. Avocational Activities

Information must be obtained regarding sports, recreational, and other avocational activities that might contribute to or be impacted by CTD development. Activities such as hand-operated video games, crocheting/needlepoint, home computer operation, golf, racquet sports, bowling, and gardening are included in this category. g. Social History

Exercise habits, alcohol consumption, and psychosocial factors.

3. Physical Examination

Please refer to Table 1 for respective sensitivities and specificities for findings used to diagnose CTS (a-f). a. Sensory loss to pinprick, light touch, two-point discrimination or Semmes-Weinstein Monofilament tests in a median nerve distribution may occur b. Thenar atrophy may appear, but usually late in the course c. Weakness of the abductor pollicis brevis may be present d. Phalen's sign may be positive e. Tinel's sign over the carpal tunnel may be positive f. Closed Fist test – holding fist closed for 60 seconds reproduces median nerve paresthesia g. Evaluation of the contralateral wrist is recommended due to the frequency of bilateral involvement h. Evaluation of the proximal upper extremity and cervical spine for other disorders including cervical radiculopathy, thoracic outlet syndrome, other peripheral neuropathies, and other musculoskeletal disorders i. Signs of underlying medical disorders associated with CTS, e.g., diabetes mellitus, arthropathy, and hypothyroidism j. Myofascial findings requiring treatment may present in soft tissue areas near other CTD pathology, and should be documented. Refer to Rule XVII, Exhibit B, Cumulative Trauma Disorder

Table 1: Sensitivities and Specificities and Evidence Level for Physical Examination findings Procedure Sensitivity (%) Specificity (%) 1. Sensory testing Hypesthesia 15-51 85-93 Katz Hand Diagram 62-89 73-88 Two-point discrimination 22-33 81-100 Semmes-Weinstein 52-91 59-80 Vibration 20-61 71-81 2. Phalen's 51-88 32-86 3. Tinel's 25-73 55-94 4. Carpal tunnel 28-87 33-95 compression 5. Thenar atrophy 3-28 82-100 Abductor pollicis brevis 63-66 62-66 weakness 6. Closed fist test 61 92 7. Tourniquet test 16-65 36-87

4. Risk Factors

A critical review of epidemiologic literature identified a number of physical exposures associated with CTS. For example, trauma and fractures of the hand and wrist may result in CTS. Other physical exposures considered risk factors include: repetition, force, vibration, pinching and gripping, and cold environment. When workers are exposed to several risk factors simultaneously, there is an increased likelihood of CTS. Not all risk factors have been extensively studied. Exposure to cold environment, for example, was not examined independently; however, there is good evidence that combined with other risk factors, cold environment increases the likelihood of a CTS. The table at the end of this section entitled, “Risk Factors Associated CTS,” summarizes the results of currently available literature.

No single epidemiologic study will fulfill all criteria for causality. The clinician must recognize that currently available epidemiologic data is based on population results, and that individual variability lies outside the scope of these studies. Many published studies are limited in design and methodology, and, thus, preclude conclusive results. Most studies' limitations tend to attenuate, rather than inflate, associations between workplace exposures and CTS.

These guidelines are based on current epidemiologic knowledge. As with any scientific work, the guidelines are expected to change with advancing knowledge. The clinician should remain flexible and incorporate new information revealed in future studies.

Table 2: Risk Factors Associated with Carpal Tunnel Syndrome Diagnosis Strong evidence Good evidence Some evidence

Carpal Tunnel Syndrome Combination of high Repetition or force Wrist ulnar deviation and exertional force (Varied independen tly, use of extension. from > 6 kg) and high vibration hand tools. repetition (work cycles<30 sec or >50% of cycle time performing same task, length of shortest task <10 sec).

5. Laboratory Tests

Laboratory tests are generally accepted, well established and widely used procedures. Patients should be carefully screened at the initial exam for signs or symptoms of diabetes, hypothyroidism, arthritis, and related inflammatory diseases. The presence of concurrent disease does not negate work-relatedness of any specific case. When a patient's history and physical examination suggest infection, metabolic or endocrinologic disorders, tumorous conditions, systemic musculoskeletal disorders (e.g., rheumatoid arthritis), or potential problems related to prescription of medication (e.g., renal disease and nonsteroidal anti-inflammatory medications), then laboratory tests, including, but not limited to, the following can provide useful diagnostic information: a. Serum rheumatoid factor and ANA for rheumatoid work-up; b. TSH for hypothyroidism; c. Fasting glucose - recommended for obese men and women over 40 years of age, patients with a history of family diabetes, those from high-risk ethnic groups, and with a previous history of impaired glucose tolerance. A fasting blood glucose >125mg/dl is diagnostic for diabetes. Urine dipstick positive for glucose is a specific but not sensitive screening test. Quantitative urine glucose is sensitive and specific in high-risk populations; d. Serum protein electrophoresis; e. Sedimentation rate, nonspecific, but elevated in infection, neoplastic conditions and rheumatoid arthritis; f. Serum calcium, phosphorus, uric acid, alkaline and acid phosphatase for metabolic, endocrine and neoplastic conditions; g. CBC, liver and kidney function profiles for metabolic or endocrine disorders or for adverse effects of various medications; h. Bacteriological (microorganism) work-up for wound, blood and tissue i. Serum B6 – routine screening is not recommended due to the fact that vitamin B6 supplementation has not been proven to affect the course of carpal tunnel syndrome. However, it may be appropriate for patients on medications that interfere with the effects of vitamin B6, or for those with significant nutritional problems.

E. FOLLOW-UP DIAGNOSTIC TESTING PROCEDURES

1. Electrodiagnostic (EDX) Studies

Electrodiagnostic (EDX) studies are well established and widely accepted for evaluation of patients suspected of having CTS. The results are highly sensitive and specific for the diagnosis. Studies may confirm the diagnosis or direct the examiner to alternative disorders. Studies require clinical correlation due to the occurrence of false positive and false negative results. Symptoms of CTS may occur with normal EDX studies, especially early in the clinical course.

EDX findings in CTS reflect slowing of median motor and sensory conduction across the carpal tunnel region due to demyelination. Axonal loss, when present, is demonstrated by needle electromyography in median nerve-supplied thenar muscles. Findings include fibrillations, fasciculations, neurogenic recruitment and polyphasic units (reinnervation). a. Needle electromyography of a sample of muscles innervated by the C5 to T1 spinal roots, including a thenar muscle innervated by the median nerve of the symptomatic limb, is frequently required. b. The following EDX studies are not recommended to confirm a clinical diagnosis of CTS:

1) Low sensitivity and specificity compared to other EDX studies: multiple median F wave parameters, median motor nerve residual latency, and sympathetic skin response

2) Investigational studies: evaluation of the effect on median NCS of limb ischemia, dynamic hand exercises, and brief or sustained wrist positioning c. To assure accurate testing, temperature should be maintained at 30-34C preferably recorded from the hand/digits. For temperature below 30C the hand should be warmed. d. All studies must include normative values for their laboratories. e. Positive Findings – Any of these nerve conduction study findings must be accompanied by median nerve symptoms to establish the diagnosis.

1) Slowing of median distal sensory and/or motor conduction through the carpal tunnel region

2) Electromyographic changes in the median thenar muscles in the absence of proximal abnormalities 3) Suggested guidelines for the upper limits of normal latencies:

e. Because laboratories establish their own norms, a degree of variability from the suggested guideline values is acceptable. f. In all cases, normative values are to be provided with the neurodiagnostic evaluation. g. Suggested grading scheme by electrodiagnostic criteria for writing a consultation or report may be:

1) Mild CTS-prolonged (relative or absolute) median sensory or mixed action potential distal latency (orthodromic, antidromic, or palmar).

2) Moderate CTS-abnormal median sensory latencies as above, and prolongation (relative or absolute) of median motor distal latency.

3) Severe CTS-prolonged median motor and sensory distal latencies, with either absent or sensory or palmar potential, or low amplitude or absent thenar motor action potential. Needle examination reveals evidence of acute and chronic denervation with axonal loss. h. Frequency of Studies/Maximum Number of Studies:

1) Indications for Initial Testing:

(a) Patients who do not improve symptomatically or functionally with conservative measures for carpal tunnel syndrome over a 3-4 week period

(b) Patients in whom the diagnosis is in question

(d) To rule out other nerve entrapments or a radiculopathy

2) Repeated studies may be performed:

(a) To determine disease progression. 8-12 weeks is most useful when the initial studies were normal and CTS is still suspected

(b) For inadequate improvement with non-surgical treatment for 8-12 weeks

(c) For persistent or recurrent symptoms following carpal tunnel release, post-op 3-6 months, unless an earlier evaluation is required by the surgeon

2. Imaging Studies: a. Radiographic Imaging

Not generally required for most CTS diagnoses. However, it may be necessary to rule out other pathology in the cervical spine, shoulder, elbow, wrist or hand. Wrist and elbow radiographs would detect degenerative joint disease, particularly scapholunate dissociation and thumb carpometacarpal abnormalities which occasionally occur with CTS. b. MRI

Considered experimental and not recommended for diagnosis of Carpal Tunnel Syndrome. Trained neuroradiologists have not identified a single MRI parameter that is highly sensitive and specific. MRI is less accurate than standard electrodiagnostic testing, and its use as a diagnostic tool is not recommended. c. Sonography

This tool has not been sufficiently studied to define its diagnostic performance relative to electrodiagnostic studies. It is not a widely applied test. Sonography may detect synovial thickening in CTS caused by rheumatoid arthritis. It may be useful if space-occupying lesions, such as, lipomas, hemangiomas, fibromas, and ganglion cysts, are suspected. Its routine use in CTS is not recommended.

3. Adjunctive Testing

Clinical indications for the use of tests and measurements are predicated on the history and systems review findings, signs observed on physical examination, and information derived from other sources and records. They are not designed to be the definitive indicator of dysfunction. a. Electromyography

Electromyography is a generally accepted, well-established procedure. It is indicated when acute and/or chronic neurogenic changes in the thenar eminence are associated with the conduction abnormalities discussed above. b. Electroneurometer

Not recommended as a diagnostic tool because it requires patient participation, cannot distinguish between proximal and distal lesions, and does not have well-validated reference values. c. Portable Automated Electrodiagnostic Device

Measures distal median nerve motor latency and F-wave latency at the wrist and has been tested in one research setting. It performed well in this setting following extensive calibration of the device. Motor nerve latency compared favorably with conventional electrodiagnostic testing, but F-wave latency added little to diagnostic accuracy. It remains an investigational instrument whose performance in a primary care setting is as yet not established, and is not recommended as a substitute for conventional electrodiagnostic testing in clinical decision-making. d. Quantitative Sensory Testing (QST)

May be used as a screening tool in clinical settings pre- and post-operatively. Results of tests and measurements of sensory integrity are integrated with the history and systems review findings and the results of other tests and measures. QST has been divided into two types of testing:

1) Threshold tests measure topognosis, the ability to exactly localize a cutaneous sensation, and pallesthesia, the ability to sense mechanical using vibration discrimination testing (quickly adapting fibers); Semmes-Wienstein monofilament testing (slowly adapting fibers);

2) Density Tests also measure topognosis and pallesthesia using static two-point discrimination (slowly adapting fibers); moving two-point discrimination (quickly adapting fibers) e. Pinch And Grip Strength Measurements

Not generally accepted as a diagnostic tool for CTS. Strength is defined as the muscle force exerted by a muscle or group of muscles to overcome a resistance under a specific set of circumstances. Pain, the perception of pain secondary to abnormal sensory feedback, and/or the presence of abnormal sensory feedback affecting the sensation of the power used in grip/pinch may cause a decrease in the force exerted and thereby not be a true indicator of strength. When all five handle settings of the dynamometer are used, a bell-shaped curve, reflecting maximum strength at the most comfortable handle setting, should be present. These measures provide a method for quantifying strength that can be used to follow a patient's progress and to assess response to therapy. In the absence of a bell-shaped curve, clinical reassessment is indicated. f. Laboratory Tests

In one study of carpal tunnel patients seen by specialists, 9% of patients were diagnosed with diabetes, 7% with hypothyroidism, and 15% with chronic inflammatory disease including spondyloarthropathy, arthritis, and systemic lupus erythematosis. Up to two thirds of the patients were not aware of their concurrent disease. Estimates of the prevalence of hypothyroidism in the general population vary widely, but data collected from the Colorado Thyroid Disease Prevalence Study revealed subclinical hypothyroidism in 8.5% of participants not taking thyroid medication. The prevalence of chronic joint symptoms in the Behavioral Risk Factor Surveillance System (BRFSS) from the Centers for Disease Control was 12.3%. If after 2-3 weeks, the patient is not improving, the physician should strongly consider the following laboratory studies: thyroid function studies, rheumatoid screens, chemical panels, and others, if clinically indicated.

Laboratory testing may be required periodically to monitor patients on chronic medications.

4. Special Tests

Personality/psychological/psychosocial evaluations are generally accepted and well-established diagnostic procedures with selective use in the CTS population, but have more widespread use in subacute and chronic pain populations.

Formal psychological or psychosocial evaluation should be performed on patients not making expected progress within 6-12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests. In addition to the customary initial exam, the evaluation of the injured worker should specifically address the following areas: 1) Employment history;

2) Interpersonal relationships — both social and work;

3) Leisure activities;

4) Current perception of the medical system;

5) Results of current treatment;

6) Perceived locus of control; and

7) Childhood history, including abuse and family history of disability

Results should provide clinicians with a better understanding of the patient, thus allowing for more effective rehabilitation. The evaluation will determine the need for further psychosocial interventions, and in those cases, a DSM IV diagnosis should be determined and documented. An individual with a PhD, PsyD, or Psychiatric MD/DO credentials may perform initial evaluations, which are generally completed within one to two hours. When issues of chronic pain are identified, the evaluation should be more extensive and follow testing procedures as outlined in Division Rule XVII, Exhibit F, Chronic Pain Disorder Medical Treatment Guideline.

Frequency: One time visit for evaluation. If psychometric testing is indicated as a portion of the initial evaluation, time for such testing should not exceed an additional two hours of professional time. b. Jobsite Evaluation

Frequency: One time with additional visits as needed for follow-up per job site. c. Functional Capacity Evaluation

Frequency: Can be used initially to determine baseline status. Additional evaluations can be performed to monitor and assess progress and aid in determining the endpoint for treatment. d. Vocational Assessment

Frequency: One time with additional visits as needed for follow-up. e. Work Tolerance Screening

Frequency: One time for evaluation. May monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations.

F. THERAPEUTIC PROCEDURES – NON-OPERATIVE

Before initiation of any therapeutic procedure, the authorized treating provider, employer and insurer must consider these important issues in the care of the injured worker.

Non-operative treatment procedures for CTS can be divided into two groups: conservative care and rehabilitation. Conservative care is treatment applied to a problem in which spontaneous improvement is expected in 90% of the cases within three months. It is usually provided during the tissue-healing phase and lasts no more than six months, and often considerably less. Rehabilitation is treatment applied to a more chronic and complex problem in a patient with deconditioning and disability. It is provided during the period after tissue healing to obtain maximal medical recovery. Treatment modalities may be utilized sequentially or concomitantly depending on chronicity and complexity of the problem, and treatment plans should always be based on a diagnosis utilizing appropriate diagnostic procedures. The following procedures are listed in alphabetical order.

1. Acupuncture

Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain.

1) Time to produce effect: 3 to 6 treatments

2) Frequency: 1 to 3 times per week

3) Optimum duration: 1 to 2 months

4) Maximum duration: 14 treatments b. Acupuncture with Electrical Stimulation

Acupuncture with electrical stimulation is the use of electrical current (micro-amperage or milli-amperage) on the needles at the acupuncture site. It is used to increase effectiveness of the needles by continuous stimulation of the acupoint. Physiological effects (depending on location and settings) can include endorphin release for pain relief, reduction of inflammation, increased blood circulation, analgesia through interruption of pain stimulus, and muscle relaxation.

It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.

1) Time to produce effect: 3 to 6 treatments

2) Frequency: 1 to 3 times per week

3) Optimum duration: 1 to 2 months

4) Maximum duration: 14 treatments c. Other Acupuncture Modalities

Acupuncture treatment is based on individual patient needs and therefore treatment may include a combination of procedures to enhance treatment effect. Other procedures may include the use of heat, soft tissue manipulation/massage, and exercise. Refer to Active Therapy and Passive Therapy sections for a description of these adjunctive acupuncture modalities.

1) Time to produce effect: 3 to 6 treatments

2) Frequency: 1 to 3 times per week

3) Optimum duration: 1 to 2 months

4) Maximum duration: 14 treatments

2. Biofeedback

1) Time to produce effect: 3 to 4 sessions

2) Frequency: 1 to 2 times per week

3) Optimum duration: 5 to 6 sessions

4) Maximum duration: 10 to 12 sessions. Treatment beyond 12 sessions must be documented with respect to need, expectation, and ability to facilitate positive symptomatic or functional gains.

3. Injections — Therapeutic

Steroids Injections — Beneficial effects of injections are well established, but generally considered to be temporary. Recurrence of symptoms is frequent. It is not clear whether or not injections slow progression of electrodiagnostic changes. Therefore, although symptoms may be temporarily improved, nerve damage may be progressing. When motor changes are present, surgery is preferred over injections. 1) Time to produce effect: 2-5 days

2) Frequency: every 6-8 weeks

3) Optimum number: 2 injections

4) Maximum number: 3 injections in 6 months

If, following the first injection, symptomatic relief is followed by recurrent symptoms, the decision to perform a second injection must be weighed against alternative treatments such as surgery. Surgery may give more definitive relief of symptoms.

4. Job Site Alteration

Early evaluation and training of body mechanics and other ergonomic factors are essential for every injured worker and should be done by a qualified individual. In some cases, this requires a work site evaluation. Some evidence supports alteration of the work site in the early treatment of Carpal Tunnel Syndrome (CTS). There is no single factor or combination of factors that is proven to prevent or ameliorate CTS, but a combination of ergonomic and psychosocial factors is generally considered to be important. Physical factors that may be considered include use of force, repetition, awkward positions, upper extremity vibration, cold environment, and contact pressure on the carpal tunnel. Psychosocial factors to be considered include pacing, degree of control over job duties, perception of job stress, and supervisory support.

The job analysis and modification should include input from the employee, employer, and ergonomist or other professional familiar with work place evaluation. The employee must be observed performing all job functions in order for the job site analysis to be valid. Periodic follow-up is recommended to evaluate effectiveness of the intervention and need for additional ergonomic changes. a. Ergonomic changes

Ergonomic changes should be made to modify the hazards identified. In addition workers should be counseled to vary tasks throughout the day whenever possible. OSHA suggests that workers who perform repetitive tasks, including keyboarding, take 15-30 second breaks every 10 to 20 minutes, or 5-minute breaks every hour. Mini breaks should include stretching exercises. b. Interventions

Interventions should consider engineering controls, e.g., mechanizing the task, changing the tool used, or adjusting the work site, or administrative controls, e.g., adjusting the time an individual performs the task. c. Seating Description

The following description may aid in evaluating seated work positions: The head should incline only slightly forward, and if a monitor is used, there should be 18-24 inches of viewing distance with no glare. Arms should rest naturally, with forearms parallel to the floor, elbows at the sides, and wrists straight or minimally extended. The back must be properly supported by a chair, which allows change in position and backrest adjustment. There must be good knee and legroom, with the feet resting comfortably on the floor or footrest. Tools should be within easy reach, and twisting or bending should be avoided. d. Job Hazard Checklist

The following Table 3 is adopted from Washington State's job hazard checklist, and may be used as a generally accepted guide for identifying job duties which may pose ergonomic hazards. The fact that an ergonomic hazard exists at a specific job, or is suggested in the table, does not establish a causal relationship between the job and the individual with a musculoskeletal injury. However, when an individual has a work-related injury and ergonomic hazards exist that affect the injury, appropriate job modifications should be made. Proper correction of hazards may prevent future injuries to others, as well as aid in the recovery of the injured worker.

Table 3: Identifying Job Duties Which May Pose Ergonomic Hazards Type of Job Duty Hours per Day Pinching an unsupported object(s) weighing 2 lbs or more per hand or pinching with a force of 4 lbs or more per hand (comparable to pinching a half a ream of paper): 1. Highly repetitive More than 3 hours motion total/day 2. Palmar flexion >30 degrees, dorsiflexion >45 degrees, or radial deviation >30 degrees ______3. No other risk factors More than 4 hours total/day Gripping an unsupported object(s) weighing 10 lbs or more/hand, or gripping with a force of 10 lbs or more/hand (comparable to clamping light duty automotive jumper cables onto a battery): *Handles should be rounded and soft, with at least 1-2.5” in diameter grips at least 5” long. 1. Highly repetitive motion 2. Palmar flexion >30 More than 3 hours degrees, dorsiflexion >45 total/day degrees, or radial deviation > 30 degrees ______3. No other risk factors More than 4 hours total/day Repetitive Motion (using the same motion with little or no variation every few seconds, excluding keying activities: 1. High, forceful More than 2 hours exertions with the hands, total/day with palmar flexion >30 degrees, dorsiflexion >45 degrees, or radial deviation > 30 degrees ______2. No other risk factors More than 6 hours total/day Intensive Keying: 1. Palmar flexion >30 More than 4 hours degrees, dorsiflexion >45 total/day degrees, or radial deviation > 30 degrees ______2. No other risk factors More than 7 hours total/day Repeated Impact: 1. Using the hand More than 2 hours (heel/base of palm) as a total/day hammer more than once/minute Vibration: Two determinants of the More than 30 minutes at tolerability of segmental a time vibration of the hand are the frequency and the acceleration of the motion of the vibrating tool, with lower frequencies being more poorly tolerated at a given level of imposed acceleration, expressed below in multiples of the acceleration due to gravity (10m/sec/sec). 1. Frequency range 8-15 Hz and acceleration 6 g 2. Frequency range 80 Hz and acceleration 40 g 3. Frequency range 250 Hz and acceleration 250 g ______4. Frequency range 8-15 More than 4 hours at a Hz and acceleration 1.5 g time 5. Frequency range 80 Hz and acceleration 6 g 6. Frequency range 250 Hz and acceleration 20 g

5. Medications

Medications including nonsteroidal anti-inflammatory medications, oral steroids, diuretics and pyridoxine (Vitamin B6) have not been shown to have significant long-term beneficial effect in treating Carpal Tunnel Syndrome. Although NSAIDS are not curative, they and other analgesics may provide symptomatic relief. All narcotics and habituating medications should be prescribed with strict time, quantity, and duration guidelines with a definite cessation parameter. Prescribing these drugs on an as needed basis (PRN) should almost always be avoided. a. Vitamin B6

Randomized trials have demonstrated conflicting results. Higher doses may result in development of a toxic peripheral neuropathy. In the absence of definitive literature showing a beneficial effect, use of Vitamin B6 cannot be recommended. b. Oral Steroids

Oral steroids have been shown to have short-term symptomatic benefit but no longterm functional benefit and are not recommended due to possible side effects.

6. Occupational Rehabilitation Programs a. Non-Interdisciplinary

1) Work Conditioning — These programs are usually initiated once reconditioning has been completed but may be offered at any time throughout the recovery phase. It should be initiated when imminent return of a patient to modified or full duty is not an option, but the prognosis for returning the patient to work at completion of the program is at least fair to good.

(a) Length of visit: 1 to 2 hours per day

(b) Frequency: 2 to 5 visits per week

(d) Maximum duration: 6 weeks. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.

2) Work Simulation — Work simulation is a program where an individual completes specific work-related tasks for a particular job and return to work. Use of this program is appropriate when modified duty can only be partially accommodated in the work place, when modified duty in the work place is unavailable, or when the patient requires more structured supervision. The need for work place simulation should be based upon the results of a Functional Capacity Evaluation and or Jobsite Analysis.

(a) Length of visit: 2 to 6 hours per day

(b) Frequency: 2 to 5 visits per week

(d) Maximum duration: 6 weeks. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains. b. Interdisciplinary

1) Work Hardening — Work Hardening is an interdisciplinary program addressing a patient's employability and return to work. It includes a progressive increase in the number of hours per day that a patient completes work simulation tasks until the patient can tolerate a full workday. This is accomplished by addressing the medical, psychological, behavioral, physical, functional, and vocational components of employability and return-to-work.

(a) Length of visit: Up to 8 hours/day (b) Frequency: 2 to 5 visits per week

(d) Maximum duration: 6 weeks. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.

7. Orthotics/Immobilization With Splinting

Immobilization with splinting is a generally accepted, well-established and widely used therapeutic procedure. There is some evidence that splinting leads to more improvement in symptoms and hand function than watchful waiting alone. Because of limited patient compliance with day and night splinting in published studies, evidence of effectiveness is limited to nocturnal splinting alone. Splints should be loose and soft enough to maintain comfort while supporting the wrist in a relatively neutral position. This can be accomplished using a soft or rigid splint with a metal or plastic support. Splint comfort is critical and may affect compliance. Although off-the-shelf splints are usually sufficient, custom thermoplastic splints may provide better fit for certain patients.

Splints may be effective when worn at night or during portions of the day, depending on activities. Most studies show that full time night splinting for a total of 4 to 6 weeks is the most effective protocol. Depending on job activities, intermittent daytime splinting can also be helpful. Splint use is rarely mandatory. Providers should be aware that over-usage is counterproductive, and should counsel patients to minimize daytime splint use in order avoid detrimental effects such as stiffness and dependency over time.

Splinting is generally effective for milder cases of CTS. Long-term benefit has not been established. An effect should be seen in 2-4 weeks.

1) Time to produce effect: 1-4 weeks. If, after 4 weeks, the patient has partial improvement, continue to follow since neuropathy may worsen, even in the face of diminished symptoms.

2) Frequency: Nightly. Daytime intermittent, depending on symptoms and activities

3) Optimum duration: 4 to 8 weeks

4) Maximum duration: 2 to 4 months. If symptoms persist, consideration should be given to either repeating electrodiagnostic studies or to more aggressive treatment.

8. Patient Education

1) Time to produce effect: Varies with individual patient

2) Frequency: Should occur at every visit

9. Personality/Psychological/Psychosocial Intervention

Personality/Psychological/Psychosocial Intervention is generally accepted, widely used and well established. This group of therapeutic and diagnostic modalities includes, but is not limited to, individual counseling, group therapy, stress management, psychosocial crises intervention, hypnosis and meditation. Any screening or diagnostic workup should clarify and distinguish between preexisting versus aggravated versus purely causative psychological conditions. Psychosocial intervention is recommended as an important component in the total management program that should be implemented as soon as the problem is identified. This can be used alone or in conjunction with other treatment modalities. Providers treating patients with chronic pain should refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder Medical Treatment Guideline.

1) Time to produce effect: 2 to 4 weeks

2) Frequency: 1 to 3 times weekly for the first 4 weeks (excluding hospitalization, if required), decreasing to 1 to 2 times per week for the second month. Thereafter, 2 to 4 times monthly.

3) Optimum duration: 6 weeks to 3 months

4) Maximum duration: 3 to 12 months. Counseling is not intended to delay but to enhance functional recovery. For select patients, longer supervised treatment may required, and if further counseling beyond 3 months is indicated, documentation addressing which pertinent issues are preexisting versus aggravated versus causative, as well as projecting a realistic functional prognosis, should be provided by the authorized treating provider every 4 to 6 weeks during treatment.

10. Restriction of Activities

Continuation of normal daily activities is the recommendation for acute and chronic pain without neurologic symptoms. There is good evidence against the use of bed rest in cases without neurologic symptoms. Bed rest may lead to deconditioning and impair rehabilitation. Complete work cessation should be avoided, if possible, since it often further aggravates the pain presentation. Modified return-to- work is almost always more efficacious and rarely contraindicated in the vast majority of injured workers with Carpal Tunnel Syndrome.

Medication use in the treatment of Carpal Tunnel Syndrome is appropriate for controlling acute and chronic pain and inflammation. Use of medications will vary widely due to the spectrum of injuries from simple strains to post-surgical healing. All drugs should be used according to patient needs. A thorough medication history, including use of alternative and over the counter medications, should be performed at the time of the initial visit and updated periodically.

11. Return to Work

Early return-to-work should be a prime goal in treating Carpal Tunnel Syndrome (CTS) given the poor prognosis for the injured employee who is out of work for more than six months. The employee and employer should be educated in the benefits of early return-to-work. When attempting to return an employee with CTS to the workplace, clear, objective physical restrictions that apply to both work and non-work related activities should be specified by the provider. Good communication between the provider, employee, and employer is essential.

Return-to-work is any work or duty that the employee can safely perform, which may not be the worker's regular job activities. Due to the large variety of jobs and the spectrum of severity of CTS, it is not possible for the Division to make specific return-to-work guidelines, but the following general approach is recommended: a. Establishment of Return-To-Work

Ascertainment of return-to-work status is part of the medical treatment and rehabilitation plan, and should be addressed at every visit. Limitations in activities of daily living (ADLs) should also be reviewed at every encounter, and help to provide the basis for work restrictions provided they are consistent with objective findings. The Division recognizes that employers vary in their ability to accommodate restricted duty, but encourages employers to be active participants and advocates for early return-to-work. In most cases, the patient can be returned to work in some capacity, either at a modified job or alternate position, immediately unless there are extenuating circumstances, which should be thoroughly documented and communicated to the employer. Return-to-work status should be periodically reevaluated, at intervals generally not to exceed three weeks, and should show steady progression towards full activities and full duty. b. Establishment of Activity Level Restrictions

It is the responsibility of the physician/provider to provide both the employee and employer clear, concise, and specific restrictions that apply to both work and non-work related activities. The employer is responsible to determine whether modified duty can be provided within the medically determined restrictions. The Division's WC M164 form can be used as a guide to document and communicate the activity level restrictions. Refer to the “Job Site Alteration” section for specific activity and ergonomic factors to be considered when establishing work restrictions for an employee with CTS. c. Compliance with Activity Level Restrictions

The employee's compliance with the activity level restrictions is an important part of the treatment plan and should be reviewed at each visit. In some cases, a job site analysis, a functional capacity evaluation, or other special testing may be required to facilitate return-to-work and document compliance. Refer to the “Job Site Alteration” and “Work Tolerance Screening” sections.

12. Therapy — Active

Active therapies are based on the philosophy that therapeutic exercises and/or activities are beneficial for restoring flexibility, strength, endurance, function, range of motion, and alleviating discomfort. Active therapy requires an internal effort by the individual to complete a specific exercise or task, and thus assists in developing skills promoting independence to allow self-care to continue after discharge. This form of therapy requires supervision from a therapist or medical provider such as verbal, visual and/or tactile instructions(s). At times a provider may help stabilize the patient or guide the movement pattern, but the energy required to complete the task is predominately executed by the patient.

Interventions are selected based on the complexity of the presenting dysfunction with ongoing examination, evaluation and modification of the plan of care as improvement or lack thereof occurs. Change and/or discontinuation of an intervention should occur if there is attainment of expected goals/outcome, lack of progress, lack of tolerance and/or lack of motivation. Passive interventions/ modalities may only be used as adjuncts to the active program. a. Nerve Gliding

Nerve gliding exercises consist of a series of flexion and extension movements of the hand and wrist that produce tension and longitudinal movement along the length of the median and other nerves of the upper extremity. These exercises are based on the principle that the tissues of the peripheral nervous system are designed for movement, and that tension and glide (excursion) of nerves may have an effect on neurophysiology through alterations in vascular and axoplasmic flow. Biomechanical principles have been more thoroughly studied than clinical outcomes. Randomized trials have been lacking or have suffered from design flaws that preclude sound conclusions of the effectiveness of these exercises, but these flaws have tended to underestimate rather than overestimate the usefulness of nerve gliding. The exercises are simple to perform and can be done by the patient after brief instruction. It is considered accepted therapy for CTS.

1) Time to Produce Effect: 2-4 weeks

2) Frequency: Up to 5 times per day by patient (patient-initiated)

3) Optimum Duration: 2 sessions

4) Maximum Duration: 3 sessions b. Instruction in Therapeutic Exercise

Instruction should focus on alleviating associated myofascial symptoms. Please refer to the Cumulative Trauma Disorder (CTD) guideline for information on therapeutic exercise techniques. c. Proper Work Techniques

Please refer to the “Job Site Evaluation” and “Job Site Alteration” sections of this guideline.

13. Therapy — Passive

Passive therapy includes those treatment modalities that do not require energy expenditure on the part of the patient. They are principally effective during the early phases of treatment and are directed at controlling symptoms such as pain, inflammation and swelling and to improve the rate of healing soft tissue injuries. They should be used in adjunct with active therapies. They may be used intermittently as a therapist deems appropriate or regularly if there are specific goals with objectively measured functional improvements during treatment. Diathermies have not been shown to be beneficial to patients with CTS and may interfere with nerve conduction. a. Manual Therapy Techniques

Manual Therapy Techniques are passive interventions in which the providers use his or her hands to administer skilled movements designed to modulate pain; increase joint range of motion; reduce/eliminate soft tissue swelling, inflammation or restriction; induce relaxation; and improve contractile and non- contractile tissue extensibility. These techniques are applied only after a thorough examination is performed to identify those for whom manual therapy would be contraindicated or for whom manual therapy must be applied with caution.

Soft tissue mobilization/ manipulation techniques are generally accepted and widely used adjunctive treatment modalities in the treatment of myofascial symptoms related to carpal tunnel syndrome. Mobilization and manipulation can include myofascial release therapy, muscle energy techniques, neural gliding, high velocity, low amplitude (HVLA) technique, osteopathic manipulation, and non-force techniques.

1) Time to produce effect: 2-6 treatments

2) Frequency: 1-3 times/week, decreasing over time

3) Optimum duration: 4-6 weeks

4) Maximum duration: 8-10 weeks b. Ultrasound There is some evidence that ultrasound may be effective in symptom relief and in improving nerve conduction in mild to moderate cases of CTS. No studies have demonstrated long-term functional benefit. It may be used in conjunction with an active therapy program for non-surgical patients who do not improve with splinting and activity modification. It is not known if there are any long-term deleterious neurological effects from ultrasound. c. Microcurrent TENS

There is some evidence that concurrent application of microamperage TENS applied to distinct acupuncture points and low-level laser treatment may be useful in treatment of mild to moderate CTS. This treatment may be useful for patients not responding to initial conservative treatment or who wish to avoid surgery. Patient selection criteria should include absence of denervation on EMG and motor latencies not exceeding 7 ms. The effects of microamperage TENS and low-level laser have not been differentiated; there is no evidence to suggest whether only one component is effective or the combination of both is required.

1) Time to produce effect: 1 week

2) Frequency: 3 sessions per week

3) Optimum duration: 3 weeks

4) Maximum duration: 4 weeks d. Other Passive Therapy

For associated myofascial symptoms, please refer to the Cumulative Trauma Disorder (CTD) guideline.

14. Vocational Rehabilitation

Vocational rehabilitation is a generally accepted intervention, but Colorado limits its use as a result of Senate Bill 87-79. Initiation of vocational rehabilitation requires adequate evaluation of patients for quantification of highest functional level, motivation and achievement of maximum medical improvement. Vocational rehabilitation may be as simple as returning to the original job or as complicated as being retrained for a new occupation.

G. THERAPEUTIC PROCEDURES — OPERATIVE

1. Surgical Decompression

Surgical decompression is well-established, generally accepted and widely used and includes open and endoscopic techniques. There is good evidence that surgery is more effective than splinting in producing long-term symptom relief and normalization of median nerve conduction velocity. a. Endoscopic techniques have had a higher incidence of serious complications (up to 5%) compared to open techniques (<1%). The most commonly seen serious complications are incomplete transection of the transverse carpal ligament and inadvertent nerve or vessel injuries. The incidence of complications may be lower for surgeons who have extensive experience and familiarity with certain endoscopic techniques. Choice of technique should be left to the discretion of the surgeon. b. Indications for surgery include positive history, abnormal electrodiagnostic studies and/or failure of conservative management. Job modification should be considered prior to surgery. Please refer to the “Job Site Alteration” section for additional information on job modification. c. Surgery should be considered as an initial therapy in situations where:

1) Median nerve trauma has occurred; “acute carpal tunnel syndrome”, or

2) Electrodiagnostic evidence of moderate to severe neuropathy. EMG findings showing evidence of acute or chronic motor denervation suggest the possibility that irreversible damage may be occurring. d. Surgery may be considered in cases where electrodiagnostic testing is normal. A second opinion from a hand surgeon is strongly recommended. The following criteria should be considered in deciding whether to proceed with surgery:

1) The patient experiences significant temporary relief following steroid injection into the carpal tunnel; or

2) The patient has failed 3-6 months of conservative treatment including work site change; and

3) Psychosocial factors have been addressed through psychological screening requirements as defined “Adjunctive Testing” in this Section; and

4) The patient's signs and symptoms are specific for carpal tunnel syndrome e. Suggested parameters for return-to-work are: Timeframe Activity Level 2 days Return to work with restrictions on utilizing the affected extremity 2 - 3 weeks Sedentary and non- repetitive work 4-6 weeks Case-by-case basis 6-12 weeks Heavy labor, forceful and repetitive

Note: All return-to-work decisions are based upon clinical outcome.

2. Neurolysis

Neurolysis has not been proven advantageous for carpal tunnel syndrome. Internal neurolysis should never be done. Very few indications exist for external neurolysis.

3. Tenosynovectomy

Tenosynovectomy has not proven to be of benefit in carpal tunnel syndrome.

4. Considerations for Repeat Surgery

The single most important factor in predicting symptomatic improvement following carpal tunnel release is the severity of preoperative neuropathy. Patients with moderate electrodiagnostic abnormalities have better results than those with either very severe or no abnormalities. Incomplete cutting of the transverse carpal ligament or iatrogenic injury to the median nerve are rare.

If median nerve symptoms do not improve following initial surgery or symptoms improve initially and then recur, but are unresponsive to non-operative therapy (see Section II.D., Therapeutic Procedures, Non- Operative) consider the following: a. Recurrent synovitis; b. Repetitive work activities may be causing “dynamic” CTS; c. Scarring; d. Work-up of systemic diseases

A second opinion by a hand surgeon is required if repeat surgery is contemplated. The decision to undertake repeat surgery must factor in all of the above possibilities. Results of surgery for recurrent carpal tunnel syndrome vary widely depending on the etiology of recurrent symptoms.

5. Post-Operative Treatment

Considerations for post-operative therapy are: a. Immobilization

There is some evidence showing that immediate mobilization of the wrist following surgery is associated with less scar pain and faster return to work. Final decisions regarding the need for splinting post- operatively should be left to the discretion of the treating physician based upon his/her understanding of the surgical technique used and the specific conditions of the patient. b. Home Program

It is generally accepted that all patients should receive a home therapy protocol involving stretching, ROM, scar care, and resistive exercises. Patients should be encouraged to use the hand as much as possible for daily activities, allowing pain to guide their activities. c. Supervised Therapy Program

Supervised Therapy Programs may be helpful in patients who do not show functional improvements post- operatively or in patients with heavy or repetitive job activities. The therapy program may include some of the generally accepted elements of soft tissue healing and return to function:

1) Soft tissue healing/remodeling:

May be used after the incision has healed. It may include all of the following: evaluation, whirlpool, electrical stimulation, soft tissue mobilization, scar compression pad, heat/cold application, splinting or edema control may be used as indicated. Following wound healing, ultrasound and iontophoresis with Sodium Chloride (NaCl) may be considered for soft tissue remodeling. Diathermy is a non-acceptable adjunct.

2) Return to function:

Range-of-motion and stretching exercises, strengthening, activity of daily living adaptations, joint protection instruction, posture/body mechanics education; worksite modifications may be indicated.

(a) Time to produce effect: 2-4 weeks

(b) Frequency: 2-3 times/week (c) Optimum duration: 4-6 weeks

(d) Maximum duration: 8 weeks

III. THORACIC OUTLET SYNDROME

TABLE OF CONTENTS SECTION DESCRIPTION

III THORACIC OUTLET SYNDROME A. Definition B. Initial Diagnostic Procedures 1. History Taking and Physical Examination (Hx & PE) C. Follow-up Diagnostic Imaging and Testing Procedures 1. Cervical CT or MRI 2. Electrodiagnostic Studies 3. Vascular Studies 4. Thermography 5. Scalene Muscle Blocks 6. Personality/Psychological /Psychosocial Evaluations D. Therapeutic Procedures 1. Nonoperative Treatment Procedures 2. Operative Treatment Procedures 3. Post-Operative Treatment

A. DEFINITION:

Thoracic Outlet Syndrome (TOS) is felt to be a neurovascular disorder affecting the upper extremity which, on rare occasions, is caused by workplace factors, such as jobs that require repetitive activities of the upper extremities. It should be emphasized that occupational TOS is a relatively uncommon disorder and other disorders with similar symptomatology need to be ruled out.

Because of the frequency of TOS being diagnosed in the workplace in Colorado and the clinical and financial factors that result, these guides are to be used in the evaluation and treatment of occupational TOS. The most commonly associated history before the development of TOS is acute trauma where hyperextension of the neck occurs, usually the result of a motor vehicle accident (MVA) and a resultant “whiplash” injury. Since approximately 19% of occupational spinal cord injuries are from MVA's, this may also be a common cause of TOS from a work-related injury.

The majority of occupations resulting in TOS are probably related to tasks requiring repetitive activities and awkward postures. Although little published literature exists regarding TOS as an occupational disorder, at-risk occupations include workers on assembly lines with repetitive head motions and keyboard work (e.g. typewriter, computer, adding machine). A common factor in the development of TOS in these occupations is that the workers' hands are fixed to a keyboard or machine. When attempting to talk to others in the work area or talk on the telephone, or when looking from copy to monitor to keyboard, in a suboptimal ergonomic worksite. The worker must extend his/her neck in various directions in order to keep the hands in a fixed position. When working on an assembly line, the worker must look up or down for the next item. The result probably is small neck traumata which eventually lead to scalene muscle stretching, fibrosis, and nerve compression, since the nerves of the brachial plexus are normally in contact with these muscle fibers.

B. INITIAL DIAGNOSTIC PROCEDURES:

1. History Taking and Physical Examination (Hx & PE) are generally accepted, well-established and widely used procedures which establish the foundation/basis for and dictate all other following stages of diagnostic and therapeutic procedures. When findings of clinical evaluations and those of other diagnostic procedures are not complementing each other, the objective clinical findings should have preference. a. History Taking:

1) Occupational relationship: activities requiring fixed upper extremity positions and extension of the neck should be documented.

2) History of nonoccupational injury and avocational pursuits needs to be specifically documented.

3) Symptoms Positive to TOS:

a) Neck pain: often first symptom within few days of injury.

b) Occipital headaches: also an early symptom

c) Arm pain.

d) Numbness and paresthesia in arm, hand and fingers:

1 - all 5 fingers: most common pattern

2 - 4th and 5th digits: next most common pattern

3 - 1st, 2nd and 3rd digits: may occur, but must rule out carpal tunnel syndrome

e) Upper extremity weakness: arm and/or hand; “dropping things” is a common complaint

f) Exacerbating factor: elevating arms; common complaints are trouble combing hair, driving car, etc.

g) Intermittent symptoms: if constant symptoms, consider diagnosis of brachial plexus injury, “true neurogenic” TOS b. Physical Findings:

1) Physical Examination Signs Positive in TOS:

a) Tenderness over scalene muscles in supraclavicular area

b) Pressure in supraclavicular area elicits symptoms in arm/hand c) Tinel's sign over brachial plexus is positive

d) 90°; AER test*: While the radial pulse may or may not disappear, this is not important. Duplication of the patient's symptoms of pain and paresthesia in hand and arm are characteristic. (* The 90°; AER test is a modified Adson's position test, with the test performed with the arm abducted 90°; and in external rotation. There are other test positions which purport to evaluate neurovascular compromise. The best known position is the Adson's, however, many patients with TOS do not have alteration of their radial pulse with any of these maneuvers and many normals will have reduced pulses with positional testing. Neurovascular testing is not felt to be reliable in establishing the diagnosis of TOS.)

e) Head Tilting: lateral flexion of the neck (ear to shoulder) causes radiating pain and paraesthesia in the contralateral shoulder and sometimes in the arm and hand.

f) Neurologic Examination: usually normal, but may be abnormal

(1) Sensory exam: may show decreased sensation to light touch, pin and temperature in lower brachial plexus distribution.

(2) Motor exam: weakness and/or muscle atrophy in either upper or lower trunk distributions including, but, not limited to, valid dynamometer readings indicative of relative weakness in the affected limb.

2) Clinical Prognosis: if the patient has unilateral symptoms, positive physical findings on the ipsilateral side strongly support the diagnosis of TOS. In patients with bilateral symptoms, positive scalene muscle tenderness and a positive response to 90°; in abduction and external rotation can still support the diagnosis, but, it is not as strong as in the unilateral situation.

3) Physical findings suggest other disorders to consider:

a) Neck rotation may or may not be restricted; present in many conditions.

b) Rotator cuff/acromioclavicular (AC) joint tenderness; suggests rotator cuff or biceps tendinitis or AC joint disease.

c) Trapezius muscle, shoulder girdle muscles or paraspinal muscle tenderness suggests myofascial component.

d) Tinel's sign and/or Phalen's sign at wrist suggests carpal tunnel syndrome.

e) Tinel's sign at elbow (over ulnar groove) suggests ulnar nerve entrapment.

f) Tinel's sign over pronator or radial tunnel, when positive, suggests nerve compression. c. Cervical Spine X-ray is a generally accepted, wellestablished procedure indicated to rule out cervical spine disease, fracture, cervical rib or rudimentary first rib when clinical findings suggest these diagnoses. Cervical spine x-rays should also be considered when there is asymmetric diminished pulse in an arm that is symptomatic. Routine roentgenographic evaluation of the cervical spine in the primary care setting provides little significant information.

C. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES:

1. Cervical CT or MRI are a generally accepted, wellestablished procedures indicated to rule out cervical disc or other cervical spine disorders when clinical findings suggest these diagnoses. MRI is the preferred test over a CT unless a fracture is suspected, then CT may be superior to MRI. CT/MRI is not indicated early unless there is a neurological deficit. Either CT or MRI should be done, not both. Repeat cervical CT/MRI is never indicated. If cervical spine injury is confirmed, refer to Division Rule XVII, Exhibit E., Cervical Spine Injury Medical Treatment Guidelines. If a cervical spine disorder is not suspected, conservative therapy as indicated in this Section III., Therapeutic Procedures, should be done for at least 8–12 weeks, prior to ordering an MRI for persistent symptoms.

2. Electrodiagnostic Studies: a) Electromyography/Nerve Conduction Studies (EMG/NCV) is a generally accepted, well-established procedure. EMG/NCV is primarily indicated to rule out other nerve entrapment syndromes such as carpal tunnel or cubital tunnel syndrome when indicated by clinical examination. Most cases of TOS have normal electrodiagnostic studies, but EMG/NCV should be considered when symptoms have been present for approximately 3 months or failed 8 weeks of conservative therapy. EMG/NCV may also be performed to rule out other disorders. Criteria for Neurogenic TOS:

1) Reduction of the ulnar sensory nerve action potential to digits; or

2) Reduction of the median M-wave amplitude; or

3) Prolongation of ulnar F-wave latencies; or

4) Needle EMG examination reveals neurogenic changes in intrinsic hand muscles. b) Ouantitative Sensory Testing (OST) is not generally accepted and has limited use. Research is not currently available on the use of QST in the evaluation of TOS, but the use of QST may be useful in ruling out other nerve entrapments of the upper extremity. Studies in peripheral neuropathy and carpal tunnel syndrome show these studies to be more sensitive than EMG/NCV in detecting subtle nerve injuries; however, these studies are not as localizing as EMG/NCV). QST may be considered when all other studies are negative. Types of QST are

1) Vibration Perception Thresholds

2) Thermal Perception Thresholds

3) Current Perception Thresholds

QST is not essential in the evaluation of TOS, but may be a useful, cost-effective method of screening for nerve injuries of the upper extremities or in those cases where conventional EMG/NCV is normal.

3. Vascular Studies:

Noninvasive vascular testing, such as pulse-volume recording in different positions, is not indicated in cases of neurogenic TOS. Since the presence or absence of a pulse cutoff on physical examination is not helpful in establishing a diagnosis of TOS, the recording of finer degrees of positional pulse alteration will not add much to the diagnosis. Procedures that include vascular laboratory studies, duplex scanning, Doppler studies and arteriography are not cost effective in cases of neurogenic TOS. These studies are only indicated in patients who have arterial occlusive symptoms.

4. Thermography is not generally accepted or widely used for TOS. In experienced evaluators, “stress” thermography, done while having a patient perform the 90°; AER test, may be a useful tool in evaluating some cases of TOS if surgery is being considered. It may be used if differential diagnosis includes RSD; in such cases refer to Division Rule XVII, Exhibit D., Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome Medical Treatment Guidelines.

5. Scalene Muscle Blocks are useful only for diagnosis, not for treatment. a. Time to produce effect: 2–5 minutes b. Duration or effect: 20–30 minutes c. Frequency: 1

The interscalene block, sometimes used to treat TOS, is a brachial plexus block and is not indicated to treat or diagnose neurogenic TOS. Repeated blocks are not indicated for therapy.

6. Personality/Psychological/Psychosocial Evaluations are generally accepted and well-established diagnostic procedures with selected use in the acute TOS population, but have more widespread use in the subacute and chronic TOS population. These procedures may be useful for patients with delayed recovery, chronic pain, recurrent painful conditions, suspected concomitant closed head injury, disability problems and pre-operative evaluation, as well as a possible predictive value for post-operative response. Results may provide clinicians with a better understanding of the patient, thus allowing for more effective rehabilitation. Formal psychological or psychosocial screening should be performed on patients not making expected progress within 6–12 weeks following injury and whose subjective symptoms do not correlate with clinical signs and tests as outlined in this Section III., Initial Diagnostic Procedures. This testing will determine the need for further psychosocial interventions. Evaluations should be performed by an individual with PH.D., PSY.D., L.S.W. or Psychiatric M.D./D.O. credentials. Initial psychological screening is generally completed within one hour. If psychometric testing is indicated as a portion of the initial screening process, the time for such testing should not exceed an additional two hours of professional time.

D. THERAPEUTIC PROCEDURES:

1. Nonoperative Treatment Procedures:

Worksite analysis should be done early in all cases. Most cases are treated conservatively first for a minimum of 3 months. a. Physical Medicine and Rehabilitation: It is understood that patients undergoing therapeutic procedures may return to modified or restricted duty during their rehabilitation, at the earliest appropriate time. It is also understood that cessation and/or review of treatment modalities should be undertaken when no further significant subjective or objective improvement in the patient's condition is noted.

1) Worksite Analysis should be performed by a qualified individual in all cases of suspected occupational TOS unless previously performed. Postural risk factors should be identified and awkward postures of overhead reach, hyperextension or rotation of the neck, shoulder drooped or forward-flexed and head-chin forward postures should be eliminated. Unless combined with one of the above postures, repetitiveness is not by itself a risk factor. Work activities need to be modified early in treatment to avoid exposing the patient to these ergonomic risk factors while trying to treat symptoms. 2) Neck and Thoracic Stretching Exercises are primarily a daily home program developed and supervised by an appropriately trained professional. Stretching exercises should include the following muscle groups: scalene, pectoralis minor, trapezius and levator scapulae. A patient should attend therapy for up to 4 weeks, then be seen once a week thereafter. Most patients will need to continue to be monitored and progressed in their activities for another 4–8 weeks or until they are able to return to the same level of duties or activities prior to symptom onset.

a) Time to produce effect: 2–3 weeks

b) Frequency: 3 times/week for first 2 weeks; 2 times/week for second two weeks; 1 time/week for weeks 4–6

c) Optimum duration: 6–8 weeks

d) Maximum duration: 3 months under supervision to assure compliance, then indefinitely on an independent home program as long as symptoms persist.

3) Exercise: Unless confined to the lower extremities, do not do endurance or strengthening early in the course of therapy and do not exacerbate cervical or upper extremity symptoms. Endurance and strengthening activities may be contraindicated early on. If the patient becomes asymptomatic for 2 weeks, standard endurance and strengthening exercises may begin.

a) Time to produce effect: 2–4 weeks

b) Frequency: 3–4 times/week

c) Optimum duration: 4–6 weeks

d) Maximum duration: 3 months

4) Abdominal Breathing, Postural Exercises (Reeducation) are part of an overall therapy program and should be primarily a home program supervised by qualified therapist.

a) Time to produce effect: 2–4 weeks

b) Frequency: 3–4 times/week

c) Optimum duration: 4–6 weeks

d) Maximum duration: 3 months under supervision to assure compliance, then indefinitely on an independent home program as long as symptoms persist.

5) Biofeedback is the use of physiological monitoring equipment to:

a) Improve the patient's awareness to, and control of muscle activity (to include a variety of muscle placements that are related to the symptoms and/or areas of entrapment);

b) Reinforce the release of muscle tension that is being obtained from stretches, exercises, and abdominal breathing for the purpose of decreasing sympathetic arousal that is associated with stress;

c) Improve the patient's ability to feel like they can effect their physical responses and symptoms;

d) Assist in avoiding re-injury through the individual returning to repetitive movement and bracing patterns; or

e) Prepare for surgery.

Treatment time may or may not overlap return-to-work or maximum medical improvement (MMI).

a) Time to produce effect: 3–4 sessions

b) Frequency: 1–2 times/week

c) Optimum duration: 5–6 sessions

d) Maximum duration: 10–12 sessions

6) Medications usually include narcotics, minor tranquilizers/muscle relaxants, nonsteroidal anti- inflammatory drugs (NSAIDs), non-narcotic analgesics, and hypnotic/sedatives, including antidepressants (refer to Section II., Occupational Carpal Tunnel Syndrome, for details on medication recommendations).

7) Education in correct body mechanics, sleep postures, activities-of-daily-living and work-station design is important to prevent reinjury.

8) Injections:

a) Scalene blocks have no role in the treatment of TOS; use as a diagnostic tool only as indicated in Section III., Follow-up Diagnostic Imaging and Testing Procedures.

b) Trigger point injections are generally accepted well-established procedures and of value in treating a co-existing myofascial pain syndrome, which may be contributing to some of the symptoms that the patient is experiencing. Trigger point injections are indicated in those patients where well circumscribed trigger points have been consistently observed, demonstrating a local twitch response characteristic radiation of pain pattern and local autonomic reaction, such as persistent hyperemia following palpation. Generally, these injections are not necessary unless consistently observed trigger points are not responding to specific, noninvasive, myofascial interventions within a six-week time frame. However, trigger point injections may occasionally be effective when utilized in the patient with immediate, acute onset of upper extremity complaints. Injection efficacy can be enhanced if injections are immediately followed by myofascial therapeutic interventions, such as vapocoolant spray and stretch, ischemic pressure massage (myotherapy), specific soft tissue mobilization and hot packs. Potential, but rare, complications of trigger point injections include infection, anaphylaxis, neuroapraxia and neuropathy. As with the therapeutic blocks discussed above, trigger point injections should be utilized primarily for the purpose of facilitating functional progress. Muscles requiring injection should not be aggressively exercised until post-injection soreness resolves and/or the trial of injections has been completed. However, patients should continue in an aggressive aerobic and stretching therapeutic exercise program as tolerated throughout the time period they are undergoing intensive myofascial interventions.

1) Frequency: weekly, suggest no more than 4 injection sites per session per week to avoid significant post-injection soreness

2) Optimum duration: 4 weeks

3) Maximum duration: 8 weeks; occasional patient may require 2–4 repetitions of trigger point injection series over a 1–2 year period

9) Manual Therapy Techniques, such as soft tissue and vertebral mobilization/manipulation techniques, may be used as adjunctive therapy to improve thoracic mobility and relieve pain.

a) Time to produce effect: 2–3 visits

b) Frequency: 1–3 times/week

c) Optimum duration: 6–12 weeks

d) Maximum duration: 12 weeks

10) Work Restrictions are prescribed to get the patient back to work with modified activities which will not aggravate the conditions. It is important to note that these work restrictions would also be applicable during the time that the patient is undergoing conservative treatment. Patients with occupational TOS seldom miss any work time, since most patients will respond with the restrictions below, ergonomic adaptation, and ongoing therapy including an independent home program. It is also important to reemphasize that TOS is an uncommon occupational disorder. Suggested work restrictions include:

a) No repetitive reaching

b) No reaching above shoulder level or into hyperextension

c) No lifting more than 10–15 pounds

d) No repetitive or postural cervical hyperextension

e) No shoulder drooped or head forward postures, e.g., looking into a monitor positioned too low, etc.

f) Frequent changes in activities

2. Operative Treatment Procedures: a. Diagnostic Criteria for Surgical Procedures:

1) Definite TOS:

a) Clinical: at least two consistent clinical sign plus symptoms consistent with TOS (see discussion in Section III., Initial Diagnostic Procedures).

b) Neurophysiologic meets criteria for neurogenic TOS (refer to Section III., Follow-up Diagnostic Imaging and Testing Procedures).

2) Probable TOS:

a) Clinical: at least four consistent clinical signs plus symptoms consistent with TOS, refer to discussion in Section III., Initial Diagnostic Procedures.

b) Neurophysiologic: may have normal EMG/NCV studies.

3) Possible TOS:

a) Clinical: inconsistent clinical signs plus symptoms of TOS for more than 3 months.

b) Neurophysiologic: may have normal EMG/NCV studies. b. Surgical Procedures Used:

1) First rib resection

2) Anterior and middle scalenectomy

3) Anterior scalenectomy

4) Combined first rib resection and scalenectomy Since the success rates for the various surgical procedures are similar, the Division suggests that the surgeon performing the procedure use the technique with which the surgeon has the most experience. Complications are felt to be slightly higher for first rib resection than for scalenectomy, RSD is a potential complication of any TOS surgery. No good research is available to establish numbers. c. Surgical Indications:

1) Early surgical intervention should only be performed if there is:

a) Documented EMG/NCV evidence of nerve compression with sensory loss, weakness (with or without muscle atrophy) or

b) Acute subclavian vein thrombosis or arterial thrombosis.

2) After failed conservative therapy, the following criteria must be fulfilled:

a) For definite or probable TOS see the preceding subsection, and

b) Failed 3 months of conservative therapy, and

c) Disabling symptoms interfering with work, recreation, normal daily activities, sleep, and

d) Pre-surgical psychiatric or psychological clearance has been obtained, demonstrating motivation and long-term commitment without major issues of secondary gain and with an expectation that surgical relief of pain probably would improve the patient's functioning.

3) Even if return to their prior job is unlikely, an individual may need surgical intervention for both increasing activities-of-daily-living and/or return to work in a different job.

4) It is critically important that all other pathology, especially shoulder disorders, be treated prior to surgical intervention for TOS. d. Return-to-Work Time: 1) Modified duty in 2 months.

2) Full duty with changes outlined previously in 6 months.

3. Post-Operative Treatment: a. Physical Medicine and Rehabilitation:

2) Neck and Thoracic Stretching Exercises are primarily a daily home program developed and supervised by an appropriately trained professional. Stretching exercises should include the following muscle groups: scalene, pectoralis minor, upper trapezius and levator. A patient should attend therapy for up to four weeks, then be seen once a week thereafter. Most patients will need to continue to be monitored and progressed in their activities for another 4–8 weeks or until they are able to return to the same level of duties or activities prior to symptom onset.

a) Time to produce effect: 2–3 weeks

b) Frequency: 3 times/week for first 2 weeks; 2 times/week for second 2 weeks; 1 time/week for weeks 4–6

c) Optimum duration: 6–8 weeks

d) Maximum duration: 3 months to assure compliance

3) Exercise Unless confined to the lower extremities, do not do endurance or strengthening early in the course of therapy and do not exacerbate cervical or upper extremity symptoms. Endurance and strengthening activities may be contraindicated early on. If the patient becomes asymptomatic for 2 weeks, standard endurance and strengthening exercises may begin.

a) Time to produce effect: 2–4 weeks

b) Frequency: 3–4 times/week

c) Optimum duration: 4–6 weeks

d) Maximum duration: 3 months

4) Abdominal Breathing, Postural Exercises (Reeducation) are part of an overall therapy program and should be primarily a home program supervised by qualified therapist.

a) Time to produce effect: 2–4 weeks

b) Frequency: 3–4 times/week

c) Optimum duration: 4–6 weeks d) Maximum duration: 3 months

5) Home Program Instruction for Persistent Symptoms: Symptoms which persist without improvement 3 weeks post-operatively may indicate referral to a therapy program which includes home program instruction. The therapy program should include elements of soft tissue healing and return to function as indicated:

a) Soft tissue healing/remodeling: Evaluation, electrical stimulation, soft tissue mobilization, scar compression pad, heat/cold application, or edema control may be used as indicated. Ultrasound may be considered after 6 weeks post- operative for soft tissue remodeling. Diathermy is a nonacceptable adjunct.

b) Return to function: Range-of-motion and stretching exercises, strengthening, activity of daily living adaptations, joint protection instruction, posture/body mechanics education, and worksite modifications may be as indicated:

(1) Time to produce effect: 2–4 weeks

(2) Frequency: 2–3 times/week

(3) Optimum duration: 4–6 weeks

(4) Maximum duration: 8 weeks b. Biofeedback is the use of physiological monitoring equipment to:

1) Improve the patient's awareness and control of muscle activity to include a variety of muscle placements that are related to the symptoms and/or areas of entrapment;

2) Reinforce the release of muscle tension that is being obtained from stretches, exercises, and abdominal breathing;

3) Decrease sympathetic arousal that is associated with stress;

4) Improve the patient's ability to feel like they can effect their physical responses and symptoms; and

5) Assist in avoiding re-injury through the individual returning to repetitive movement and bracing patterns

Treatment time may or may not overlap return-to-work or MMI.

1) Time to produce effect: 3–4 sessions

2) Frequency: 1–2 time/week

3) Optimum duration: 5–6 sessions

4) Maximum duration: 10–12 sessions c. Reactivation and Reconditioning are generally accepted, well-established and widely used modalities which should be included in any standard therapeutic exercise program, see this guideline, Section IV.D., Shoulder Injury, Physical Medicine and Rehabilitation:

1) Reactivation implies returning the patient to a higher level of activity than was previously utilized during the disabling episode; conducted in the form of encouragement of activities with limited supervised training (walking, stationary bicycle, etc.)

a) Time to produce effect: 2–4 visits

b) Frequency: Supervised 2–5 times/week for first 2 weeks, decreasing to 2–3 times/week

c) Optimum duration: 4–6 weeks

d) Maximum duration: 2 months

2) Supervised Reconditioning/Therapeutic Exercise is considered more specific therapeutic exercise, involving activation, strength/stabilization training and endurance/agility training of the injured body parts and used only in the presence of documented physical deficit. In nonsurgical cases of upper extremity pain, the Division recommends initiation of a supervised reconditioning program and implementation of a less-active treatment plan if:

a) The patient has not demonstrated objective carry over and benefit from an assigned home exercise program; or

b) The patient has not objectively progressed within a preceding 3-week period; or

c) The patient has not been released to return to full duty or modified work within 3 weeks.

This does not preclude an earlier implementation of an active, supervised reconditioning program:

a) Time to produce effect: 2–6 weeks

b) Frequency: 2–6 times/week supervised for the first 3–4 weeks, decreasing to 2–4 times/week thereafter

c) Optimum duration: 4–6 weeks

d) Maximum duration: 2 months, exclusive of intervening medical complications

A self-monitored program with periodic monitoring is recommended thereafter. d. Work Simulation modalities are generally accepted, well-established and widely used. They are simulated activities-of-daily-living including those generally performed by disabled workers in the work place. If placement at modified duty at the work place is unavailable, work simulation should run concurrently or sequentially based upon analysis of physical capacity and job analysis:

1) Time to produce effect: 1–3 weeks

2) Frequency: 2–5 times/week

3) Optimum duration: 2–3 weeks

4) Maximum duration: 3–6 weeks

Work simulation is generally followed either by work hardening, return to work, or a combination thereof, see this Section III., Work Hardening, for further discussion. e. Psychosocial Intervention is generally accepted, widely used and well-established. This group of therapeutic and diagnostic modalities includes, but is not limited to, individual counseling, group therapy, stress management, psychosocial crisis intervention, biofeedback, hypnosis and meditation. Any screening or diagnostic workup should clarify and distinguish between preexisting versus aggravated versus purely causative psychological conditions. Psychosocial intervention is recommended as an important component in the total management program which should be implemented as soon as the problem is identified. This could be used in conjunction with other treatment modalities:

1) Time to produce effect: 2–4 weeks

2) Frequency: 1–3 time/week (excluding hospitalization, if required) for the first 4 weeks, decreasing to 1–2 times/week for the second month

3) Optimum duration: 6–10 weeks

4) Maximum duration: 6–12 months

Occasionally, longer supervised treatment may be required, but if further counseling beyond 6 months seems indicated, extensive documentation addressing which pertinent issues are pre-existing versus aggravated versus causative, as well as projecting a realistic functional prognosis, should be provided by the authorized treating practitioner every 4–6 weeks. f. Vocational Rehabilitation is a generally accepted intervention, but Colorado limits its use by statute. Initiation of vocational rehabilitation requires adequate evaluation of patients for quantification of highest functional level, motivation and achievement of MMI. Vocational rehabilitation may be as simple as returning to the original job or as complicated as being retrained for a new occupation. g. Vocational Assessment: once an authorized practitioner has reasonably determined and objectively documented that a patient will not be able to return to his/her former employment, can reasonably prognosticate final restrictions and date of MMI, implementation of a timely vocational assessment can provide valuable guidance in the determination of future rehabilitation program design. Clarification of rehabilitation goals optimize both patient motivation and utilization of rehabilitation resources. Except in the most extenuating circumstances, this process should be implemented within 3–12 months post-injury at the latest, if prognosis for return to former occupation is determined to be guarded to poor. Declaration of MMI should not be delayed solely due to lack of attainment of a vocational assessment. h. Interdisciplinary Team Approach interventions are generally accepted, well-established and widely used. This approach includes work hardening programs, functional restoration programs and pain clinics. In general, these programs are more comprehensive, time consuming and costly and are, therefore, appropriate for patients with greater levels of (perceived) disability, dysfunction, deconditioning and psychological involvement. For upper extremity involvement, interdisciplinary teams should include a physical therapist or an occupational therapist.

1) Work Hardening Programs are generally more comprehensive than the work simulation and include education, reconditioning and specific work simulation with respect to task quality, quantity and intensity (for further discussion, reference this Section III., Work Simulation). Work Hardening involving repetitive use of the upper extremity should be pursued cautiously for most TOS patients, as it may bring back symptoms (even postsurgically). The Division recommends the Commission for the Accreditation of Rehabilitation Facilities (CARF) eligibility and/or accreditation of work hardening programs for all facilities treating injured workers to assure that such programs meet certain standards involving program design and efficacy. Work hardening is generally initiated after reconditioning or functional restoration has been completed if imminent return of a patient to modified or full duty is not an option but the prognosis for returning the patient to work at completion of the program is at least fair to good. As discussed in this Section III., Vocational Rehabilitation and Vocational Assessment, identification of realistic vocational goals is essential for the successful completion of a work hardening program. Generally, work hardening programs entail a progressive increase in the number of hours per day that a patient completes work simulation tasks until the patient can tolerate a full work day:

a) Time to produce effect: 2–4 weeks

b) Frequency: 2–5 times/week

c) Optimum duration: 4–6 weeks

d) Maximum duration: 2–3 months

2) Functional Restoration Programs are intended for patients with both physical deconditioning and/or significant psychological and socioeconomic involvement. It encompasses work hardening, quantification of function, disability management, adjustment counseling and outcome review. The interdisciplinary team must consist of physicians and therapists working in a structured environment. The Division recommends an interdisciplinary team include physical therapy, occupational therapy and psychology or at least related supervised personnel addressing the physiologic, psychologic and ergonomic factors impacting a patient's upper extremity pain presentation. Regular, documented interdisciplinary team meetings to discuss patient progress and upgrade rehabilitation goals must be a part of any credible interdisciplinary approach. The Division recommends programs which meet criteria consistent with those for work hardening established by CARF. In nonsurgical upper extremity pain patients with evidence of delayed recovery, the Division strongly recommends referral to an interdisciplinary/functional restoration program within three months post-injury.

a) Time to produce effect: 4–6 weeks

b) Frequency: 2–6 times/week

c) Optimum duration: 6–12 weeks

d) Maximum duration: 4 months

3) Pain Clinics have been the traditional rehabilitation program for chronically disabled upper extremity patients who have not responded to functional restoration interventions. In general, pain clinics deal with irreversible, painful neurological disorders and psychological issues, including drug dependence, high levels of stress and anxiety, failed surgery and pre-existing or latent psychopathology. The Division recommends CARF eligibility and/or accreditation of pain clinics treating injured workers to assure that such programs meet certain standards involving program design and efficacy. The Division also recommends consideration of referral to a pain clinic within 6 months post-injury in those patients with delayed recovery unless surgical interventions or other medical complications intervene. It may be useful in determining the appropriateness of referral to a pain clinic to consider the Colorado Foundation for Medical Care's “Criteria for Outpatient (or Inpatient) Management of Chronic Pain.”

a) Time to produce effect: 3–8 weeks

b) Frequency: 2–7 times/week for the first month, decreasing to 2–3 times/week thereafter

c) Optimum duration: 6–12 weeks, including follow-up for outpatient pain clinics; 3–4 weeks for inpatient pain clinics

d) Maximum duration: 4 months, including follow-up

Periodic review and monitoring on an as-needed basis is thereafter founded upon the documented maintenance of functional gains.

IV. SHOULDER INJURY

TABLE OF CONTENTS SECTION DESCRIPTION

IV SHOULDER INJURY A. History Taking and Physical Examination 1. History Taking 2. Physical Findings B. Specific Diagnosis, Testing and Treatment Procedures 1. Acromioclavicular Joint Sprains/Dislocations 2. Adhesive Capsulation/Frozen Shoulder Disorders 3. Bicipital Tendon Disorders 4. Brachioplexus Injuries 5. Bursitis of the Shoulder 6. Impingement Syndrome 7. Rotator Cuff Tear 8. Rotator Cuff Tendinitis 9. Shoulder Fractures 10. Shoulder Instability C. Medications 1. Nonsteroidal Anti- Inflammatory Drugs (NSAID) 2. Aanalgesics 3. Psychotropic Medication 4. Hypnotics 5. Narcotics 6. Minor Tranquilizers/Muscle Relaxants. D. Nonoperative Treatment Procedures 1. Immobilization 2. Relative Rest 3. Therapeutic Exercise 4. Alteration of Occupation and Work Station 5. Thermal Treatment 6. Transcutaneous Electrical Nerve Stimulation (TENS) 7. Therapeutic Ultrasound With or Without Electric Stimulation 8. Electrical Therapeutic Modality 9. Return-to-Work 10. Biofeedback 11. Physical Medicine and Rehabilitation 12. Work Simulation 13. Personality/Psychological /Psychosocial Evaluations 14. Vocational Rehabilitation 15. Vocational Assessment 16. Interdisciplinary Team Approach

This section addresses the shoulder and the ten most common work-related injuries/syndromes/disorders to or involving the shoulder complex. The following format was developed to reduce repetitive text:

● SUBSECTION A., HISTORY TAKING AND PHYSICAL EXAMINATION, provides information common to all injuries through a discussion of provider procedures which should be applied to each patient, regardless of the injury and diagnosis (this subsection is standard to all Division medical treatment guidelines).

● SUBSECTION B., SPECIFIC DIAGNOSIS, TESTING AND TREATMENT PROCEDURES, provides information unique to each of the following work-related injuries/syndromes/disorders:

1. Acromioclavicular (AC) Joint Sprains/Dislocations

2. Adhesive Capsulitis/Frozen Shoulder Disorders

3. Bicipital Tendon Disorders

4. Brachioplexus Injuries

a. Brachial Plexus

b. Axillary Nerve

c. Long Thoracic Nerve

d. Musculocutaneous Nerve e. Spinal Accessory Nerve

f. Suprascapular Nerve

5. Bursitis of the Shoulder

6. Impingement Syndrome

7. Rotator Cuff Tears

8. Rotator Cuff Tendinitis

9. Shoulder Fractures

a. Clavicular Fracture

b. Proximal Humeral Fracture

c. Humeral Shaft Fracture

d. Scapular Fracture

e. Sternoclavicular Dislocation/Fracture

10. Shoulder Instability

Each diagnosis is presented in the following format:

1. A definition of the injury/disorder/syndrome;

2. Discussion of relevant physical findings;

3. Applicable testing and diagnostic procedures;

4. Diagnosis-based, nonoperative therapeutic treatment procedures;

5. Options for operative/surgical treatment; and

6. Options for post-operative rehabilitation/treatment procedures.

● SUBSECTION C., MEDICATION, provides information common to all injuries through detailed discussions of referenced medications with indications for expected time to produce effect, frequency, and optimum and maximum durations.

● SUBSECTION D., NONOPERATIVE TREATMENT PROCEDURES, provides information common to all injuries through detailed discussions of referenced therapeutic procedures with indications for expected time to produce effect, frequency, and optimum and maximum durations.

As shoulder injuries frequently involve a complex of problems, it is always necessary to consider the possible interaction of the various parts of the shoulder mechanism when proceeding with a diagnostic workup and a therapeutic treatment plan. Injuries to the shoulder may require the provider to reference and/or use the other Division medical treatment guidelines (i.e., Rule XVII, Exhibit B., Section III, Thoracic Outlet Syndrome and Section V., Cumulative Trauma Disorder, and/or Exhibit D., Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome). A. HISTORY TAKING AND PHYSICAL EXAMINATION (Hx & PE):

There are two standard procedures that should be utilized when initially diagnosing work-related shoulder instability. These procedures are generally accepted, well-established and widely used procedures which establish the foundation/basis for and dictate all other following stages of diagnostic and therapeutic procedures. When findings of clinical evaluations and those of other diagnostic procedures are not complementing each other, the objective clinical findings should have preference.

1. History Taking should address at least the following for each shoulder injury diagnosis: a. Occupational relationship, and b. History of nonoccupational injury and avocational pursuits need to be specifically documented.

2. Physical Findings are specific to and addressed within each shoulder injury diagnosis noted in this section. Given the complexity of the shoulder mechanism, an evaluation for concomitant injury should be considered.

B. SPECIFIC DIAGNOSIS, TESTING AND TREATMENT PROCEDURES:

1. Acromioclavicular Joint Sprains/Dislocations:

An acute acromioclavicular (AC) joint injury is frequently referred to as a shoulder separation. There are six classifications of an AC joint separation which are based upon the extent of ligament damage and bony displacement:

Type I Partial disruption of the AC ligament and capsule.

Type II Sprains consisting of a ruptured AC ligament and capsule with incomplete injury to the coracoclavicular ligament, resulting in minimal AC joint subluxation.

Type III Separation or complete tearing of the AC ligament and/or coracoclavicular ligaments, possible deltoid trapezius fascial injury, and dislocation of the AC joint.

Type IV Dislocation consisting of a displaced clavicle that penetrates posteriorly through or into the trapezius muscle.

Type V Dislocation consisting of complete separation of the AC and CC ligaments and dislocation of the acromioclavicular joint with a large coracoclavicular interval.

Type VI Dislocation consisting of a displaced clavicle that penetrates inferior to the coracoid.

Types I–III are common, while Types IV–VI are not and, when found, require surgical consultation. For AC joint degeneration from repetitive motion that is found to be work-related, see this Section IV.B.6., Impingement Syndrome. a. History and Initial Diagnostic Procedures (AC Joint Sprains/Dislocations)

1) Occupational Relationship - generally, workers sustain an AC joint injury when they land on the point of the shoulder, driving the acromion downward, or fall on an outstretched hand or elbow, creating a backward and outward force on the shoulder. It is important to rule out other sources of shoulder pain from an acute injury, including rotator cuff tear, fracture and nerve injury. b. Physical Findings (AC Joint Sprains/Dislocations) may include

1) Tenderness at the AC joint with, at times, contusions and/or abrasions at the joint area; prominence/asymmetry of the shoulder can be seen; and/or

2) One finds decreased shoulder motion and with palpation, the distal end of the clavicle is painful; there may be increased clavicular translation; cross-body adduction can cause exquisite pain. c. Laboratory Tests (AC Joint Sprains/Dislocations) are not indicated unless a systemic illness or disease is suspected. d. Testing Procedures (AC Joint Sprains/Dislocations)

1) Plain x-rays may include

a) AP view;

b) AP radiograph of the shoulder with the beam angled 10°; cephalad (Zanca view);

c) Axillary lateral views; and

d) Stress view; side-to-side comparison with 10–15 lbs. of weight in each hand. e. Nonoperative Treatment Procedures (AC Joint Sprains/Dislocations) may include

1) Procedures outlined in this Section IV.D., such as thermal therapy and immobilization (up-to-6 weeks for Type I–III AC joint separations). Immobilization treatments for Type III injuries are controversial and may range from a sling to surgery.

2) Medication, such as nonsteroidal anti-inflammatories and analgesics, would be indicated; narcotics are not normally indicated. In the face of chronic acromioclavicular joint pain, a series of injections with or without cortisone, may be injected 6–8 times per year.

3) Physical medicine interventions, as outlined in this Section IV.D., should emphasize a progressive increase in range-of-motion without exacerbation of the AC joint injury. With increasing motion and pain control, a strengthening program should be instituted and return to modified/limited duty would be considered at this time. By 8–11 weeks, with restoration of full motion, return to full duty should be anticipated. f. Operative Procedures (AC Joint Sprains/Dislocations)

1) With a Type III AC joint injury, an appropriate orthopedic consultation could be considered initially, but should be considered when conservative care fails to increase function.

2) With a Type IV–VI AC joint injury, an orthopedic surgical consultation is recommended. g. Post-Operative Procedures (AC Joint Sprains/Dislocations) should be coordinated by the orthopedic and the primary care physician working with the interdisciplinary team. Keeping with the therapeutic and rehabilitation procedures found in this Section IV.D., the patient could be immobilized for 2–3 weeks, restricted in activities, both workrelated and avocational for 6–8 weeks while undergoing rehabilitation, and be expected to progress to return to full duty based upon the his/her response to rehabilitation and the demands of the job. 2. Adhesive Capsulitis/Frozen Shoulder Disorders:

Adhesive capsulitis of the shoulder, also known as frozen shoulder disorder, is a soft tissue lesion of the glenohumeral joint resulting in restrictions of passive and active range-of-motion. Occupational adhesive capsulitis arises secondarily to any chest or upper extremity trauma. Primary adhesive capsulitis is rarely occupational in origin. The disorder goes through stages, specifically:

Stage 1 Consists of acute pain with some limitation in range-of-motion; generally lasting 2–9 months.

Stage 2 Characterized by progressive stiffness, loss of range-of-motion, and muscular atrophy; it may last an additional 4–12 months beyond Stage 1.

Stage 3 Characterized by partial or complete resolution of symptoms and restoration of range-of-motion and strength; it usually takes an additional 6–9 months beyond Stage 2. a. History and Initial Diagnostic Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder)

1) Occupational Relationship - There should be some history of work-related injury. Often adhesive capsulitis is seen with impingement syndrome or other shoulder disorders; refer to appropriate subsection of this guideline.

2) Patient will usually complain of pain in the subdeltoid region, but occasionally over the long head of the biceps or radiating down the lateral aspect of the arm to the forearm. Pain is often worse at night with difficulty sleeping on the involved side. Motion is restricted and painful. b. Physical Findings (Adhesive Capsulitis/Frozen Shoulder Disorder) may include

1) Restricted active and passive glenohumeral range-of-motion is the primary physical finding. It may be useful for the examiner to inject the glenohumeral joint with lidocaine and then repeat range-of-motion to rule out other shoulder pathology; lack of range-of-motion confirms the diagnosis. Postural changes and secondary trigger points along with atrophy of the deltoid and supraspinatus muscles may be seen. c. Laboratory Tests (Adhesive Capsulitis/Frozen Shoulder Disorder) are not indicated unless systemic illness or disease is suspected. d. Testing Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder)

1) Plain x-rays are generally not helpful except to rule out concomitant pathology.

2) Arthrography may be helpful in ruling out other pathology. Arthrography can also be therapeutic as steroids and/or anesthetics may be injected and a brisement or distension arthrogram can be done at the same time (refer to the next subsection on nonoperative treatment procedures for further discussion). e. Nonoperative Treatment Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder) address the goal to restore and maintain function and may include:

1) Physical medicine interventions are the main-stay of treatment and may include thermal treatment, ultrasound, TENS, manual therapy, and passive and active range-of-motion exercises; as the patient progresses, strengthening exercises should be included in the exercise regimen; refer to this Section IV.D.

2) Medications, such as NSAIDs and analgesics, may be helpful; rarely, the use of oral steroids are helpful to decrease acute inflammation; narcotics are indicated only for post- manipulation or post-operative cases; refer to this Section IV.C.

3) Occasionally, subacromial bursal and/or glenohumeral steroid injections can decrease inflammation and allow the therapist to pro-gress functional exercise and range-of- motion. Injections should be limited to two injections to any one site, given at least one month apart.

4) In cases that are refractory to conservative therapy lasting at least 3–6 months and in whom range-of-motion remains significantly restricted (abduction less than. 90°;), the following more aggressive treatment may be considered:

(a) Distension arthrography or “brisement” in which saline, an anesthetic and usually a sterold are forcefully injected into the shoulder joint causing disruption of the capsule. Early and aggressive physical medicine to maintain range-of-motion and restore strength and function should follow distension arthrography or manipulation under anesthesia; return-to-work with restrictions should be expected within one week of the procedure; return to full duty is expected within 4–6 weeks. f. Operative Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder)

For cases failing conservative therapy of at least 3–6 months duration and which are significantly limited in range-of-motion (abduction less than 90°;), the following operative procedures may be considered:

1) Manipulation under anesthesia which may be done in combination with steroid injection or distension arthrography; and

2) In rare cases, refractory to conservative treatment and in which manipulation under anesthesia is contraindicated, an open capsular release or arthroscopy with resection of the coracohumeral and/or coracoacromial ligaments may be done; other disorders, such as impingement syndrome, may also be treated at the same time. g. Post-Operative Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder) would include an individualized rehabilitation program based upon communication between the surgeon and the therapist.

1) Early and aggressive physical medicine interventions are recommended to maintain range-of- motion and progress strengthening; return-to-work with restrictions after surgery should be discussed with the treating provider; patient should be approaching MMI within 8–12 weeks post-operative, however, coexistence of other pathology should be taken into consideration.

3. Bicipital Tendon Disorders:

Disorders may include 1) primary bicipital tendinitis which is exceedingly rare; 2) secondary bicipital tendinitis which is generally associated with rotator cuff tendinitis or impingement syndrome (see appropriate diagnosis subsections); 3) subluxation of the biceps tendon which occurs with dysfunction of the transverse intertubercular ligament and massive rotator cuff tears; and 4) acute disruption of the tendon which can result from an acute distractive force or transection of the tendon from direct trauma. a. History and Initial Diagnostic Procedures (Bicipital Tendon Disorders)

1) Occupational Relationship - bicipital tendon disorders may include symptoms of pain and/or achiness that occur after repetitive use of the shoulder and/or blunt trauma to the shoulder. Secondary bicipital tendinitis may be associated with prolonged above-the- shoulder activities, and/or repeated shoulder flexion, external rotation and abduction. Acute trauma to the biceps tendon of the shoulder girdle may also give rise to occupational injury of the biceps tendon.

2) Occupational disorders of the biceps tendon may accompany scapulothoracic dyskinesis, rotator cuff injury, AC joint separation, subdeltoid bursitis, shoulder instability or other shoulder pathology. Symptoms should be exacerbated or provoked by work that activated the biceps muscle. Symptoms may be exacerbated by other activities that are not necessarily work related.

3) Symptoms may include aching, burning and/or stabbing pain in the shoulder, usually involving the anterior medial portion of the shoulder girdle. The symptoms are exacerbated with above-the-shoulder activities and those specifically engaging the biceps (flexion at the shoulder, flexion at the elbow and supination of the forearm). Relief occurs with rest. Patient may report nocturnal symptoms which interfere with sleep during the acute stages of inflammation; pain and weakness in shoulder during activities; repeated snapping phenomenon with a subluxing tendon; immediate sharp pain and tenderness along the course of the long head of the biceps following a sudden trauma which would raise suspicions of acute disruption of the tendon; and/or with predominant pain at the shoulder referral patterns which may extend pain into the cervical or distal structures, including the arm, elbow, forearm and wrist. b. Physical Findings (Bicipital Tendon Disorders) may include

1) If continuity of the tendon has been lost (biceps tendon rupture), inspection of the shoulder would reveal deformity (biceps bunching);

2) Palpation demonstrates tenderness along the course of the bicipital tendon;

3) Pain at end range of flexion and abduction as well as biceps tendon activation; and/or

4) Provocative testing may include

a) Yeagerson's sign – pain with resisted supination of forearm;

b) Speed's Test – pain with resisted flexion of the shoulder (elbow extended and forearm supinated); or

c) Ludington's Test – pain with contraction of the biceps (hands are placed behind the head placing the shoulders in abduction and external rotation). c. Laboratory Tests (Bicipital Tendon Disorders) are not indicated unless a systemic illness or disease is suspected. d. Testing Procedures (Bicipital Tendon Disorders)

1) Plain x-rays include

a) AP view visualizes elevation of the humeral head, indicative of absence of the rotator cuff due to a tear;

b) Lateral view in the plane of the scapula or an axillary view determines if there is anterior or posterior dislocation or the presence of a defect in the humeral head (a Hill-Sachs lesion); c) 30°; caudally angulated AP view determines if there is a spur on the anterior/interior surface of the acromion and/or the far end of the clavicle; and

d) Outlet view determines if there is a downwardly tipped acromion.

2) Adjunctive testing, such as sonography, MRI or arthrography, should be considered when shoulder pain is refractory to 4-6 weeks of nonoperative conservative treatment and the diagnosis is not readily identified by standard radiographic techniques. e. Nonoperative Treatment Procedures (Bicipital Tendon Disorders)

1) Benefit may be achieved through procedures outlined in this Section IV.D., such as thermal therapy, immobilization, alteration of occupation and/or work station, manual therapy and biofeedback.

2) Medication, such as nonsteroidal anti-inflam-matories and analgesics, would be indicated; narcotics are not normally indicated. Refer to this Section IV.C. for further discussions.

3) Physical medicine and rehabilitation interventions, as outlined in this Section IV.D., should emphasize a progressive increase in range-of-motion without exacerbation of the AC joint injury. With increasing motion and pain control, a strengthening program should be instituted and return to modified/limited duty would be considered at this time. By 8-11 weeks, with restoration of full motion, return to full duty should be anticipated.

4) Biceps tendon injections may be therapeutic if the patient responds positively to an injection of an anesthetic. Injection of the corticosteroids directly into the tendon should be avoided due to possible tendon breakdown and degeneration, limited to 3 injections per year at the same site, and avoided in patients under 30 years of age. f. Operative Procedures (Bicipital Tendon Disorders)

1) Bicipital Tendinitis: Conservative care prior to potential surgery must address flexibility and strength imbalances. Surgical remedies would be considered after 12 weeks of appropriate conservative care has failed. Since impingement of the biceps tendon could cause continued irritation, an acromioplasty may be necessary, especially when the presence of an obstructing osteophyte is demonstrated on plain x-rays.

2) Subluxing Bicipital Tendon: The decision to surgically stabilize the bicipital tendon is not commonly indicated. In the vast majority of cases, optimal outcome is achieved through successful rehabilitation procedures and appropriate conservative measures should be maximized prior to surgical intervention.

3) Acute Disruption of the Bicipital Tendon: Surgical treatment shows variable responses. Conservative care should be the mainstay of treatment with particular attention given to the patient's age, work description and motivation. g. Post-Operative Procedures (Bicipital Tendon Disorders) would include an individualized rehabilitation program based upon communication between the surgeon and the therapist. Rehabilitation, lasting 6-12 weeks, is necessary to facilitate maximum medical improvement (MMI). Rehabilitation procedures discussed in this Section IV.D. should be referenced and used.

4. Brachioplexus Injuries:

Injuries to the nerves and shoulder girdle region resulting in loss of motor and sensory function, pain and instability of the shoulder. Signs and symptoms vary with the degree of mechanism of injury. The two modes of injury are: 1) acute direct trauma, and 2) repetitive motion or overuse. Transient compression, stretch or traction (neuropraxia) causes sensory and motor signs lasting days to weeks. Damage to the axon (axonomesis) without disruption of the nerve framework may cause similar symptoms. The recovery time is delayed and depends upon axon regrowth distally from the site of injury. Laceration or disruption of the entire nerve with complete loss of framework (neuromesis) is the most severe form of nerve injury. Return of function is dependent upon regrowth of the nerve distal to the injury site.

Electromyography (EMG) is the most commonly used diagnostic modality to analyze nerve injuries. Electrophysiologic studies, such as electromyography and nerve conduction studies, are generally accepted, well-estab-lished and widely used for localizing the source of neurological symptoms. These studies should be utilized as an extension of the history and clinical examination.

Slowing of motor nerve conduction velocities due to demyelinization localizes regions of entrapment and injury. Denervation demonstrated on the electromyographic portion is indicative of motor axonal or anterior horn cell loss. Studies should be performed 3-4 weeks following injury or description of symptoms. If the symptoms have been present for longer than 3-4 weeks, studies may be performed immediately after the initial evaluation. Serial studies may be indicated if initial studies are negative and may also be useful for gauging prognosis. Limb temperature should be controlled at 30-40°; centigrade. There are six relatively common nerve injuries to the shoulder girdle; each type will be addressed separately. a. Brachial Plexus is formed by the nerve roots of C5-C8 and T1; these nerve roots exit the cervical spine and pass through the scalene musculature; after leaving the scalene musculature, at the level of the clavicle, they form trunks, division and chords which ultimately form the peripheral nerves of the arm.

1) History and Initial Diagnostic Procedures (Brachial Plexus)

a) Occupational Relationship – direct injury to brachial plexus results in widespread sensory and motor loss. Direct trauma, subluxation to shoulder, clavicular fractures, shoulder depression, head deviation away to the arm may result in variable brachial plexus lesions. It is important to differentiate injuries to the brachial plexus from the acquired (nonwork-related) syndrome of brachial plexus neuritis, Parsonage-Turner Syndrome and/or neuralgia demyotrophy.

2) Physical Findings (Brachial Plexus) may include

a) Inspection for evidence of trauma or deformity;

b) Identification of sensory loss and demonstration of weakness which relates to the severity and anatomy of the injury to the brachial plexus; and/or

c) Pain with recreation of the motions during the mechanism of injury.

3) Laboratory Tests (Brachial Plexus) are not indicated unless a systemic illness or disease is suspected.

4) Testing Procedures (Brachial Plexus) would include EMG and Nerve Conduction Studies. If they do not localize and give sufficient information, then additional information may be obtained from MRI and/or myelography. These studies are employed to differentiate root avulsion from severe brachial plexus injuries.

5) Nonoperative Treatment Procedures (Brachial Plexus)

a) In closed injuries, observation is favored; repeat electrophysiologic studies may be helpful to follow recovery.

b) Rehabilitation can be utilized using procedures set forth in this Section IV.D. However, utilization of ultrasound, cold and heat should be discussed with the Primary Care Physician since these modalities can aggravate nerve injury.

c) Medications, such as analgesics, nonsteroidal anti-inflammatories and anticonvulsants, are indicated; steroids may be prescribed to help diminish the inflammatory response, and narcotics may be indicated acutely; all medications should be prescribed as seen in this Section IV.C.

6) Operative Procedures (Brachial Plexus) in open injuries, exploration may be worthwhile if there is poor progression of recovery from a conservative approach; in closed injuries, if progressive weakness and loss of function is documented after 4-6 months of conservative care, then exploration is also warranted.

7) Post-Operative Procedures (Brachial Plexus) would include an individualized rehabilitation program based upon communication between the surgeon and the therapist. This program would begin with 4-6 weeks of rest followed by progressive increase in motion and strength. b. Axillary Nerve is derived from the 5th and 6th cervical roots; it passes around the shoulder and supplies motor branches to the teres minor and the three heads of the deltoid; it gives sensation to the top of the shoulder at the level of the deltoid.

1) History and Initial Diagnostic Procedures (Axillary Nerve)

a) Occupational Relationship – direct injury and penetrating wounds to the shoulder and upward pressure on the axilla can cause injury to the axillary nerve; abnormalities of the nerve can also be seen with fractures of the surgical neck of the humerus and dislocation of the shoulder; finally, axillary nerve injury can be seen with shoulder surgery in and of itself.

2) Physical Findings (Axillary Nerve) may include

a) Weakness and atrophy of the deltoid muscle;

b) Strength is lost in abduction, flexion and extension of the shoulder; and/or

c) Sensory loss can be seen over the upper arm.

3) Laboratory Tests (Axillary Nerve) are not indicated unless a systemic illness or disease is suspected.

4) Testing Procedures (Axillary Nerve) would include EMG and Nerve Conduction Studies.

5) Nonoperative Treatment Procedures (Axillary Nerve)

a) Rehabilitation can be utilized using procedures set forth in this Section IV.D. Utilization of ultrasound, cold and heat should be discussed with the Primary Care Physician since these modalities can aggravate the nerve injury.

b) Medications such as analgesics, nonsteroidal anti-inflammatories and anticonvulsants are indicated and narcotics may be indicated acutely; all medications should be prescribed as seen in this Section IV.C. 6) Operative Procedures (Axillary Nerve) are usually not necessary, since most injuries to the axillary nerve are due to stretch and/or traction. One may consider surgery after 4-6 months with EMG/NCV documentation of ongoing denervation and loss of function.

7) Post-Operative Procedures (Axillary Nerve) would include an individualized rehabilitation program based upon communication between the surgeon and the therapist. This program would begin with 4-6 weeks of rest followed by progressive increase in motion and strength. c. Long Thoracic Nerve is formed by the cervical fifth, sixth, and seventh roots; it crosses the border of the first rib and descends along the posterior surface of the thoracic wall to the serratus anterior.

1) History and Initial Diagnostic Procedures (Long Thoracic Nerve)

a) Occupational Relationship – injury can occur by direct trauma to the posterior triangle of the neck or trauma may be the result of chronically repeated or forceful shoulder depression. Repeated forward motion of the arms as well as stretch or compression of the nerve with the arms abducted can lead to long thoracic nerve dysfunction.

2) Physical Findings (Long Thoracic Nerve) may include

a) Dull ache in the region of the shoulder without sensory loss;

b) Scapular deformity and/or winging may be described by patient or family; and/or

c) Serratus Anterior (scapular winging) may be demonstrated by asking the patient to extend and lean on his arms, such as against a wall and/or the examiner resisting protraction.

3) Laboratory Tests (Long Thoracic Nerve) are not indicated unless a systemic illness or disease is suspected.

4) Testing Procedures (Long Thoracic Nerve) EMG and Nerve Conduction Studies are used to define the anatomy and severity of the injury; side-to-side comparisons of the nerve can be helpful to confirm the diagnosis; studies may also exclude more widespread brachial plexus involvement.

5) Nonoperative Treatment (Long Thoracic Nerve)

a) Rehabilitation can be utilized using procedures set forth in this Section IV.D. Utilization of ultrasound, cold, and heat should be discussed with the Primary Care Physician since these modalities can aggravate nerve injury.

b) Medications, such as analgesics, nonsteroidal anti-inflammatories and anticonvulsants, are indicated and narcotics may be indicated acutely; all medications should be prescribed as seen in this Section IV.C.

6) Operative Procedures (Long Thoracic Nerve), such as scapular fixation, may be recommended but only in the most severe cases where there is documented significant loss of function.

7) Post-Operative Procedures (Long Thoracic Nerve) should include an individualized rehabilitation program based upon communication between the surgeon and the therapist. This program would begin with 8-10 weeks of rest followed by progressive increase in motion and strength. d. Musculocutaneous Nerve is derived from the fifth and sixth cervical roots; it innervates the coracobrachialis, biceps and brachioradialis muscles and also provides sensation to the lateral aspect of the forearm; trauma (including surgery) or penetrating wound to the brachial plexus, coracobrachialis, and shoulder often can cause nerve injury.

1) History and Initial Diagnostic Procedures (Musculocutaneous Nerve)

a) Occupational Relationship – most commonly a stretch/traction injury due to forceful extension of the elbow induces nerve dysfunction; trauma can be seen to the sensory component (lateral antebrachial cutaneous nerve) which delineates loss of sensation to the forearm.

2) Physical Findings (Musculocutaneous Nerve) may include

a) Pain in the arm;

b) Weakness and atrophy in the biceps and brachialis; and/or

c) Sensory loss over the lateral aspect of the forearm; however, is not always seen.

3) Laboratory Tests (Musculocutaneous Nerve) are not indicated unless a systemic illness or disease is suspected.

4) Testing Procedures (Musculocutaneous Nerve) include EMG and nerve conduction studies; side-to-side comparisons of the motor and sensory components of the nerve may be useful since standard norms are not always reliable.

5) Nonoperative Treatment Procedures (Musculocutaneous Nerve)

a) Rehabilitation can be utilized using procedures set forth in this Section IV.D. Utilization of ultrasound, cold, and heat should be discussed with the Primary Care Physician, since these modalities can aggravate nerve injury.

b) Medications, such as analgesics, nonsteroidal anti-inflammatories and anticonvulsants, are indicated and narcotics may be indicated; all medications should be prescribed as seen in this Section IV.C.

6) Operative Procedures (Musculocutaneous Nerve) are usually not necessary unless there has been increasing loss of function over 4-6 months and/or a laceration to the nerve has been identified.

7) Post-Operative Procedures (Musculocutaneous Nerve) would include an individualized rehabilitation program based upon communication between the surgeon and the therapist. This program would begin with 8-10 weeks of rest followed by progressive increase in motion and strength. e. Spinal Accessory Nerve is the eleventh cranial nerve; the nerve innervates the ipsilateral sternocleidomastoid and trapezius muscles which are extremely important for scapular control and ultimately shoulder function.

1) History and Initial Diagnostic Procedures (Spinal Accessory Nerve)

a) Occupational Relationship – direct trauma to the posterior neck, forceful compression of the shoulder downward and/or deviation of the head away from the traumatized shoulder can lead to injury to this nerve; surgical resection of the posterior neck can disrupt the nerve.

2) Physical Findings (Spinal Accessory Nerve) may include

a) Pain in the shoulder;

b) Weakness or paralysis of the trapezius which is seen as winging with the arms out to the side (abduction); and/or

c) Drooping of the shoulder.

3) Laboratory Tests (Spinal Accessory Nerve) are not indicated unless a systemic illness or disease is suspected.

4) Testing Procedures (Spinal Accessory Nerve) include EMG and Nerve Conduction Studies are used to define the anatomy and severity of the injury; side-to-side comparisons of the nerve can be helpful to confirm the diagnosis; radiographic procedures may be necessary to exclude lesion at the base of the brain or upper cervical spine.

5) Nonoperative Treatment Procedures (Spinal Accessory Nerve)

a) Rehabilitation can be utilized using procedures set forth in this Section IV.D. Utilization of ultrasound, cold, and heat should be discussed with the Primary Care Physician, since these modalities can aggravate nerve injury.

6) Operative Procedures (Spinal Accessory Nerve) are usually not necessary unless increased loss of function over 4-6 months has been documented and/or a laceration to the nerve has been identified.

7) Post-Operative Procedures (Spinal Accessory Nerve) would include an individualized rehabilitation program based upon communications between the surgeon and the therapist. This program would begin with 8-10 weeks of rest followed by progressive increase in motion and strength. f. Suprascapular Nerve is derived from the fifth and sixth cervical root, superior trunk of the brachialplexus, and it innervates the supraspinatus and infraspinatus muscles of the rotator cuff.

1) History and Initial Diagnostic Procedures (Suprascapular Nerve)

a) Occupational Relationship – supraclavicular trauma, stretch, and friction through the suprascapular notch or against the transverse ligament at the notch can cause injury to the nerve; repetitive use of the arm has been shown on occasion to cause traction to the nerve.

2) Physical Findings (Suprascapular Nerve) may include

a) Pain at the shoulder;

b) Wasting at the supraspinatus and/or infraspinatus muscles with weakness; and/or c) Tinel's can help to elicit a provocative pain response.

3) Laboratory Tests (Suprascapular Nerve) are not indicated unless a systemic illness or disease is suspected.

4) Testing Procedures (Suprascapular Nerve) include EMG and nerve conduction studies; side- to-side comparisons may be useful since standard norms are not always reliable. If one suspects a mass lesion at the suprascapular notch, then an MRI may be indicated.

5) Nonoperative Treatment Procedures (Suprascapular Nerve)

a) Rehabilitation can be utilized using procedures set forth in this Section IV.D. Utilization of ultrasound, cold, and heat should be discussed with the Primary Care Physician, since these modalities can aggravate nerve injury.

b) Medications, such as analgesics, nonsteroidal anti-inflammatories and anticonvulsants, are indicated and narcotics may be indicated acutely; all medications should be prescribed as seen in this Section IV.C.

6) Operative Treatment Procedures (Suprascapular Nerve) involving surgical release at the suprascapular notch or spinoglenoid region is warranted depending upon the results of the electrophysiologic studies and/or absence of improvement with conservative management.

7) Post-Operative Procedures (Suprascapular Nerve) would include an individualized rehabilitation program based upon communication between the surgeon and the therapist. This program would begin with 8-10 weeks of rest followed by progressive increase in motion and strength.

5. Bursitis of the Shoulder:

Acute or chronic inflammation of the bursa (a potential fluid filled sac) that may be caused by trauma, chronic overuse, inflammatory arthritis, and acute or chronic infection which generally presents with localized pain and tenderness of the shoulder. a. History and Initial Diagnostic Procedures (Bursitis of the Shoulder)

1) Occupational Relationship – onset of symptoms, date, mechanism of onset, and occupational history and current requirements should be correlated with the intensity, character, duration and frequency of associated pain and discomfort.

2) History may include nocturnal pain, pain with over-the-shoulder activities, feeling of shoulder weakness, prior treatment for presenting complaint(s), specific limitations of movement and pertinent familial history. b. Physical Findings (Bursitis of the Shoulder) may include

1) Palpation elicits localized tenderness over the particular bursa or inflamed tendon; loss of motion during activity;

2) Painful arc may be seen between 40-120°;; and/or

3) Bursitis may be associated with other shoulder injury diagnoses such as impingement, rotator cuff instability, tendinitis, etc.; refer to applicable diagnosis subsections for additional guidelines. c. Laboratory Tests (Bursitis of the Shoulder) may be used to rule out systemic illness or disease when proper clinical presentation indicates the necessity for such testing. Testing could include sedimentation rate, rheumatoid profile, CBC with differential, serum uric acid level, routine screening of other medical disorders may be necessary, as well as bursal aspiration with fluid analysis. d. Testing Procedures (Bursitis of the Shoulder)

1) Plain x-rays include

a) AP view visualizes elevation of the humeral head, indicative of absence of the rotator cuff due to a tear;

b) Lateral view in the plane of the scapula or an axillary view determines if there is anterior or posterior dislocation or the presence of a defect in the humeral head (a Hill-Sachs lesion);

c) 30°; caudally angulated AP view determines if there is a spur on the anterior/interior surface of the acromion and/or the far end of the clavicle; and

d) Outlet view determines if there is a downwardly tipped acromion. e. Nonoperative Treatment Procedures (Bursitis of the Shoulder)

1) Benefits may be achieved through procedures outlined in this Section IV.D., such as immobilization, therapeutic exercise, alteration of occupation and work station, thermal therapy, TENS unit, and ultrasound.

2) May return to work without overhead activities and lifting with involved arm until cleared by physician for those and heavier activities.

3) Additional modalities/treatment procedures may include biofeedback; physical medicine and rehabilitation including instruction in therapeutic exercise, proper work technique and manual therapy; psychosocial intervention; vocational rehabilitation, vocational assessment and interdisciplinary team approach.

4) Medications, such as nonsteroidal anti-inflam-matories and analgesics. Subacromial space injection may be therapeutic if the patient responded positively to a diagnostic injection of an anesthetic. Injection of the corticosteroids directly into the tendons should be

a) Avoided due to possible tendon breakdown and degeneration,

b) Limited to 3 injections per year at the same site, and

c) Avoided in patients under 30 years of age. f. Operative Procedures (Bursitis of the Shoulder) are not commonly indicated for pure bursitis; refer to other appropriate diagnoses in this Section IV.B.

6. Impingement Syndrome:

A collection of symptoms, not a pathologic diagnosis. The symptoms result from the encroachment of the acromion, coracoacromial ligament, coracoid process, and/or the AC Joint of the rotator cuff mechanism that passes beneath them as the shoulder is moved. The cuff mechanism is intimately related to the coracoacromial arch. Separated only by the thin lubricating surfaces of the bursa, compression and friction can be minimized by several factors, such as

– Shape of the coracoacromial arch that allows passage of the subjacent rotator cuff;

– Normal undersurface of the AC Joint;

– Normal bursa;

– Normal capsular laxity; and

– Coordinated scapulothoracic function.

The impingement syndrome may be associated with AC joint arthritis and both partial- and full-thickness rotator cuff tears, as well as adhesive capsulitis/frozen shoulder. Normal function of the rotator cuff mechanism and biceps tendon assist to diminish impingement syndrome. a. History and Initial Diagnostic Procedures (Impingement Syndrome)

1) Occupational Relationship – established repetitive overuse of the upper extremity; many times this is seen with constant overhead motion.

2) History may include:

a) Delayed presentation; since the syndrome is usually not an acute problem; patients will access care if their symptoms have not resolved with rest, time and “trying to work it out”;

b) Complaints of functional losses due to pain, stiffness, weakness and catching when the arm is flexed and internally rotated; and

c) Poor sleep is common and pain is often felt down the lateral aspect of the upper arm near the deltoid insertion or over the anterior proximal humerus. b. Physical Findings (Impingement Syndrome) may include

1) Inspection of the shoulder may reveal deltoid and rotator cuff atrophy;

2) Range-of-motion is limited particularly in internal rotation and in cross-body adduction;

3) Passive motion through the 60-90°; arc of flexion may be accompanied by pain and crepitus; this is accentuated as the shoulder is moved in-and-out of internal rotation;

4) Active elevation of the shoulder is usually more uncomfortable than passive elevation;

5) Pain on maximum active forward flexion is frequently seen with impingement syndrome, but is not specific for diagnosis;

6) Strength testing may reveal weakness of flexion and external rotation in the scapular plain; this weakness may be the result of disuse, tendon damage, or poor scapulothoracic mechanics;

7) Pain on resisted abduction or external rotation may also indicate that the integrity of the rotator cuff tendons may be compromised; and/or

8) Weakness of the posterior scapular stabilizers can also be seen as a contributing factor to impingement syndrome by altering the mechanics of the glenohumeral joint. c. Laboratory Tests (Impingement Syndrome) are not indicated unless a systemic illness or disease is suspected. d. Testing Procedures (Impingement Syndrome)

1) Plain x-rays include:

a) AP view visualizes elevation of the humeral head, indicative of rotator cuff fiber failure with diminished space at the subacromial area;

b) Lateral view in the plane of the scapula or an axillary view can help to determine aspects of instability which can give symptoms similar to impingement syndrome;

c) 30°; caudally angulated AP view can assess for a spur on the anterior/inferior surface of the acromion and/or the distal end of the clavicle which can lead to encroachment on the rotator cuff mechanism with motion; and

d) Outlet view determines if there is a downwardly tipped acromion.

2) Adjunctive testing, such as standard radiographic techniques (sonography, arthrography or MRI), should be considered when shoulder pain is refractory to 4-6 weeks of nonoperative conservative treatment and the diagnosis is not readily identified by a good history and clinical examination. e. Nonoperative Treatment Procedures (Impingement Syndrome) may include

1) Medications, such as nonsteroidal anti-inflammatories and analgesics, should be prescribed as seen in this Section IV.C. Subacromial space injection may be therapeutic if the patient responded positively to a diagnostic injection of an anesthetic. Injections of corticosteroids into the subacromial space should be

a) Limited to 3 injections per year at the same site, and

b) Avoided in patients less than 30 years.

2) In order to have the most favorable outcome from a conservative approach, an aggressive attempt should be made to define the contributing factors which are driving the syndrome, such as shoulder stiffness, humeral head depressor weakness (rotator cuff fiber failure), and subacromial crowding AC Joint arthritis.

3) Procedures outlined in this Section IV.D. should considered, such as relative rest, immobilization, thermal treatment, ultrasound, therapeutic exercise and physical medicine and rehabilitation. f. Operative Procedures (Impingement Syndrome) should restore functional anatomy by reducing the potential for repeated impingement; procedures might include distal clavicular resection, coracoacromial ligament release, and/or acromioplasty. g. Post-Operative Procedures (Impingement Syndrome) would include an individualized rehabilitation program based upon communication between the surgeon and the therapist.

1) Individualized rehabilitation program based upon communication between the surgeon and the therapist might include: a) Sling or abduction splint;

b) Gentle pendulum exercise, passive glenohumeral range-of-motion and aggressive posterior scapular stabilizing training can be instituted;

c) At 4 weeks post-operative, begin isometrics and ADL involvement; and/or

d) Depending upon the patient's functional response, at 6 weeks post-operative consider beginning light resistive exercise; concomitantly, return to a light/modified duty may be plausible given the ability to accommodate “no repetitive overhead activities.”

2) Progressive resistive exercise from 2 months with gradual returning to full activity at 5-7 months; all active nonoperative procedures listed in this Section IV.D. should be considered.

3) Work restrictions should be evaluated every 4-6 weeks during post-operative recovery and rehabilitation with appropriate written communications to both the patient and the employer. Should progress plateau, the provider should reevaluate the patient's condition and make appropriate adjustments to the treatment plan.

7. Rotator Cuff Tear:

Partial- or full-thickness tears of the rotator cuff tendons, most often the supraspinatus can be caused by vascular, traumatic or degenerative factors or a combination. Further tear classification includes: a small tear is less than 1cm; medium tear is 1-3cm; large tear is 3-5cm; and massive tear is greater than 5cm, usually with retraction. a. History and Initial Diagnostic Procedures (Rotator Cuff Tear)

1) Occupational Relationship – established with sudden trauma to the shoulder or chronic overuse with repetitive overhead motion with internal or external rotation.

2) History may include:

a) Partial-thickness cuff tears usually occur in age groups older than 30. Fullthickness tears can occur in younger age groups.

b) Complaints of pain along anterior, lateral or posterior glenohumeral joint. b. Physical Findings (Rotator Cuff Tear) may include

1) Partial-Thickness Tear

a) There will be pain at the end of range-of-motion with full passive range-of-motion for abduction, elevation, external rotation; internal rotation is attainable;

b) Active range-of-motion will be limited and painful for abduction and external rotation, as well as internal rotation and forward flexion;

c) A painful arc may be present with active elevation;

d) Pain will be positive for resisted tests (abduction, flexion, external rotation, internal rotation, abduction/internal rotation at 90°;, and abduction/external rotation at 45°;; and/or e) If there are positive impingement signs, see this Section IV.B., Impingement Syndrome.

2) Full-Thickness Tears

a) Passive and resisted findings are similar to those for partial-thickness tears; and/or

b) Active elevation will be severely limited with substitution of scapular rotation being evident. c. Laboratory Tests (Rotator Cuff Tear) are not indicated unless a systemic illness or disease is suspected. d. Testing Procedures (Rotator Cuff Tear)

1) Plain x-rays include

a) AP view visualizes elevation of the humeral head, indicative of absence of the rotator cuff due to a tear;

b) Lateral view in the plane of the scapula or an axillary view determines if there is anterior or posterior dislocation or the presence of a defect in the humeral head (a Hill-Sachs lesion);

c) 30°; caudally angulated AP view determines if there is a spur on the anterior/interior surface of the acromion and/or the far end of the clavicle; and

d) Outlet view determines if there is a downwardly tipped acromion.

2) Adjunctive testing should be considered when shoulder pain is refractory to 4-6 weeks of nonoperative conservative treatment and the diagnosis is not readily identified by standard radiographic techniques, then sonography, arthrography or MRI may be indicated. e. Nonoperative Treatment Procedures (Rotator Cuff Tear)

1) Medications, such as nonsteroidal anti-inflammatories and analgesics, would be indicated; acute rotator cuff tear could indicate the need for limited narcotics use.

2) Relative rest and procedures outlined in this Section IV.D., such as immobilization, therapeutic exercise, alteration of occupation/work station, thermal treatment, TENS unit, therapeutic ultrasound, return-to-work, biofeedback and physical medicine and rehabilitation. If no increase in function for a partial- or full-thickness tear is observed after 6-12 weeks, a surgical consultation is indicated. Early surgical intervention produces better surgical outcome due to healthier tissues and often less limitation of movement prior to and after surgery. f. Operative Procedures (Rotator Cuff Tear) options would include arthroscopic repair or an open debridement and repair. Goals of surgical intervention are to restore functional anatomy by reestablishing continuity of the rotator cuff, and to reduce the potential for repeated impingement by the performance of procedures such as distal clavicular resection, coracoacromial ligament release, and/or anterior acromioplasty. g. Post-Operative Procedures (Rotator Cuff Tear) would include an individualized rehabilitation program based upon communication between the surgeon and the therapist. 1) Individualized rehabilitation program based on communication between the surgeon and the therapist might include:

a) Sling or abduction splint;

b) Gentle pendulum exercise, passive glenohumeral range-of-motion in flexion and external rotation to prevent adhesions and maintain mobilization;

c) At 6 weeks post-operative begin isometrics and ADL involvement;

d) Active assisted range-of-motion in supine with progression to sitting;

e) At 6-8 weeks, depending on quality of tissue, begin light resistive exercise;

f) Pool exercise, manual resistive exercise to 90°;, scapula mobilization exercise with glenohumeral stabilization; and

g) Scapula plane exercise.

2) Progressive resistive exercise from 3-6 months with gradual returning to full activity at 6-9 months. All active nonoperative procedures listed in this Section IV.D. should be considered.

3) Work restrictions should be evaluated every 4-6 weeks during post-operative recovery and rehabilitation with appropriate written communications to both the patient and employer. Should progress plateau, the provider should reevaluate the patient's condition and make appropriate adjustments to the treatment plan.

8. Rotator Cuff Tendinitis:

Inflammation of one or more of the four musculotendincus structures which arise from the scapula and insert on the lesser or greater tuberosity of the humerus. These structures include one internal rotator (subscapularis), and two external rotators (infraspinatus and teres minor), and the supraspinatus which assists in abduction. a. History and Initial Diagnostic Procedures (Rotator Cuff Tendinitis)

1) Occupational Relationship – may include symptoms of pain and/or achiness that occur after repetitive use of the shoulder and/or blunt trauma to the shoulder. b. Physical Findings (Rotator Cuff Tendinitis) may include

1) Pain with palpation to the shoulder with active or passive abduction and external rotation of the shoulder (painful arc);

2) Pain with impingement signs; and/or

3) Pain with specific activation of the involved muscles. c. Laboratory Tests (Rotator Cuff Tendinitis) are not indicated unless a systemic illness or disease is suspected. d. Testing Procedures (Rotator Cuff Tendinitis) may include

1) Plain x-ray films including AP lateral, axial, 30°; caudally angulated AP, Outlet view. 2) If shoulder pain is refractory to 4-6 weeks of nonoperative care and the diagnosis is not readily identified by standard radiographic techniques, then adjunctive testing, such as MRI, sonography or arthrography, may be indicated.

3) Subacromial space injection can be used as a diagnostic procedure by injecting an anesthesia, such as sensorcaine or xylocaine solutions, into the space. If the pain is alleviated with the injection the diagnosis is confirmed. e. Nonoperative Treatment Procedures (Rotator Cuff Tendinitis) may include

1) Medications, such as nonsteroidal anti-inflammatories and analgesics. Subacromial space injection may be therapeutic if the patient responded positively to a diagnostic injection of an anesthetic. Injection of the corticosteroids directly into the tendons should be:

a) Avoided due to possible tendon breakdown and degeneration,

b) Limited to 3 injections per year at the same site, and

c) Avoided in patients under 30 years of age.

2) Procedures outlined in this Section IV.D. – such as relative rest, immobilization, thermal treatment, ultrasound, therapeutic exercise, physical medicine and rehabilitation. f. Operative Procedures (Rotator Cuff Tendinitis) are not indicated for this diagnosis.

9. Shoulder Fractures:

There are five common types of shoulder fractures; each type will be addressed separately and in the order of most frequent occurrence. a. Clavicular Fracture

1) History and Initial Diagnostic Procedures (Clavicular Fracture)

a) Occupational Relationship – can result from direct blows or axial loads applied to the upper limb; commonly associated injuries include rib fractures, long-bone fractures of the ipsilateral limb and scapulothoracic dislocations.

2) Physical Findings (Clavicular Fracture) may include

a) Pain in the clavicle;

b) Abrasions on the chest wall, clavicle and shoulder can be seen;

c) Deformities can be seen in the above regions; and/or

d) Pain with palpation and motion at the shoulder joint area.

3) Laboratory Tests (Clavicular Fracture) are not indicated unless a systemic illness or disease is suspected.

4) Testing Procedures (Clavicular Fracture) would usually include routine chest x-rays. If they do not reveal sufficient information, then a 20°; caudalcranial AP view centered over both clavicles can be done. 5) Nonoperative Treatment Procedures (Clavicular Fracture)

a) Most are adequately managed by closed techniques and do not require surgery. After reduction, the arm is immobilized in a sling or figure-8 bandage. Shoulder rehabilitation is begun with pendulum exercises 10-14 days after injury. Subsequently, with pain control, the therapy program can be progressed with therapeutic approaches as seen in this Section IV.D.

b) Medication, such as analgesics and nonsteroidal anti-inflammatories, would be indicated; narcotics may be indicated acutely for fracture and should be prescribed as indicated use is indicated in this Section IV.C.

6) Operative Procedures (Clavicular Fracture) would be indicated for open fractures, vascular or neural injuries requiring repair, bilateral fractures, ipsilateral scapular or glenoid neck fractures, scapulothoracic dislocations, flail chest and nonunion displaced-closed fractures that show no evidence of union after 4-6 months. Also a Type II fracture/dislocation at the AC joint where the distal clavicular fragment remains with the acromion and the coracoid, and the large proximal fragment is displaced upwards.

7) Post-Operative Procedures (Clavicular Fracture) would include an individualized rehabilitation program based upon communication between the surgeon and the therapist. This program would begin with 2-3 weeks of rest with a shoulder immobilizer while encouraging isometric deltoid strengthening; pendulum exercises with progression to assisted forward flexion and external rotation would follow; strengthening exercises should be started at 10-12 weeks as seen in this Section IV.D. b. Proximal Humeral Fractures

1) History and Initial Diagnostic Procedures (Proximal Humeral Fractures)

a) Occupational Relationship – may be caused by a fall onto an abducted arm; may also be caused by high-energy (velocity or crush) trauma with an abducted or nonabducted arm; associated injuries are common, such as glenohumeral dislocation, stretch injuries to the axillary, musculocutaneous, and radial nerves; axillary artery injuries with high energy accident.

2) Physical Findings (Proximal Humeral Fractures) may include

a) Pain in the upper arm;

b) Swelling and bruising in the upper arm, shoulder and chest wall;

c) Abrasions about the shoulder; and/or

d) Pain with any attempted passive or active shoulder motion.

3) Laboratory Tests (Proximal Humeral Fractures) are not indicated unless a systemic illness or disease is suspected.

4) Testing Procedures (Proximal Humeral Fracture)

a) X-ray trauma series (3 views) are needed; AP view, axillary view and a lateral view in the plane of the scapula. The latter two views are needed to determine if there is a glenohumeral dislocation. b) Vascular studies are obtained emergently if the radial and brachial pulses are absent.

c) Classification is by the Neer Method; there can be four fragments – the humeral shaft, humeral head, greater tuberosity, and the lesser tuberosity. The fragments are not truly considered fragments unless they are separated by 1cm or are angulated 45°; or more.

5) Nonoperative Treatment Procedures (Proximal Humeral Fractures)

a) Impacted fractures of the humeral neck or greater tuberosity are managed nonoperatively.

b) Isolated and minimally displaced (less than 1cm) fractures are treated nonoperatively.

c) Anterior or posterior dislocation associated with minimally displaced fractures can usually be reduced by closed means, but a general anesthetic is needed.

d) Immobilization is provided with a sling, to support the elbow, or with an abduction immobilizer if a nonimpacted greater tubercsity fragment is present.

e) Immobilization is continued for 4-6 weeks

f) Shoulder rehabilitation is begun with pendulum exercises 10-14 days after injury. Subsequently, with pain control, the therapy program can be progressed with therapeutic approaches as seen in this Section IV.D.

6) Operative Procedures (Proximal Humeral Fractures)

a) Indications for operative treatment would include

(1) Unstable surgical neck fractures (no contact between the fracture fragments).

(2) Partially unstable fractures (only partial contact) with associated same upper extremity injuries.

(3) Displaced 3- and 4-part fractures may be managed by a prosthetic hemiarthroplasty and reattachment of the tuberosities.

7) Post-Operative Procedures (Proximal Humeral Fractures) would include an individualized rehabilitation program based upon communication between the surgeon and the therapist.

a) See this Subsection IV.B.9., Shoulder Fracture, Nonoperative Treatment Procedures.

b) Schanz pins are removed from the greater tuberosity fragment at 2-3 weeks.

c) Schanz pins across the humeral neck are removed at 4-6 weeks. c. Humeral Shaft Fractures

1) History and Initial Diagnostic Procedures (Humeral Shaft Fractures)

a) Occupational Relationship – a direct blow can fracture the humeral shaft at the junction of its middle and distal thirds; twisting injuries to the arm will cause a spiral humeral shaft fracture; high energy (velocity or crush) will cause a comminuted humeral shaft fracture.

2) Physical Findings (Humeral Shaft Fractures) may include

a) Deformity of the arm;

b) Bruising and swelling; and/or

c) Possible sensory and/or motor dysfunction of the radial nerve.

3) Laboratory Tests (Humeral Shaft Fractures) are not indicated unless a systemic illness or disease is suspected.

4) Testing Procedures (Humeral Shaft Fractures)

a) Plain x-rays including AP view and lateral of the entire humeral shaft.

b) Vascular studies if the radial pulse is absent.

c) Compartment pressure measurements if the surrounding muscles are swollen, tense and painful and particularly if the fracture resulted from a crush injury.

5) Nonoperative Treatment Procedures (Humeral Shaft Fractures)

a) Most isolated humeral shaft fractures can be managed nonoperatively.

b) A coaptation splint may be applied. The splint is started in the axilla, extended around the elbow and brought up to the level of the acromion. It is held in place with large elastic bandages.

c) At 2-3 weeks after injury, a humeral fracture orthosis may be used to allow for full elbow motion.

6) Operative Treatment (Humeral Shaft Fractures)

a) Indications for operative care would include

(1) Open fracture;

(2) Associated forearm or elbow fracture (i.e., the floating elbow injury);

(3) Burned upper extremity;

(4) Associated paraplegia;

(5) Multiple injuries (polytrauma);

(6) A radial nerve palsy which came on after closed reduction; and/or

(7) Pathologic fracture related to an occupational injury.

b) Accepted methods of internal fixation include:

(1) A broad plate and screws; and/or (2) Intramedullary rodding with or without cross-locking screws.

7) Post-Operative Procedures (Humeral Shaft Fractures would include an individualized rehabilitation program based upon communication between the surgeon and the therapist. Following rigid internal fixation, therapy may be started to obtain passive and later active shoulder motion using appropriate therapeutic approaches as seen in this Section IV.D. Active elbow and wrist motion may be started immediately. d. Scapula Fractures

1) History and Initial Diagnostic Procedures (Scapular Fractures)

a) Occupational Relationship – these are the least common of the fractures about the shoulder and include acromial, glenoid, glenoid neck and scapular body fractures. With the exception of anterior glenoid lip fractures caused by an anterior shoulder dislocation, all other scapular fractures are due to a high energy injury.

2) Physical Findings (Scapular Fractures) may include

a) Pain about the shoulder and thorax;

b) Bruising and abrasions;

c) Possibility of associated humeral or rib fractures; and/or

d) Assess vascular status (pulse evaluation and Doppler examination).

3) Laboratory Tests (Scapular Fractures), because of the association of high energy trauma, may include a complete blood count, urinalysis and chest x-ray are warranted.

4) Testing Procedures (Scapular Fractures)

a) Trauma x-ray series – AP view axillary view, and a lateral view in the plane of the scapula.

b) Arteriography if a vascular injury is suspected.

c) Electromyographic exam if nerve injuries are noted.

5) Nonoperative Treatment Procedures (Scapular Fractures)

a) Nondisplaced Acromial, coracoid, glenoid, glenoid neck and scapular body fractures may all be treated with the use of a shoulder immobilizer.

b) Pendulum exercises may be started within the first week.

c) Progress to assisted range-of-motion exercises at 3-4 weeks using appropriate therapeutic procedures as seen in this Section IV.D.

6) Operative Treatment (Scapular Fractures)

a) Acromial fractures which are displaced should be internally fixed to prevent a nonunion. These fractures may be fixed with lagged screws and a superiorly placed plate to neutralize the muscular forces. b) Glenoid fractures which are displaced greater than 2-3 mm should be fixed internally. The approach is determined by studying the results of a CT scan.

c) Scapular body fractures require internal fixation if the lateral or medial borders are displaced to such a degree as to interfere with scapulothoracic motion.

d) Displaced fractures of the scapular neck and the ipsilateral clavicle require internal fixation of the clavicle to reduce the scapular neck fracture.

7) Post-Operative Treatment (Scapular Fractures) would include an individualized rehabilitation program based upon communication between the surgeon and the therapist using the appropriate therapeutic procedures seen in this Section IV.D., a shoulder immobilizer is utilized, pendulum exercises at one week, deltoid isometric exercises are started early, and, at 4-6 weeks, active range-of-motion is commenced. e. Sternoclavicular Dislocation/Fracture

1) History and Initial Diagnostic Procedures (Sternoclavicular Dislocation/Fracture)

a) Occupational Relationship – established with sudden trauma to the shoulder/anterior chest wall; anterior dislocations of the sternoclavicular joint usually do not require active treatment; however, symptomatic posterior dislocations will require reduction.

2) Physical Findings (Sternoclavicular Dislocation/Fracture) may include

a) Pain at the sternoclavicular area;

b) Abrasions on the chest wall, clavicle and shoulder can be seen;

c) Deformities can be seen in the above regions; and/or

d) Pain with palpation and motion at the sternoclavicular joint area.

3) Laboratory Tests (Sternoclavicular Dislocation/Fracture) are not indicated unless a systemic illness or disease is suspected.

4) Testing Procedures (Sternoclavicular Dislocation/Fracture)

a) Plain x-rays of the sternoclavicular joint are routinely done. When indicated, comparative views of the contralateral limb may be necessary.

b) X-rays of other shoulder areas and chest wall may be done if clinically indicated.

c) Vascular studies should be considered if the history and clinical examination indicate extensive injury.

5) Nonoperative Treatment Procedures (Sternoclavicular Dislocation/Fracture)

a) Symptomatic posterior dislocations should be reduced in the operating room under general anesthesia.

b) Immobilize with a sling for 3-4 weeks. Subsequently, further rehabilitation may be utilized using procedures set forth in this Section IV.D. c) Medications, such as analgesics and nonsteroidal anti-inflammatories, would be indicated; narcotics may be indicated acutely for fracture and should be prescribed as indicated use is indicated in this Section IV.C.

6) Operative Procedures (Sternoclavicular Dislocation/Fracture) would be warranted following failure of reduction by manipulation with pointed reduction forceps. Caution should be utilized when pins or screws are used for stabilization secondary to migration.

7) Post-Operative Procedures (Sternoclavicular Dislocation/Fracture) would include an individualized rehabilitation program based upon communication between the surgeon and the therapist. This program would begin with 4-6 weeks of rest with a shoulder immobilizer and be followed by pendulum exercises with progression to assisted forward flexion and external rotation. Strengthening exercises should be started at 8-10 weeks.

10. Shoulder Instability:

Subluxation (partial dislocation) or dislocation of the glenohumeral joint in either an anterior, interior, posterior or multidirectional position. a. History and Initial Diagnostic Procedures (Shoulder Instability)

1) Occupational Relationship – instability should be apparent following a direct traumatic blow to the shoulder, or indirectly by falling on an outstretched arm, or while applying significate traction to the arm, or may also develop with a cumulative trauma to the shoulder. Symptoms should be exacerbated or provoked by work and initially alleviated with a period of rest. Symptoms may be exacerbated by other activities that are not necessarily work related (e.g., driving a car).

2) History may include:

a) A slipping sensation in the arm;

b) Severe pain with inability to move the arm;

c) Abduction and external rotation produce a feeling that the shoulder might “come out”; or

d) Feeling of shoulder weakness.

3) In subacute and/or chronic instabilities, age of onset of instability is important in the history. Older age group (over age 30) has a propensity not to redislocate. Younger age groups need a more aggressive treatment plan.

4) Avoid any aggressive treatment in patients with history of voluntary subluxation or dislocation. These patients may need a psychiatric evaluation. b. Physical Findings (Shoulder Instability) may include

1) Anterior dislocations would likely include loss of normal shoulder contour; a fullness in the axilla; pain over the shoulder with any motion and often the patient holding the extremity in a very still position;

2) Posterior dislocations usually occur with a direct fall on the shoulder or outstretched arm resulting in posteriorly directed forces to the humeral head. These patients present with inability to externally rotate the shoulder; 3) Neurologic examination could reveal most commonly axillary nerve injuries, but occasionally musculocutaneous nerve injuries are seen; and/or

4) Abduction and external rotation positioning will produce pain in those who have anterior instability. Direct posterior stress in a supine position will produce pain in those with posterior instability. Longitudinal traction will produce a “sulcus sign” (a large dimple on the lateral side of the shoulder) when there is inferior instability. c. Laboratory Tests (Shoulder Instability) are not indicated unless a systemic illness or disease is suspected. d. Testing Procedures (Shoulder Instability)

1) Plain x-rays to rule out bony deficit on the glenoid, including AP, axillary view, lateral in the plane of the scapula and possibly the West Point view. Axillary view to identify larger Hill- Sachs lesion of humeral head.

2) On more difficult diagnostic cases with subtle history and physical findings suggesting instability, MRI, or a CT assisted arthrogram or MRI assisted arthrogram may be ordered for lateral detachment after 4-8 weeks of therapy. (This is done only after other conservative therapies have failed.) e. Nonoperative Treatment Procedures (Shoulder Instability)

1) First-Time Acute Severe Bony Involvement:

a) Therapeutic Procedures

(1) Immobilization

(2) Therapeutic Exercise

(3) Alteration of Occupation & Work Station

(4) Thermal Treatment

(5) TENS Unit

(6) Ultrasound

b) May not return to work with overhead activity or lifting with involved arm until cleared by physician for heavier activities.

c) Additional modalities may include

(1) Biofeedback

(2) Physical Medicine and Rehabilitation

(a) Instruction in Therapeutic Exercise and Proper Work Techniques

(b) Manual Therapy Techniques

(3) Psychosocial Intervention (4) Work Conditioning

(a) Vocational Rehabilitation

(b) Vocational Assessment

1] Work Hardening

2] Functional Restoration Programs

3] Pain Clinics

d) Medications – medication discussions are in this Section IV.C.

(1) Analgesics

(2) Anti-inflammatories

2) Acute or chronic dislocations with large fracture fragments contributing to instability;

a) Attempt to treat with immobilization if in acceptable position, otherwise repair surgically

b) Return-to-work may be directly related to time it takes for the fracture to heal

3) Subacute and/or chronic instability:

a) Provocative dislocation should first be treated similarly to acute dislocation.

b) If acute treatment is unsuccessful, and still having findings of instability, would consider operative repair. f. Operative Procedures (Shoulder Instability)

1) Identify causative agent for the instability (i.e., labral detachment, bony lesion, or multidirectional instability), then proceed with

a) Bony block transfer;

b) Capsular tightening; or

c) Bankart lesion repair. g. Post-Operative Procedures (Shoulder Instability) would include an individualized rehabilitation program based upon communication between the surgeon and the therapist. Depending upon the type of surgery, the patient will be immobilized for 3-6 weeks. As soon as it is safe to proceed without damaging the repair, progressive therapy with consultation involving an occupational and/or physical therapist should begin with therapeutic exercise, physical medicine and rehabilitation (refer to this Section IV.D.). During this period of time, the patient could resume working when

1) A job assessment results in the treating physician's identification of needed modifications and restrictions; 2) The patient has attained a general level of comfort;

3) Medications which would predispose to injury are no longer being prescribed or used; and

4) The treating physician has cleared the patient for the specific vocational activities.

MMI can be expected 3 months after non operative medications and 3-6 months after operative medications. Further job assessment and adjusted work restrictions may be needed prior to the patients return to full duty.

C. MEDICATIONS:

For shoulder disorders medications play a secondary role and should never be the sole modality of treatment. If a patient's symptoms resolve quickly with medications or any other passive modality, the practitioner should still consider prescribing a brief course in shoulder and upper extremity education and safety. When required, a wide range of medication is available. Modalities in this group are generally accepted, established and widely used. All narcotics and habituating medications should be prescribed with strict time, quantity and duration guidelines with a definite cessation parameter. Prescribing these drugs on an as-needed basis (PRN) should almost always be avoided.

1. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are probably the most useful medications in acute and chronic shoulder injury. In mild cases, they may be the only drug required for analgesia. There are several classes of NSAIDs and the response of the individual patient to a specific medication is unpredictable. For this reason, a range of anti-inflammatory medications may be tried in each case with the most effective preparation being continued. Acute Pain / Chronic Pain a. Time to produce effect: 3-7 days / 3-7 days b. Frequency: 1-4 times/day / 1-4 times/day c. Optimum duration: 2 weeks / Up to 1 year d. Maximum continuous duration: 6 weeks / 1 year

For prolonged use of NSAIDs greater than 1-3 months, patients should be monitored for adverse reactions. Appropriate intervals for metabolic screening are dependent upon the patient's age, general health status and should be within parameters listed for each specific medication.

2. Analgesics

(acetaminophen and acetylsalicylic acid) are the common choice for non-narcotic analgesia. a. Time to produce effect: immediate, usually ineffective in severe attacks b. Frequency: 3-5 times/day c. Optimum duration: 3-4 days d. Maximum continuous duration: 6 weeks

3. Psychotropic Medication may be used in patients with a high level of anxiety or depression. A variety of psychotropic drugs may be used. In acute or subacute shoulder injury, these medications are generally unnecessary except for the use of tricyclic antidepressants as substitutes for hypnotics and/or analgesics. In most cases, major tranquilizers, anxiolytics and antidepressants are reserved for chronic pain disorders. Patients whose chief complaint is shoulder injury, but require use of major tranquilizers or anxiolytics for greater than two weeks, should be considered for psychological and/or psychiatric consultation. In particular, benzodiazepams are almost always contraindicated in patients with shoulder injury unless a severe anxiety state exists requiring psychiatric supervision or in cases of extremely severe, objectively visualized acute muscle spasm. In this type of acute scenario, the maximum duration for benzodiazepam administration should be limited to less than five days. a. Time to produce effect: 2-3 weeks b. Frequency: for tricyclics, prefer single dose at night c. Optimum duration: 1-6 months d. Maximum duration: 6-12 months, with monitoring

4. Hypnotics may be given to shoulder injury sufferers because of a chief complaint of “inability to sleep.” Such medication must be used with caution because of their dependence-producing capabilities. The Division recommends consideration of sedating tricyclic anti-depressants as an alternative when necessary. Physical methods of restoring a normal sleep pattern can usually be employed as an alternative to medication. a. Time to produce effect: 1-3 days b. Frequency: at night c. Optimum duration: 1 week d. Maximum duration: 2-3 weeks

5. Narcotics should be primarily reserved for the treatment of acute shoulder injury or the treatment of patients with objectively documented acute exacerbations. The action of these drugs is central, affecting the patient's perception of pain rather than the pain process itself. a. Time to produce effect: immediate b. Frequency: every 3-4 hours c. Optimum duration: 3 days d. Maximum duration: 2 weeks

Narcotics are rarely indicated in the treatment of patients with pure shoulder injury without fracture. In mild to moderate cases of upper extremity pain, narcotic medication should not be used at all. Adverse effects include respiratory depression and the development of physical and psychological dependence.

6. Minor Tranquilizers/Muscle Relaxants should be primarily reserved for the treatment of acute shoulder with muscle spasm or the treatment of patients with objectively documented acute exacerbations. Muscle relaxants may have a significant effect on the early phases of acute shoulder disorders. Their action is central and with no effect on the neuromuscular junction of the muscles themselves. Purported peripheral effects are difficult to separate from the anxiolytic central action. a. Time to produce effect: 1 day b. Frequency: 1-4 times/day; preferably just at night c. Optimum duration: 1 week d. Maximum duration: 4 weeks

D. NONOPERATIVE TREATMENT PROCEDURES:

1. Immobilization time is dependent upon type of injury, then progress with muscle girdle strengthening a. Time to produce effect: 1 day b. Frequency: once c. Optimum duration: 1 week d. Maximum duration: 12 weeks

The arm is immobilized in a sling for 1-12 weeks postinjury, depending upon the age of the patient. The patient is instructed in Isometric exercises while in the sling for the internal and external rotators and the deltoid.

2. Relative Rest may last 3-5 weeks and require job modification/modified duty so as not to exacerbate the acute inflamed shoulder.

3. Therapeutic Exercise where the therapist instructs the patient in a supervised clinic and home program to increase strength of the supporting shoulder musculature. Motions and muscles to be strengthened include shoulder internal and external rotators, abductors and scapula stabilizers. Isometrics are performed initially, progressing to Isotonic exercises as tolerated. a. Frequency of visits: 2-3 times/week for 8-12 wks Weeks 1-3: Isometrics in sling Weeks 3-8: Progressive Isotonic exercises Weeks 8-12: Begin overhead activities when the rotator cuff strength is normalized and full active elevation has been achieved.

4. Alteration of Occupation and Work Station early evaluation and training of body mechanics and joint protection and other ergonomic factors is essential and should be done by a qualified individual. Ergonomic risk factors to be addressed include repetitive overhead work, lifting and/or tool use.

5. Thermal Treatment includes applications of heat and cold (superficial and deep); therapeutic modalities in this group are generally accepted, established and widely used procedures. a. Time to produce effect: 2-4 treatments b. Frequency: 2-3 times/week up to 3 weeks, decreasing to 1-2 times/week after 1 month. Ongoing thermal treatment may be self-administered by the unsupervised patient c. Optimum duration: 2-3 months in conjunction with other therapies

6. Transcutaneous Electrical Nerve Stimulation (TENS) is generally accepted, established and widely used but the mode of action is poorly understood. a. Time to produce effect: 1 or 2 sessions per trial, up to 3 trials b. Frequency: 2-3 times/week (supervised) for 3 weeks; during this supervised period, the patient may utilize the TENS unit daily on a self-monitored basis after receiving instructions c. Optimum duration: 1-3 months

Initially, TENS should be prescribed within a supervised setting in order to assure proper electrode placement and patient education. TENS can be used for short-term pain control. If the response to three treatments is beneficial, it may be continued for 1-3 months and for intermittent unsupervised use thereafter if it facilitates objective functional gains. The Division would not recommend purchase of a TENS unit until efficacy has been substantiated after a 90-day trial period. It may be occasionally useful in specific myofascial pain cases within the above time frames.

7. Therapeutic Ultrasound With or Without Electric Stimulation using sonic generators to deliver acoustic energy for therapeutic thermal and/or nonthermal soft tissue treatment. There may be a concurrent delivery of electrical energy and/or medication (iontophoresis). Indications include scar tissue, adhesions, collagen fiber and muscle spasm, and the need to extend muscle tissue or accelerate the soft tissue healing. a. Time to produce effect: 6-15 treatments b. Frequency: 3 times/week c. Optimum duration: 4 weeks

8. Electrical Therapeutic Modality can be utilized as an adjunct for recovery. In order to justify its use, one must provide documentation regarding functional gains. a. Time to produce effect: 8-12 sessions b. Frequency: 3 times/week c. Optimum duration: 4 weeks

9. Return-to-Work

May return to work with no overhead activity, lifting, or repetitive motion with the involved arm until cleared by the primary treating physician for heavier activities. Each case regarding task tolerance should be individualized based on the diagnosis and job demands.

10. Biofeedback is the use of physiological monitoring equipment to: a. Improve the patient's awareness and control of muscle activity; b. Reinforce the release of muscle tension that is being obtained from stretches and exercises; c. Decrease sympathetic arousal that is associated with stress; d. Improve the patient's ability to feel like they can affect their physical responses and symptoms; e. Assist in avoiding reinjury through the individual returning to repetitive movement and bracing patterns; or f. Prepare for surgery.

Treatment time may or may not overlap return-to-work or MMI.

1) Time to produce effect: 3-4 sessions

2) Frequency: 1-2 times/week

3) Optimum duration: 5-6 sessions

4) Maximum duration: 10-12 sessions

11. Physical Medicine and Rehabilitation a. Instruction in Therapeutic Exercise and Proper Work Techniques: an active therapeutic exercise program may be beneficial and should contain elements of improving patient flexibility, mobility, posture/body mechanics, activities-of-daily-living, splinting, bracing, sensory reeducation, endurance, strength and education.

1) Time to produce effect: 2 weeks

2) Frequency: 2-3 times/week

3) Optimum duration: 4-6 weeks

4) Maximum duration: 12 weeks b. Manual Therapy Techniques: soft tissue mobilization/manipulation techniques may be used as an adjunctive treatment modality. c. Post-Operative Treatment may include scar/adhesion reduction techniques.

12. Work Simulation modalities are generally accepted, wellestablished and widely used. They are simulated activities of daily living including those generally performed by disabled workers in the work place. If placement at modified duty at the work place is unavailable, work simulation should run concurrently or sequentially based upon analysis of physical capacity and job analysis: a. Time to produce effect: 1-3 weeks b. Frequency: 2-5 times/week c. Optimum duration: 2-3 weeks d. Maximum duration: 3-6 weeks

Work simulation is generally followed either by work hardening, return to work, or a combination thereof (see for Work Hardening additional discussion).

13. Personality/Psychological/Psychosocial Evaluations are generally accepted and well-established diagnostic procedures with selected use in the shoulder population, but have more widespread use in the subacute and chronic shoulder population. These procedures may be useful for patients with delayed recovery, chronic pain, recurrent painful conditions, suspected concomitant closed head injury, disability problems and pre-operative evaluation, as well as a possible predictive value for post-operative response. Results may provide clinicians with a better understanding of the patient, thus allowing for more effective rehabilitation. Formal psychological or psychosocial screening should be performed on patients not making expected progress within 6-12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests. This testing will determine the need for further psychosocial interventions. Evaluations should be performed by an individual with PH.D., PSY.D., L.S.W. or Psychiatric M.D./D.O. credentials. Initial psychological screening is generally completed within one hour. If psychometric testing is indicated as a portion of the initial screening process, the time for such testing should not exceed an additional two hours of professional time.

14. Vocational Rehabilitation is a generally accepted intervention, but Colorado limits its use as a result of Senate Bill 87-79. Initiation of vocational rehabilitation requires adequate evaluation of patients for quantification of highest functional level, motivation and achievement of MMI. Vocational rehabilitation may be as simple as returning to the original job or as complicated as being retrained for a new occupation.

15. Vocational Assessment

Once an authorized practitioner has reasonably determined and objectively documented that a patient will not be able to return to his/her former employment and can reasonably prognosticate final restrictions and date of MMI, then implementation of a timely vocational assessment can provide valuable guidance in the determination of future rehabilitation program design. Clarification of rehabilitation goals optimize both patient motivation and utilization of rehabilitation resources. Except in the most extenuating circumstances, this process should be implemented within 3-12 months post-injury at the latest, if prognosis for return to former occupation is determined to be guarded to poor. Declaration of MMI should not be delayed solely due to lack of attainment of a vocational assessment.

16. Interdisciplinary Team Approach interventions are generally accepted, well-established and widely used. This approach includes work hardening programs, functional restoration programs and pain clinics. In general, these programs are more comprehensive, time consuming and costly and are, therefore, appropriate for patients with greater levels of (perceived) disability, dysfunction, deconditioning and psychological involvement. For shoulder injury cases, all interdisciplinary teams should include a physical therapist and/or occupational therapist who specializes in the upper extremity. a. Functional Restoration Programs are intended for patients with both physical deconditioning and/or significant psychological and socioeconomic involvement. It encompasses work hardening, quantification of function, disability management, adjustment counseling and outcome review. The interdisciplinary team must consist of physicians and therapists working in a structured environment. The Division recommends an interdisciplinary team include physical therapy, occupational therapy and psychology or at least related supervised personnel addressing the physiologic, psychologic and ergonomic factors impacting a patient's shoulder injury presentation. Regular, documented interdisciplinary team meetings to discuss patient progress and upgrade rehabilitation goals must be a part of any credible interdisciplinary approach. The Division recommends programs which meet criteria consistent with those for work hardening established by CARF. In nonsurgical shoulder injury patients with evidence of delayed recovery, the Division strongly recommends referral to an interdisciplinary/functional restoration program within three months post-injury.

1) Time to produce effect: 4-6 weeks

2) Frequency: 2-6 times/week

3) Optimum duration: 6-12 weeks

4) Maximum duration: 4 months b. Work Hardening Programs are generally more comprehensive than work simulation programs and include education, reconditioning and specific work simulation with respect to task quality, quantity and intensity (for further discussion, refer to Work Simulation). The Division recommends the Commission for the Accreditation of Rehabilitation Facilities (CARF) eligibility and/or accreditation of work hardening programs for all facilities treating injured workers to assure that such programs meet certain standards involving program design and efficacy. Work hardening is generally initiated after reconditioning or functional restoration has been completed if imminent return of a patient to modified or full duty is not an option but the prognosis for returning the patient to work at completion of the program is at least fair to good. As discussed in Vocational Assessment, identification of realistic vocational goals is essential for the successful completion of a work hardening program. Generally, work hardening programs entail a progressive increase in the number of hours per day that a patient completes work simulation tasks until the patient can tolerate a full work day:

1) Time to produce effect: 2-4 weeks

2) Frequency: 2-5 times/week

3) Optimum duration: 4-6 weeks

4) Maximum duration: 2-3 months c. Pain Clinics have been the traditional rehabilitation program for chronically disabled shoulder patients who have not responded to functional restoration interventions. In general, pain clinics deal with irreversible, painful neurological disorders and psychological issues, including drug dependence, high levels of stress and anxiety, failed surgery and preexisting or latent psychopathology. The Division recommends CARF eligibility and/or accreditation of pain clinics treating injured workers to assure that such programs meet certain standards involving program design and efficacy. The Division also recommends consideration of referral to a pain clinic within 6 months post-injury in those patients with delayed recovery unless surgical interventions or other medical complications intervene. It may be useful in determining the appropriateness of referral to a pain clinic to consider the Colorado Foundation for Medical Care's “Criteria for Outpatient (or Inpatient) Management of Chronic Pain.” 1) Time to produce effect: 3-8 weeks

2) Frequency: 2-7 times/week for first month decreasing to 2-3 times/week thereafter

3) Optimum duration: 6-12 weeks, including follow-up for outpatient pain clinics; 3-4 weeks for inpatient pain clinics

4) Maximum duration: 4 months, including follow-up

Periodic review and monitoring on an as-needed basis is thereafter founded upon the documented maintenance of functional gains.

RULE XVII, EXHIBIT B-V Cumulative Trauma Disorder (CTD) Medical Treatment Guidelines July 30, 2003 (Previously Adopted March 2, 1995 and Revised December 30, 1996, and March 15, 1998)

Presented By:

State of Colorado Department of Labor and Employment DIVISION OF WORKERS' COMPENSATION

TABLE OF CONTENTS

A. INTRODUCTION

B. GENERAL GUIDELINE PRINCIPLES

1. APPLICATION OF GUIDELINES

2. EDUCATION

3. TREATMENT PARAMATER DURATION

4. ACTIVE INTERVENTIONS

5. ACTIVE THERAPEUTIC EXERCISE PROGRAM

6. POSITIVE PATIENT RESPONSE

7. RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS

8. SURGICAL INTERVENTIONS

9. SIX-MONTH TIME FRAME

10. RETURN-TO-WORK

11. DELAYED RECOVERY

12. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE

13. CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI)

C. DEFINITION AND MECHANISMS OF INJURY: D. INTTIAL DIAGNOSTIC PROCEDURES

1. HISTORY:

a. Description of Symptoms:

b. Identification of Occupational Risk Factors:

c. Demographics: age, hand dominance, gender, etc.

d. Past Medical History and Review of Systems:

e. Activities of Daily Living (ADLs):

f. Avocational Activities:

g. Social History:

2. PHYSICAL EXAMINATION

3. PAIN BEHAVIOR EVALUATION

4. RISK FACTORS

5. MEDICAL CAUSALITY ASSESSMENT FOR CUMULATIVE TRAUMA DISORDERS

6. STAGING

STAGE 1

STAGE 2

STAGE 3

STAGE 4

E. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES

1. ELECTRODIAGNOSTIC (EDX) STUDIES

2. IMAGING STUDIES

a. Radiographic Imaging

b. MRI

3. ADJUNCTIVE TESTING

a. Personality/Psychological/Psychosocial Evaluations

b. Laboratory Tests

c. Pinch And Grip Strength Measurements

d. Quantitative Sensory Testing (QST) 4. SPECIAL TESTS

a. Computer-Enhanced Evaluations

b. Functional Capacity Evaluation (FCE)

c. Job Site Evaluation

d. Vocational Assessment

e. Work Tolerance Screening

F. THERAPEUTIC PROCEDURES – NON-OPERATIVE

1. ACUPUNCTURE

a. Acupuncture - Definition

b. Acupuncture with Electrical Stimulation

c. Other Acupuncture Modalities

2. BIOFEEDBACK

3. INJECTIONS – THERAPEUTIC

a. Steroid Injections

b. Trigger Point Injections

4. JOB SITE ALTERATION

a. Ergonomic changes

b. Interventions

c. Seating Description

d. Job Hazard Checklist

5. MEDICATIONS

a. Acetaminophen

b. Minor Tranquilizer/Muscle Relaxants

c. Narcotics

d. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

e. Psychotropic/Anti-anxiety/Hypnotic Agents

f. Tramadol

g. Topical Drug Delivery 6. OCCUPATIONAL REHABILITATION PROGRAMS

a. Non-Interdisciplinary

b. Interdisciplinary

7. PATIENT EDUCATION

8. PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION

9. RETURN TO WORK

a. Establishment of Return-To-Work

b. Establishment of Activity Level Restrictions

c. Compliance with Activity Level Restrictions

10. SLEEP DISTURBANCES

11. THERAPY-ACTIVE

a. Activities of Daily Living

b. Functional Activities

c. Nerve Gliding

d. Neuromuscular Re-education

e. Proper Work Techniques

f. Therapeutic Exercise

12. THERAPY - PASSIVE

a. Electrical Stimulation (Unattended)

b. Extracorporeal shock wave treatment

c. Iontophoresis

d. Laser irradiation

e. Manual Therapy Techniques

f. Massage

g. Orthotics/Immobilization with Splinting

h. Superficial Heat and Cold Therapy

i. Ultrasound

13. RESTRICTION OF ACTIVITIES 14. VOCATIONAL REHABILITATION

G. OPERATIVE TREATMENT:

1. PERIPHERAL NERVE DECOMPRESSION:

a. Median Nerve Decompression at the Wrist (carpal tunnel release)

b. Median Nerve Decompression in the Forearm (pronator teres or flexor digitorum superficialis release)

c. Ulnar Nerve Decompression at the Wrist (ulnar tunnel release or Guyon's canal release)

d. Ulnar Nerve Decompression/Transposition at the Elbow

e. Radial Sensory Nerve Decompression at the Wrist

f. Radial Nerve Decompression at the Elbow

g. Thoracic Outlet Syndrome

2. TENDON DECOMPRESSION OR DEBRIDEMENT

a. Subacromial Decompression

b. Medial or Lateral Epicondyle Release/Debridement

c. First Extensor Compartment Release (de Quervain's Tenosynovitis)

d. Trigger Finger/Thumb Release

3. CONSIDERATIONS FOR POST-OPERATIVE THERAPY ARE:

a. Immobilization

b. Home Program

c. Supervised Therapy Program

A. INTRODUCTION

To properly utilize this document, the reader should not skip nor overlook any sections. B. GENERAL GUIDELINE PRINCIPLES

1. Application of Guidelines

2. Education

Education of the patient and family, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of CTD and disability. Currently, practitioners often think of education last, after medications, manual therapy and surgery. Practitioners must develop and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers and the community as a whole. An education-based paradigm should always start with inexpensive communication providing reassuring information to the patient. More in-depth education currently exists within a treatment regime employing functional restorative and innovative programs of prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of facilitating self-management of symptoms and prevention.

3. Treatment Paramater Duration

4. Active Interventions

5. Active Therapeutic Exercise Program

Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and education. This includes functional application in vocational or community settings.

6. Positive Patient Response

7. Re-Evaluate Treatment Every 3 to 4 Weeks If a given treatment or modality is not producing positive results within 3 to 4 weeks, the treatment should be either modified or discontinued. Reconsideration of diagnosis should also occur in the event of poor response to a seemingly rational intervention.

8. Surgical Interventions

9. Six-Month Time Frame

10. Return-to-Work

11. Delayed Recovery

12. Guideline Recommendations and Inclusion of Medical Evidence

Consensus means the opinion of experienced professionals based on general medical principles. Consensus recommendations are designated in the guideline as “generally well accepted,” “generally accepted,” “acceptable,” or “well established.” “Some” means the recommendation considered at least one adequate scientific study, which reported that a treatment was effective.

13. Care Beyond Maximum Medical Improvement (MMI)

The remainder of this document should be interpreted within the parameters of these guideline principles that may lead to more optimal medical and functional outcomes for injured workers.

C. DEFINITION AND MECHANISMS OF INJURY:

Cumulative Trauma Disorders (CTDs) of the upper extremity comprise a heterogeneous group of diagnoses which include numerous specific clinical entities, including disorders of the muscles, tendons and tendon sheaths, nerve entrapment syndromes, joint disorders, and neurovascular disorders.

The terms “cumulative trauma disorder”, “repetitive motion syndrome”, “repetitive strain injury” and other similar nomenclatures are umbrella terms that are not acceptable diagnoses. The health care provider must provide specific diagnoses in order to appropriately educate, evaluate, and treat the patient. Examples include DeQuervain's tendonitis, cubital tunnel syndrome, lateral/medial epicondylitis, olecranon bursitis, and hand-arm vibration syndrome. Many patients present with more than one diagnosis, which requires thorough upper extremity and cervical evaluation by the health care provider. Furthermore, there must be a causal relationship between work activities and the diagnosis (see Initial Diagnostic Procedures). The mere presence of a diagnosis that may be associated with cumulative trauma does not presume work-relatedness unless the appropriate work exposure is present.

Mechanisms of injury for the development of CTDs remain controversial. Posture, repetition, force, vibration, cold exposure, and combinations thereof are postulated and generally accepted as risk factors for the development of CTDs. Evaluation of a CTD requires an integrated approach that incorporates ergonomics, clinical assessment, and psychosocial evaluation on a case-by-case basis.

D. INITIAL DIAGNOSTIC PROCEDURES

History and physical examination (Hx & PE) are generally accepted, well established and widely used procedures which establish the foundation/basis for and dictate all other diagnostic and therapeutic procedures. When findings of clinical evaluations and those of other diagnostic procedures do not complement each other, the objective clinical findings should have preference. 1. History:

Should inquire about the following issues, where relevant, and document pertinent positives and negatives where appropriate. In evaluating potential Cumulative Trauma Disorders (CTDs), the following actions should be taken: a. Description of Symptoms:

1) Onset: date of onset, sudden vs. gradual;

2) Nature of Symptoms: pain, numbness, weakness, swelling, stiffness, temperature change, color change;

3) Intensity: pain scale (0 = no pain, and 10 = worst imaginable pain) may be used.

4) Location and Radiation: use of a pain diagram is encouraged for characterizing sensory symptoms; use comprehensive diagrams and do not use limited diagrams depicting only the hand or arm, as it is important to solicit the reporting of more proximal symptoms;

5) Provocative and Alleviating Factors (occupational and non-occupational): Attempt to identify the specific physical factors that are aggravating or alleviating the problem;

6) Sleep disturbances;

7) Other associated signs and symptoms noted by the injured worker; b. Identification of Occupational Risk Factors:

Job title alone is not sufficient information. The clinician is responsible for documenting specific information regarding repetition, force and other risk factors, as listed in the Risk Factors Associated with Cumulative Trauma Table. A job site evaluation may be required. c. Demographics: age, hand dominance, gender, etc. d. Past Medical History and Review of Systems:

1) Past injury/symptoms involving the upper extremities, trunk and cervical spine;

2) Past work-related injury or occupational disease;

3) Past personal injury or disease that resulted in temporary or permanent job limitation;

4) Medical conditions associated with CTD - A study of work-related upper extremity disorder patients showed a 30% prevalence of co-existing disease. Medical conditions commonly occurring with CTD include:

a) Pregnancy,

b) Arthropathies including connective tissue disorders, rheumatoid arthritis, systemic lupus erythematosus, gout, osteoarthritis and spondyloarthropathy,

c) Amyloidosis,

d) Hypothyroidism, especially in older females, e) Diabetes mellitus, including family history or gestational diabetes,

f) Acromegaly,

g) Use of corticosteroids. e. Activities of Daily Living (ADLs):

Information must be obtained regarding sports, recreational, and other avocational activities that might contribute to or be impacted by CTD development. Activities such as hand-operated video games, crocheting/needlepoint, home computer operation, golf, tennis, and gardening are included in this category. g. Social History:

Exercise habits, alcohol consumption, and psychosocial factors.

2. Physical Examination

The evaluation of any upper extremity complaint should begin at the neck and upper back and then proceed down to the fingers and include the contralateral region. It should include evaluation of vascular and neurologic status, and describe any dystrophic changes or variation in skin color or turgor. A description of the patient's body habitus (e.g., neck rotation, shoulder depression, spine kyphosis), and anthropometric measurements, e.g. BMI (body mass index), should be documented. Refer to the Physical Examination and Findings Reference Table.

Table 2: Physical Examination Findings Reference Table (continues on next page) DIAGNOSIS SYMPTOMS SIGNS DeQuervain's Pain and swelling in the Pain worsened by active Tenosynovitis anatomical snuffbox; pain thumb abduction and/or radiating into the hand extension; crepitus along and forearm; pain the radial forearm; worsened by thumb positive Finkelstein's. abduction and/or extension. Extensor Tendinous Pain localized to the Swelling along the dorsal Disorders affected tendon(s); pain aspects of the hand/wrist/ worsened by active forearm, and pain with and/or resisted wrist or active and/or resisted finger extension. wrist/digit extension, or creaking/crepitus with wrist extension. Flexor Tendinous Pain localized to the Pain with wrist/digit Disorders affected tendons; pain in flexion and ulnar the affected tendons deviation, or crepitus with associated with wrist active motion of the flexion and ulnar flexor tendons. deviation, especially against resistance. Lateral Epicondylitis Lateral elbow pain Pain localized to lateral exacerbated by repetitive epicondyle with resisted wrist motions; pain wrist extension and/or emanating from the resisted supination. lateral aspect of the elbow. Medial Epicondylitis Pain emanating from the Pain localized to the medial elbow; mild grip medial epicondyle with weakness; medial elbow resisted wrist flexion and pain exacerbated by resisted pronation. repetitive wrist motions. Cubital tunnel syndrome Activity-related Diminished sensation of pain/paresthesias the fifth and ulnar half of involving the 4th and 5th the ring fingers; elbow fingers coupled with pain flexion/ulnar compression in the medial aspect of test; Tinels' sign between the elbow; olecranon process and pain/paresthesias worse at medial epicondyle; Later night; decreased sensation stages manifested by of the 5th finger and ulnar intrinsic atrophy and ulnar half of the ring finger innervated intrinsic (including dorsum 5th weakness. Specific finger); progressive physical signs include inability to separate clawing of the ulnar 2 fingers; loss of power digits (Benediction grip and dexterity; posture), ulnar drift of the atrophy/weakness of the 5th finger (Wartenberg's ulnar intrinsic hand sign), or flexion at the muscles (late sign). thumb IP joint during pinch (Froment's sign). Hand-Arm Vibration Pain/paresthesias in the Sensory deficits in the Syndrome digits; blanching of the digits/hand; blanching of digits; cold intolerance; digits; swelling of the tenderness/swelling of the digits/hand/forearm; digits/hand/forearm; muscle weakness of the muscle weakness of the hand; arthropathy at the hand; joint pains in hand/wrist/elbow; trophic hand/wrist/elbow/neck/ skin changes and cyanotic shoulders; trophic skin color in hand/digits. changes and cyanotic color in hand/digits. Guyon Canal (Tunnel) Numbness/tingling in Positive Tinel's at hook of Syndrome ulnar nerve distribution hamate. Numbness or distal to wrist. paresthesias of the palmar surface of the ring and small fingers. Later stages may affect ulnar innervated intrinsic muscle strength. Pronator Syndrome Pain/numbness/tingling in Tingling in median nerve median nerve distribution distribution on resisted distal to elbow. pronation with elbow flexed at 90°; Tenderness or Tinel's at the proximal edge of the pronator teres muscle over the median nerve. Radial Tunnel Syndrome Numbness/tingling or Tenderness over the radial pain in the lateral nerve near the proximal posterior forearm. edge of the supinator muscle. Rarely, paresthesias in the radial nerve distribution or weakness of thumb or finger extension.

3. Pain Behavior Evaluation a. Evaluate the patient's overall pain behavior. The behavior should be consistent with the current pain levels reported by the patient. b. Use a measurement tool to quantify and/or qualify pain. Reference the pain scale (0-10) with the worst pain imaginable being the top end of the scale (10) and/or other pain scales such as the Visual Analog Scale, Pain Drawing, or McGill Pain Questionnaire.

4. Risk Factors

A critical review of epidemiologic literature identifies a number of physical exposures associated with CTDs. Physical exposures considered risk factors include: repetition, force, vibration, pinching and gripping, and cold environment. When workers are exposed to several risk factors simultaneously, there is an increased likelihood of a CTD. Not all risk factors have been extensively studied. Exposure to cold environment, for example, was not examined independently; however, there is good evidence that, combined with other risk factors, cold environment increases the likelihood of a CTD. The table at the end of this section entitled, “Risk Factors Associated CTDs,” summarizes the results of currently available literature.

Many specific disorders, such as ulnar neuropathy (at the elbow and wrist) and pronator teres syndrome, have not been studied sufficiently to formulate evidence statements regarding causality. Based on the present understanding of mechanism of injury and utilizing the rationale of analogy, it is generally accepted that these disorders are similar to other CTDs at the elbow and wrist and are susceptible to the same risk factors. No studies examined the relationship between the development of ganglion cysts and work activities; however, work activities may aggravate existing ganglion cysts. It is generally accepted that keyboarding less than four hours per day is unlikely to be associated with a CTD when no other risk factors are present. It remains unclear how computer mouse use affects CTDs. The posture involved in mouse use should always be evaluated when assessing risk factors.

Studies measured posture, repetition and force in variable manners. In general, jobs that require less than 50% of maximum voluntary contractile strength for the individual are not considered “high force.” Likewise, jobs with wrist postures less than or equal to 25°; flexion or extension, or ulnar deviation less than or equal to 10°; are not likely to cause posture problems.

These guidelines are based on current epidemiologic knowledge. As with any scientific work, the guidelines are expected to change with advancing knowledge. The clinician should remain flexible and consider new information revealed in future studies.

Table 3: Risk Factors Associated with Cumulative Trauma Diagnosis Strong evidence Good evidence Some evidence

Elbow Musculoskeletal Combination high force High force alone. Disorders (Epicondylitis) and high repetition (Exposures were based on EMG data, observation or video analysis of job tasks, or categorization by job title. Observed movements include repeated extension, flexion, pronation and supination. Repetition work cycles<30 sec or >50% of cycle time performing same task, and number of items assembled in one hour). Wrist Tendonitis, Combination of risk Repetition, (as previously Posture including DeQuervain's factors: High repetition, defined), not including Tenosynovitis forceful hand/wrist keyboarding or force exertions, extreme wrist independently. postures (Assessed by direct observation, EMG, and video analysis. One study measured time spent in deviated wrist posture). Trigger Finger Forceful grip (Holding tools, knives. Assessed by direct observation and video analysis).

5. Medical Causality Assessment for Cumulative Trauma Disorders

The clinician must determine if it is medically probable (greater than 50% likely) that the need for treatment in a case is due to a work-related exposure or injury. Treatment for a work-related condition is covered when: 1) the work exposure causes a new condition, or 2) the work exposure causes the activation of a previously asymptomatic or latent medical condition, or 3) the work exposure worsens a pre-existing symptomatic condition. In legal terms, the question that should be answered is: “Is it medically probable that the patient would need the treatment that the clinician is recommending if the work exposure had not taken place?” If the answer is “yes,” then the condition is not work-related. If the answer is “no,” then the condition is work-related. In some cases, the clinician may need to assess diagnostic testing or work site evaluations to make a judgment on medical probability. The following steps should be used to evaluate causality in CTD cases:

Step 1: Make a specific and supportable diagnosis. Remember that cumulative trauma and repetitive motion are not diagnoses. Examples of appropriate diagnoses include tendonitis, strains, sprains, and mono-neuropathies.

Step 2: Determine whether the disorder is known to be or is plausibly associated with work. The identification of work-related risk factors are largely based on comparison of risk factors (as described in Section 3, “Risk Factors”) with the patient's work tasks.

Step 3: Interview the patient to find out whether risk factors are present in sufficient degree and duration to cause or aggravate the condition. Consider any recent change in the frequency or intensity of job tasks. In some cases, work site evaluations may be necessary to quantify the actual ergonomic risks. Refer to the Work Site Evaluation and Risk Factors sections.

Step 4: Determine whether a temporal association exists between the workplace risk factors and the onset or aggravation of symptoms.

Step 5: Identify non-occupational diagnoses, such as rheumatoid arthritis, as well as avocational activities, such as golf and tennis.

6. Staging

Staging Cumulative Trauma Disorder may be helpful to track the progress of cases and to rate permanent impairment of specific disorders when no other rating is available in the AMA Guides. CTD can be staged only after taking a thorough history and performing an appropriate physical examination (see History and Physical Examination). The CTD Staging Matrix may be used to help determine the need for further diagnostic tests and/or more extensive treatment. The factors included in the CTD Staging Matrix are:

A = History and Physical Examination

B = Response to Modification of Specific Aggravating Factors

C = Activities of Daily Living It is expected that objective signs on physical examination will correlate with subjective symptoms. The signs and symptoms are staged in the Cumulative Trauma Staging Matrix as:

Stage 1 = Minimal

Stage 2 = Mild

Stage 3 = Moderate

Stage 4 = Severe

At initial evaluation, some patients in Stages 1 or 2 for History and Physical Examination may qualify for higher stages in Response to Modification of Specific Aggravating Factors or ADLs. With treatment, patients should show progress to a stage of lower severity. In the event of failure to progress or inconsistencies in staging, the provider should consider further diagnostic testing, a psychosocial evaluation, and/or a change in treatment plan.

Stages 3 and 4 frequently may be associated with other secondary symptoms of chronic pain such as sleep alteration, chronic generalized weakness, fatigue, or depression.

Table 1: Cumulative Trauma Staging Matrix Stage 1 (Minimal) Stage 2 (Mild) Stage 3 (Moderate) History and Physical 1-2 symptoms with signs 2 or more symptoms with 3 or more symptoms with Examination identified on history and signs identified and signs identified and supported by physical supported by physical supported by the physical examination with examination with examination with consistency of subjective consistency of subjective consistency of subjective and objective findings and objective findings and objective findings AND AND AND Response to Modification Symptoms and/or signs Symptoms and/or signs Symptoms and/or signs of Specific Aggravating improve or resolve with may improve but will not do not improve with Factors modification of specific resolve completely with modification of the aggravating activity modification of specific specific aggravating aggravating activity activity, but may improve with elimination of the specific aggravating activity OR OR OR Activities of Daily Living Minimal problems with Noticeable aggravation Significant interference (ADLs) ADLs by more difficult ADLs with most ADLs Impairment Grades at 0-9% 10-19% 20-29% MMI (See Note to obtain Multiplier below)

NOTE: When the Staging Matrix is used for impairment rating at Maximum Medical Improvement (MMI), assignment of the patient to a Stage should be based primarily on limitations in ADLs and history and physical examination findings. The response to modification of specific aggravating activities may be used to aid the rater in choosing a number within the available rating range. The staging number chosen from the Impairment Grades at MMI row is to be used as a multiplier in conjunction with the AMA Guides to the Evaluation of Permanent Impairment, Third Edition, Revised, Chapter 3, Table 17, to determine the impairment rating for each specific diagnosis. All of the joints that correspond with the established diagnoses should be rated.

E. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES

1. Electrodiagnostic (EDX) Studies a. Electrodiagnostic (EDX) studies are well established and widely accepted for evaluation of patients suspected of having peripheral nerve pathology. Studies may confirm the diagnosis or direct the examiner to alternative disorders. Studies may require clinical correlation due to the occurrence of false positive and false negative results. Symptoms of peripheral nerve pathology may occur with normal EDX studies, especially early in the clinical course. Findings include fibrillations, fasciculations, neurogenic recruitment and polyphasic units (reinnervation). b. To assure accurate testing, temperature should be maintained at 30-34C preferably recorded from the hand/digits. For temperature below 30C the hand should be warmed. c. All studies must include normative values for their laboratories.

2. Imaging Studies a. Radiographic Imaging

Not generally required for most CTD diagnoses. However, it may be necessary to rule out other pathology in the cervical spine, shoulder, elbow, wrist or hand. Wrist and elbow radiographs would detect degenerative joint disease, particularly scapholunate dissociation and thumb carpometacarpal abnormalities which occasionally occur with CTD. b. MRI

May show increased T2-weighted signal intensity of the common extensor tendon in lateral epicondylitis, but this finding has commonly been found in the asymptomatic contralateral elbow and may not be sufficiently specific to warrant the use of MRI as a diagnostic test for epicondylitis. Its routine use for CTD is not recommended.

3. Adjunctive Testing a. Personality/Psychological/Psychosocial Evaluations

Personality/ psychological/ psychosocial evaluations are generally accepted and well-established diagnostic procedures with selective use in the CTD population, but have more widespread use in subacute and chronic pain populations.

2) Interpersonal relationships — both social and work;

3) Leisure activities;

4) Current perception of the medical system;

5) Results of current treatment;

6) Perceived locus of control; and

7) Childhood history, including abuse and family history of disability.

Generally accepted, well established and widely used procedures. Patients should be carefully screened at the initial exam for signs or symptoms of diabetes, hypothyroidism, arthritis, and related inflammatory diseases. The presence of concurrent disease does not negate work-relatedness of any specific case. In one study of patients with cumulative trauma disorder, other than CTD, seen by specialists, 3% of patients were diagnosed with diabetes, 6% with hypothyroidism, and 9% with chronic inflammatory disease including spondyloarthropathy, arthritis, and systemic lupus erythematosis. Up to two thirds of the patients were not aware of their concurrent disease. When a patient's history and physical examination suggest infection, metabolic or endocrinologic disorders, tumorous conditions, systemic musculoskeletal disorders (e.g., rheumatoid arthritis or ankylosing spondylitis), or problems potentially related to medication (e.g., renal disease and nonsteroidal anti-inflammatory medications), then laboratory tests, including, but not limited to, the following can provide useful diagnostic information:

1) Serum rheumatoid factor, ANA, HLA-B27 titre for rheumatoid work-up;

2) TSH for hypothyroidism.

3) Fasting glucose - recommended for obese men and women over 40 years of age, patients with a history of family diabetes, those from high risk ethnic groups, and with a previous history of impaired glucose tolerance. A fasting blood glucose >125mg/dl is diagnostic for diabetes. Urine dipstick positive for glucose is a specific but not sensitive screening test. Quantitative urine glucose is sensitive and specific in high risk populations.

4) Serum protein electrophoresis;

5) Sedimentation rate and C-Reactive Protein are nonspecific, but elevated in infection, neoplastic conditions and rheumatoid arthritis;

6) Serum calcium, phosphorus, uric acid, alkaline and acid phosphatase for metabolic, endocrine and neo-plastic conditions;

7) CBC, liver and kidney function profiles for metabolic or endocrine disorders or for adverse effects of various medications;

8) Bacteriological (microorganism) work-up for wound, blood and tissue.

The Division recommends the above diagnostic procedures be considered, at least initially, the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Laboratory testing may be required periodically to monitor patients on chronic medications. c. Pinch And Grip Strength Measurements

Not generally accepted as a diagnostic tool for CTS. Strength is defined as the muscle force exerted by a muscle or group of muscles to overcome a resistance under a specific set of circumstances. Pain, the perception of pain secondary to abnormal sensory feedback, and/or the presence of abnormal sensory feedback affecting the sensation of the power used in grip/pinch may cause a decrease in the force exerted and thereby not be a true indicator of strength. When a bell-shaped curve is present, these measures provide a method for quantifying strength that can be used to follow a patient's progress and to assess response to therapy. In the absence of a bell-shaped curve, clinical reassessment is indicated. d. Quantitative Sensory Testing (QST)

May be used as a screening tool in clinical settings pre-and post-operatively. Results of tests and measurements of sensory integrity are integrated with the history and review of systems findings and the results of other tests and measures. QST tests the entire sensory pathway, limiting its ability to localize a deficit precisely. It depends on the patient's report of perception and may not be objective. Cutaneous conditions may alter sensory thresholds.

1) Threshold tests measure topognosis, the ability to exactly localize a cutaneous sensation, and pallesthesia, the ability to detect mechanical sensation using vibration discrimination testing (quickly adapting fibers); and/or Semmes-Wienstein monofilament testing (slowly adapting fibers);

2) Density Tests also measure topognosis and pallesthesia using static two-point discrimination (slowly adapting fibers); and/or moving two-point discrimination (quickly adapting fibers).

4. Special Tests a. Computer-Enhanced Evaluations

Frequency: One time for evaluation. Can monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations. b. Functional Capacity Evaluation (FCE)

Functional capacity evaluation is a comprehensive or modified evaluation of the various aspects of function as they relate to the worker's ability to return to work. Areas such as endurance, lifting (dynamic and static), postural tolerance, specific range of motion, coordination and strength, worker habits, employability and financial status, as well as psychosocial aspects of competitive employment may be evaluated. Components of this evaluation may include: (a) musculoskeletal screen; (b) cardiovascular profile/aerobic capacity; (c) coordination; (d) lifting/carrying analysis; (e) job-specific activity tolerance; (f) maximum voluntary effort; (g) pain assessment/psychological screening; and (h) non-material and material handling activities.

Job site evaluation is a comprehensive analysis of the physical, mental and sensory components of a specific job. These components may include, but are not limited to: (a) postural tolerance (static and dynamic); (b) aerobic requirements; (c) range of motion; (d) torque/force; (e) lifting/carrying; (f) cognitive demands; (g) social interactions; (h) visual perceptual; (i) environmental requirements of a job; (j) repetitiveness; and (k) essential functions of a job. Job descriptions provided by the employer are helpful but should not be used as a substitute for direct observation.

Frequency: One time with additional visits as needed for follow-up per job site. d. Vocational Assessment

Frequency: One time with additional visits as needed for follow-up. e. Work Tolerance Screening

Work tolerance screening is a determination of an individual's tolerance for performing a specific job as based on a job activity or task. It may include a test or procedure to specifically identify and quantify work- relevant cardiovascular demands, physical fitness, and postural tolerance. It may also address ergonomic issues affecting the patient's return-to-work potential. May be used when a full Functional Capacity Evaluation is not indicated.

Frequency: One time for evaluation. May monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations.

F. THERAPEUTIC PROCEDURES – NON-OPERATIVE

Before initiation of any therapeutic procedure, the authorized treating provider, employer and insurer must consider these important issues in the care of the injured worker.

Last, formal psychological or psychosocial screening should be performed on patients not making expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests.

The following procedures are listed in alphabetical order.

1. Acupuncture

Acupuncture is an accepted and widely used procedure for the relief of pain and inflammation. There is some scientific evidence to support its use. The exact mode of action is only partially understood. Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the brain, promotes deep relaxation, and affects the release of neurotransmitters. Acupuncture is commonly used as an alternative or in addition to traditional Western pharmaceuticals. While it is commonly used when pain medication is reduced or not tolerated, it may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten the return of functional activity. Acupuncture should be performed by licensed practitioners. a. Acupuncture - Definition

Acupuncture is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points). Needles may be inserted, manipulated and retained for a period of time. Acupuncture can be used to reduce pain and inflammation, and to increase blood flow to an area and increase range of motion. Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain.

1) Time to produce effect: 3 to 6 treatments

2) Frequency: 1 to 3 times per week

3) Optimum duration: 1 to 2 months

4) Maximum duration: 14 treatments b. Acupuncture with Electrical Stimulation

Acupuncture with electrical stimulation is the use of electrical current (micro-amperage or milli-amperage) on the needles at the acupuncture site. It is used to increase effectiveness of the needles by continuous stimulation of the acupoint. Physiological effects (depending on location and settings) can include endorphin release for pain relief, reduction of inflammation, increased blood circulation, analgesia through interruption of pain stimulus, and muscle relaxation.

It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.

1) Time to produce effect: 3 to 6 treatments

2) Frequency: 1 to 3 times per week

3) Optimum duration: 1 to 2 months

4) Maximum duration: 14 treatments c. Other Acupuncture Modalities

1) Time to produce effect: 3 to 6 treatments

2) Frequency: 1 to 3 times per week

3) Optimum duration: 1 to 2 months

4) Maximum duration: 14 treatments

Any of the above acupuncture treatments may extend longer if objective functional gains can be documented or when symptomatic benefits facilitate progression in the patient's treatment program. Treatment beyond 14 sessions must be documented with respect to need and ability to facilitate positive symptomatic or functional gains.

2. Biofeedback

Parameters:

1) Time to produce effect: 3 to 4 sessions 2) Frequency: 1 to 2 times per week

3) Optimum duration: 5 to 6 sessions

4) Maximum duration: 10 to 12 sessions. Treatment beyond 12 sessions must be documented with respect to need, expectation, and ability to facilitate positive symptomatic or functional gains.

3. Injections – Therapeutic

Therapeutic injections are generally accepted, well-established procedures that may play a significant role in the treatment of patients with upper extremity pain or pathology. Therapeutic injections involve the delivery of anesthetic and/or anti-inflammatory medications to the painful structure. Therapeutic injections have many potential benefits. Ideally, a therapeutic injection will: (a) reduce inflammation in a specific target area; (b) relieve secondary muscle spasm; and (c) diminish pain and support therapy directed to functional recovery. Diagnostic and therapeutic injections should be used early and selectively to establish a diagnosis and support rehabilitation. If injections are overused or used outside the context of a monitored rehabilitation program, they may be of significantly less value. a. Steroid Injections

Steroid injections may provide both diagnostic and therapeutic value in treating a variety of upper extremity cumulative trauma disorders. These include tendonitis or bursitis about the elbow, wrist or hand. In contrast, there is no evidence to support their therapeutic use in other upper extremity compressive neuropathies; however, it is a widely accepted procedure.

Steroid injections provide a potent anti-inflammatory effect, which is usually short term in duration, lasting weeks or months. Injections should always be used as an adjunctive treatment in the context of a physical exercise and rehabilitation program.

For epicondylitis, there is good evidence that although steroid injections with physical therapy may provide short-term symptomatic relief, there is no benefit over placebo injections at 6 months. A program of physical rehabilitation in combination with judicious use of anti-inflammatory medications should be the core treatment for epicondylitis.

When performing tendon injections, the risk of tendon rupture should be discussed with the patient and the need for temporary restricted duty emphasized.

Contraindications: General contraindications include local or systemic infection, bleeding disorders, and allergy to medications used.

Local Steroid Injections:

1) Time to produce effect: 3 days

2) Frequency: monthly

3) Optimum duration: 2 injections

4) Maximum duration: 3 injections b. Trigger Point Injections

Trigger point injections are generally accepted, although used infrequently in uncomplicated cases. They may, however, be used to relieve myofascial pain and facilitate active therapy and stretching of the affected areas, and as an adjunctive treatment in combination with other treatment modalities, such as functional restoration programs, including stretching therapeutic exercise. Trigger point injections should be utilized primarily for the purpose of facilitating functional progress. The Division does not recommend their routine use in the treatment of upper extremity injuries.

1) Time to produce effect: Local anesthetic 30 minutes; 24 to 48 hours for no anesthesia.

2) Frequency: Weekly. Suggest no more than 4 injection sites per session per week

3) Optimum duration: 4 Weeks

4) Maximum duration: 8 weeks. Occasional patients may require 2 to 4 repetitions of trigger point injection series over a 1 to 2 year period.

4. Job Site Alteration

Early evaluation and training of body mechanics and other ergonomic factors are essential for every injured worker and should be done by a qualified individual. In some cases, this requires a work site evaluation. Some evidence supports alteration of the work site in the early treatment of Cumulative Trauma Disorder. There is no single factor or combination of factors that is proven to prevent or ameliorate CTD, but a combination of ergonomic and psychosocial factors are generally considered to be important. Physical factors that may be considered include use of force, repetition, awkward positions, upper extremity vibration, cold environment, and contact pressure on the nerve. Psychosocial factors to be considered include pacing, degree of control over job duties, perception of job stress, and supervisory support.

Ergonomic changes should be made to modify the hazards identified. In addition, workers should be counseled to vary tasks throughout the day whenever possible. OSHA suggests that workers who perform repetitive tasks, including keyboarding, take 15-30 second breaks every 10 to 20 minutes, or 5-minute breaks every hour. Mini breaks should include stretching exercises. b. Interventions

Interventions should consider engineering controls, e.g., mechanizing the task, changing the tool used, or adjusting the work site; or administrative controls, e.g., adjusting the time an individual performs the task. c. Seating Description

The following Table 4 is adopted from Washington State's job hazard checklist, and may be used as a generally accepted guide for identifying job duties which may pose ergonomic hazards. The fact that an ergonomic hazard exists at a specific job, or is suggested in the table, does not establish a causal relationship between the job and the individual with a musculoskeletal injury. However, when an individual has a work-related injury and ergonomic hazards exist that affect the injury, appropriate job modifications should be made. Proper correction of hazards may prevent future injuries to others, as well as aid in the recovery of the injured worker.

Table 4 : Identifying Job Duties Which May Pose Ergonomic Hazards Type of Job Duty Hours per Day Pinching an unsupported object(s) weighing 2 lbs or more per hand, or pinching with a force of 4 lbs or more per hand (comparable to pinching a half a ream of paper): 1. Highly repetitive motion 2. Palmar flexion >30 More than 3 hours degrees, dorsiflexion >45 total/day degrees, or radial ______deviation >30 degrees ______More than 4 hours ______total/day ______3. No other risk factors Gripping an unsupported object(s) weighing 10 lbs or more/hand, or gripping with a force of 10 lbs or more/hand (comparable to clamping light duty automotive jumper cables onto a battery): *Handles should be rounded and soft, with at least 1- 2.5” in diameter grips at least 5” long. 14. Highly repetitive motion 15. Palmar flexion >30 More than 3 hours degrees, dorsiflexion >45 total/day degrees, or radial deviation > 30 degrees ______16. No other risk factors More than 4 hours total/day Repetitive Motion (using the same motion with little or More than 2 hours no variation every few seconds) excluding keying total/day activities: 1. High, forceful exertions with the hands, with palmar flexion >30 degrees, dorsiflexion >45 degrees, or radial deviation > 30 degrees ______2. No other risk factors More than 6 hours total/day Intensive Keying: 1. Palmar flexion >30 More than 4 hours degrees, dorsiflexion >45 total/day degrees, or radial deviation > 30 degrees ______2. No other risk factors More than 7 hours total/day Repeated Impact: More than 2 hours total/day 1. Using the hand (heel/base of palm) as a hammer more than once/minute Vibration: Two determinants of the tolerability of segmental vibration of the hand are the frequency and the acceleration of the motion of the vibrating tool, with lower frequencies being more poorly tolerated at a given level of imposed acceleration, expressed below in multiples of the acceleration due to gravity (10m/sec/sec). 1. Frequency range 8-15 More than 30 minutes at a Hz and acceleration 6 g time 2. Frequency range 80 Hz ______and acceleration 40 g ______3. Frequency range 250 More than 4 hours at a Hz and acceleration 250 g time ______4. Frequency range 8-15 Hz and acceleration 1.5 g 5. Frequency range 80 Hz and acceleration 6 g 6. Frequency range 250 Hz and acceleration 20 g

5. Medications

Medication use in the treatment of CTD is appropriate for controlling acute and chronic pain and inflammation. Use of medications will vary widely due to the spectrum of injuries from simple strains to post-surgical analgesia. A thorough medication history, including use of alternative and over the counter medications, should be performed at the time of the initial visit and updated periodically.

Acetaminophen is an effective and safe initial analgesic. Non-steroidal anti-inflammatory drugs (NSAIDs) are useful in the treatment of inflammation, and for pain control. Pain is subjective in nature and should be evaluated using a scale to rate effectiveness of the analgesic in terms of functional gain. Other medications, including antidepressants, may be useful in selected patients with chronic pain (Refer to Chronic Pain Guideline). Narcotics are rarely indicated for treatment of upper extremity CTDs, and they should be primarily reserved for the treatment of acute severe pain for a limited time on a case-by-case basis. Topical agents may be beneficial in the management of localized upper extremity pain.

The following are listed in alphabetical order: a. Acetaminophen

1) Optimum duration: 7 to 10 days

2) Maximum duration: Chronic use as indicated on a case-by-case basis. b. Minor Tranquilizer/Muscle Relaxants

Minor tranquilizer/muscle relaxants are appropriate for muscle spasm, mild pain and sleep disorders.

1) Optimum duration: 1 week

2) Maximum duration: 4 weeks c. Narcotics

Narcotic medications should be prescribed with strict time, quantity and duration guidelines, and with definitive cessation parameters. Adverse effects include respiratory depression, impaired alertness, and the development of physical and psychological dependence.

1) Optimum duration: 3 to 7 days

2) Maximum duration: 2 weeks. Use beyond two weeks is acceptable in appropriate cases, such as patients requiring complex surgical treatment. d. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) NSAIDs are useful for pain and inflammation. In mild cases, they may be the only drugs required for analgesia. There are several classes of NSAIDs, and the response of the individual injured worker to a specific medication is unpredictable. For this reason, a variety of NSAIDs may be tried in each case with the most effective preparation being continued. Patients should be educated in and monitored for adverse reactions, including GI toxicity, liver and renal dysfunction, and thrombotic events in the case of COX-2 inhibitors. Intervals for screening are dependent on the patient's age, health status, concomitant medications usage, and specific NSAID prescribed. Intervals for metabolic screening are dependent upon the patient's age, general health status and should be within parameters listed for each specific medication.

Selective Nonsteroidal Anti-Inflammatory Drugs - Include Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and acetylsalicylic acid (aspirin).

1) Optimal duration: 1 week

2) Maximum duration: 1 year

Selective Cyclo-oxygenase-2 (COX-2) Inhibitors - Selective cyclo-oxygenase-2 (COX-2) inhibitors are more recent NSAIDs and differ in adverse side effect profiles from the traditional NSAIDs. The major advantages of selective COX-2 inhibitors over traditional NSAIDs are that they have less gastrointestinal, hepatic and renal toxicity, but may have thrombotic effects. COX-2 inhibitors should not be first-line for low risk patients who will be using an NSAID short term but are indicated in select patients whom traditional NSAIDs are not tolerated or in certain high-risk patients.

1) Optimal duration: 7 to 10 days

2) Maximum duration: Chronic use is appropriate in individual cases. e. Psychotropic/Anti-anxiety/Hypnotic Agents

Psychotropic/anti-anxiety/hypnotic agents may be useful for treatment of mild and chronic pain, dysesthesias, sleep disorders, and depression. Antidepressant medications, such as tricyclics and Selective Serotonin Reuptake Inhibitors (SSRIs), are useful for affective disorders and chronic pain management. Tricyclic antidepressant agents, in low dose, are useful for chronic pain but have more frequent side effects.

Anti-anxiety medications are best used for short-term treatment (i.e., less than 6 months). Accompanying sleep disorders are best treated with sedating antidepressants prior to bedtime. Frequently, combinations of the above agents are useful. As a general rule, physicians should assess the patient for a prior history of substance abuse or depression prior to prescribing any of these agents.

1) Optimum duration: 1 to 6 months

2) Maximum duration: 6 to 12 months, with monitoring. f. Tramadol

Tramadol is useful in relief of upper extremity pain and has been shown to provide pain relief equivalent to that of commonly prescribed narcotics. Although Tramadol may cause impaired alertness, it is generally well tolerated, does not cause gastrointestinal ulceration, or exacerbate hypertension or congestive heart failure. Tramadol should be used cautiously in patients who have a history of seizures or who are taking medication that may lower the seizure threshold, such as MAO inhibiters, SSRIs, and tricyclic antidepressants. This medication has physically addictive properties and withdrawal may follow abrupt discontinuation. It is not recommended for those with prior opioid addiction. 1) Optimum duration: 3 to 7 days

2) Maximum duration: 2 weeks. Use beyond 2 weeks is acceptable in appropriate cases. g. Topical Drug Delivery

Topical drug delivery may be an alternative treatment for localized musculoskeletal disorders and is an acceptable form of treatment in selected patients although there is no scientific evidence to support its use. It is necessary that all topical agents be used with strict instructions for application as well as maximum number of applications per day to obtain the desired benefit and avoid potential toxicity. As with all medications, patient selection must be rigorous to choose those patients with the highest probability of compliance. Refer to “Iontophoresis” in the Passive Therapy section for information regarding topical iontophoretic agents.

6. Occupational Rehabilitation Programs a. Non-Interdisciplinary

1) Work Conditioning

Work Conditioning is usually initiated once reconditioning has been completed but may be offered at any time throughout the recovery phase. It should be initiated when imminent return of a patient to modified or full duty is not an option, but the prognosis for returning the patient to work at completion of the program is at least fair to good.

(a) Length of visit: 1 to 2 hours per day

(b) Frequency: 2 to 5 visits per week

(d) Maximum duration: 6 weeks. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.

2) Work Simulation

(a) Length of visit: 2 to 6 hours per day

(b) Frequency: 2 to 5 visits per week

(c) Optimum duration: 2 to 4 weeks (d) Maximum duration: 6 weeks. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains. b. Interdisciplinary

Interdisciplinary programs are characterized by a variety of disciplines that participate in the assessment, planning, and/or implementation of an injured worker's program with the goal of the patient gaining full or optimal function and returning to work. There should be close interaction and integration among the disciplines to ensure that all members of the team interact to achieve team goals. These programs are for patients with greater levels of perceived disability, dysfunction, deconditioning and psychological involvement. For patients with chronic pain, refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder Medical Treatment Guideline.

1) Work Hardening

This can include a highly structured program involving a team approach or can involve any of the components thereof. The interdisciplinary team should, at a minimum, be comprised of a qualified medical director who is board certified with documented training in occupational rehabilitation, physicians having experience in occupational rehabilitation, occupational therapist, physical therapist, case manager, and psychologist. As appropriate, the team may also include: chiropractor, RN, or vocational specialist.

(a) Length of visit: Up to 8 hours/day

(b) Frequency: 2 to 5 visits per week

(d) Maximum duration: 6 weeks. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.

7. Patient Education

No treatment plan is complete without addressing issues of individual patient and/or group education as a means of prolonging the beneficial effects of treatment, as well as facilitating self-management of symptoms and injury prevention. The patient should take an active role in the establishment of function outcome goals, and should be educated on his or her specific injury, assessment findings, and plan of treatment. Education and instruction in proper body mechanics and posture, positions to avoid, task/tool adaptation, self-care for exacerbation of symptoms, and home exercise/task adaptation should also be addressed.

(a) Time to produce effect: Varies with individual patient.

(b) Frequency: Should occur at every visit.

8. Personality/Psychological/Psychosocial Intervention

(a) Time to produce effect: 2 to 4 weeks

(b) Frequency: 1 to 3 times weekly for the first 4 weeks (excluding hospitalization, if required), decreasing to 1 to 2 times per week for the second month. Thereafter, 2 to 4 times monthly.

(d) Maximum duration: 3 to 12 months. Counseling is not intended to delay but to enhance functional recovery. For select patients, longer supervised treatment may required, and if further counseling beyond 3 months is indicated, documentation addressing which pertinent issues are preexisting versus aggravated versus causative, as well as projecting a realistic functional prognosis, should be provided by the authorized treating provider every 4 to 6 weeks during treatment.

9. Return to Work

Early return-to-work should be a prime goal in treating Cumulative Trauma Disorder (CTD) given the poor prognosis for the injured employee who is out of work for more than six months. The employee and employer should be educated in the benefits of early return-to-work. When attempting to return an employee with CTD to the workplace, clear, objective physical restrictions that apply to both work and non-work related activities should be specified by the provider. Good communication between the provider, employee, and employer is essential.

Return-to-work is any work or duty that the employee can safely perform, which may not be the worker's regular job activities. Due to the large variety of jobs and the spectrum of severity of CTD, it is not possible for the Division to make specific return-to-work guidelines, but the following general approach is recommended: a. Establishment of Return-To-Work

Ascertainment of return-to-work status is part of the medical treatment and rehabilitation plan, and should be addressed at every visit. Limitations in activities of daily living (ADLs) should also be reviewed at every encounter, and help to provide the basis for work restrictions provided they are consistent with objective findings. In some severe CTD cases, cessation of most ADLs may be required for a short period of time. The Division recognizes that employers vary in their ability to accommodate restricted duty, but encourages employers to be active participants and advocates for early return-to-work. In most cases, the patient can be returned to work in some capacity, either at a modified job or alternate position, immediately unless there are extenuating circumstances, which should be thoroughly documented and communicated to the employer. Return-to-work status should be periodically reevaluated, at intervals generally not to exceed three weeks, and should show steady progression towards full activities and full duty. b. Establishment of Activity Level Restrictions

10. Sleep Disturbances

Disturbances of sleep are a common secondary symptom of CTD. Although primary insomnia may accompany pain as an independent co-morbid condition, it more commonly occurs secondary to the pain condition itself. Exacerbations of pain often are accompanied by exacerbations of insomnia; the reverse can also occur. Sleep laboratory studies have shown disturbances of sleep architecture in pain patients. Loss of deep slow-wave sleep and increase in light sleep occur and sleep efficiency, the proportion of time in bed spent asleep, is decreased. These changes are associated with patient reports of non- restorative sleep.

Many affected patients develop behavioral habits that exacerbate and maintain sleep disturbances. Excessive time in bed, irregular sleep routine, napping, low activity and worrying in bed are all maladaptive responses that can arise in the absence of any psychopathology. There is some evidence that behavioral modification, such as patient education and group or individual counseling, can be effective in reversing the effects of insomnia. Behavioral modifications are easily implemented and can include: a. Maintaining a regular sleep schedule, retiring and rising at approximately the same time on weekdays and weekends. b. Avoiding daytime napping. c. Avoiding caffeinated beverages after lunchtime d. Making the bedroom quiet and comfortable, eliminating disruptive lights, sounds, television sets, and keeping a bedroom temperature of about 65°;F. e. Avoiding alcohol or nicotine within two hours of bedtime. f. Avoiding large meals within two hours of bedtime. g. Exercising vigorously during the day, but not within two hours of bedtime, since this may raise core temperature and activate the nervous system. h. Associating the bed with sleep and sexual activity only, using other parts of the home for television, reading and talking on the telephone. i. Leaving the bedroom when unable to sleep for more than 20 minutes, retuning to the bedroom when ready to sleep again.

These modifications should be undertaken before sleeping medication is prescribed for long term use.

11. Therapy-Active Active therapies are based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion, and alleviating discomfort. Active therapy requires an internal effort by the individual to complete a specific exercise or task, and thus assists in developing skills promoting independence to allow self-care after discharge. This form of therapy requires supervision from a therapist or medical provider such as verbal, visual and/or tactile instructions. At times a provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is predominately executed by the patient.

Supervised instruction, active-assisted training and/or adaptation of activities or equipment to improve a person's capacity in normal daily living activities such as self-care, work re-integration training, homemaking and driving.

1) Time to produce effect: 4 to 5 treatments

2) Frequency: 3 to 5 times per week

3) Optimum Duration: 4 to 6 weeks

4) Maximum Duration: 6 weeks b. Functional Activities

Functional activities are the use of therapeutic activity to enhance mobility, body mechanics, employability, coordination, and sensory motor integration.

1) Time to produce effect: 4 to 5 treatments

2) Frequency: 3 to 5 times per week

3) Optimum duration: 4 to 6 weeks

4) Maximum duration: 6 weeks c. Nerve Gliding

Nerve gliding exercises consist of a series of flexion and extension movements of the hand, wrist, elbow, shoulder and neck that produce tension and longitudinal movement along the length of the median and other nerves of the upper extremity. These exercises are based on the principle that the tissues of the peripheral nervous system are designed for movement, and that tension and glide (excursion) of nerves may have an effect on neurophysiology through alterations in vascular and axoplasmic flow. Biomechanical principles have been more thoroughly studied than clinical outcomes.

1) Time to Produce Effect: 2-4 weeks 2) Frequency: Up to 5 times per day by patient (patient-initiated)

3) Optimum Duration: 2 sessions

4) Maximum Duration: 3 sessions d. Neuromuscular Re-education

1) Time to produce effect: 2 to 6 treatments

2) Frequency: 3 times per week

3) Optimum duration: 4 to 8 weeks

4) Maximum duration: 8 weeks e. Proper Work Techniques

Please refer to the “Job Site Evaluation” and “Job Site Alteration” sections of this guideline. f. Therapeutic Exercise

Therapeutic exercise, with or without mechanical assistance or resistance, may include isoinertial, isotonic, isometric and isokinetic types of exercises. Indications include the need for cardiovascular fitness, reduced edema, improved muscle strength, improved connective tissue strength and integrity, increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle recruitment, increased range-of-motion, and are used to promote normal movement patterns. Can also include complementary/alternative exercise movement therapy.

1) Time to produce effect: 2 to 6 treatments

2) Frequency: 3 to 5 times per week

3) Optimum duration: 4 to 8 weeks

4) Maximum duration: 8 weeks

12. Therapy - Passive

Passive therapy includes those treatment modalities that do not require energy expenditure on the part of the patient. They are principally effective during the early phases of treatment and are directed at controlling symptoms such as pain, inflammation and swelling and to improve the rate of healing soft tissue injuries. They should be used in adjunct with active therapies to help control swelling, pain and inflammation during the rehabilitation process. They may be used intermittently as a therapist deems appropriate or regularly if there are specific goals with objectively measured functional improvements during treatment. a. Electrical Stimulation (Unattended) Electrical stimulation, once applied, requires minimal on-site supervision by the physician or non- physician provider. Indications include pain, inflammation, muscle spasm, atrophy, and decreased circulation.

1) Time to produce effect: 2 to 4 treatments

2) Frequency: Varies, depending upon indication, between 2 to 3 times/day to 1 time/week. Provide home unit if frequent use.

3) Optimum duration: 1 to 3 months

4) Maximum duration: Home unit as needed. b. Extracorporeal shock wave treatment

Consists of the application of pulses of high pressure sound to soft tissues, similar to lithotriptors. It has been investigated for its effectiveness in the treatment of lateral epicondylitis. It has not been shown to have an advantage over other conservative treatments and remains investigational. It is not recommended. c. Iontophoresis

1) Time to produce effect: 1 to 4 treatments

2) Frequency: 2-3 times per week with at least 48 hours between treatments.

3) Optimum duration: 6 to 9 treatments

4) Maximum duration: 9 treatments d. Laser irradiation

Consists of the external application of an array of visible and infrared wavelengths to soft tissues. There is no evidence to support its effectiveness in epicondylitis and its use in upper extremity cumulative trauma disorders is still experimental. It is not recommended. e. Manual Therapy Techniques

Manual Therapy Techniques are passive interventions in which the providers uses his/her hands to administer skilled movements designed to modulate pain; increase joint range of motion; reduce/eliminate soft tissue swelling, inflammation or restriction; induce relaxation; and improve contractile and non- contractile tissue extensibility. These techniques are applied only after a thorough examination is performed to identify those for whom manual therapy would be contraindicated or for whom manual therapy must be applied with caution.

1) Mobilization (Joint)/Manipulation

Mobilization is passive movement involving oscillatory motions to the involved joints. The passive mobility is performed in a graded manner (I, II, III, IV, or V), which depicts the speed of the maneuver. It may include skilled manual joint tissue stretching. Indications include the need to improve joint play, improve intracapsular arthrokinematics, or reduce pain associated with tissue impingement. Contraindications include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthridities, and signs of progressive neurologic deficits.

(a) Time to produce effect: 4 to 6 treatments

(b) Frequency: 2 to 3 times per week

(d) Maximum duration: 6 weeks

2) Mobilization (Soft Tissue)

(a) Time to produce effect: 4 to 6 treatments

(b) Frequency: 2 to 3 times per week

(d) Maximum duration: 6 weeks f. Massage

Manual or Mechanical - Massage is manipulation of soft tissue with broad ranging relaxation and circulatory benefits. This may include stimulation of acupuncture points and acupuncture channels (acupressure), application of suction cups and techniques that include pressing, lifting, rubbing, pinching of soft tissues by or with the practitioners hands. Indications include edema, muscle spasm, adhesions, the need to improve peripheral circulation and range-of-motion, or to increase muscle relaxation and flexibility prior to exercise.

1) Time to produce effect: Immediate.

2) Frequency: 1 to 2 times per week

3) Optimum duration: 6 weeks

4) Maximum duration: 2 months g. Orthotics/Immobilization with Splinting

Immobilization with splinting is a generally accepted, well-established and widely used therapeutic procedure. Splints may be effective when worn at night or during portions of the day, depending on activities. Splints should be loose and soft enough to maintain comfort while supporting the involved joint in a relatively neutral position. Splint comfort is critical and may affect compliance. Although off-the-shelf splints are usually sufficient, custom thermoplastic splints may provide better fit for certain patients.

Splints may be effective when worn at night or during portions of the day, depending on activities; however, splint use is rarely mandatory. Providers should be aware that over-usage is counterproductive, and counsel patients to minimize daytime splint use in order avoid detrimental effects, such as, stiffness and dependency over time.

1) Time to produce effect: 1-4 weeks

2) Frequency: Daytime intermittent, or night use, depending on symptoms and activities.

3) Optimum duration: 4 to 8 weeks

4) Maximum duration: 2 to 4 months. If symptoms persist, consideration should be given to further diagnostic studies or to other treatment options. h. Superficial Heat and Cold Therapy

1) Time to produce effect: Immediate

2) Frequency: 2 to 5 times per week (clinic). Home treatment as needed.

3) Optimum duration: 3 weeks as primary or intermittently as an adjunct to other therapeutic procedures up to 2 months

4) Maximum duration: 2 months If symptoms persist, consideration should be given to further diagnostic studies or other treatment options. i. Ultrasound

Ultrasound uses sonic generators to deliver acoustic energy for therapeutic thermal and/or nonthermal soft tissue effects. Indications include scar tissue, adhesions, collagen fiber and muscle spasm, and to improve muscle tissue extensibility and soft tissue healing. Ultrasound with electrical stimulation is concurrent delivery of electrical energy that involves dispersive electrode placement. Indications include muscle spasm, scar tissue, pain modulation and muscle facilitation. Phonophoresis is the transfer of medication to the target tissue to control inflammation and pain through the use of sonic generators. These topical medications include, but are not limited to, steroidal anti-inflammatory and anesthetics.

1) Time to produce effect: 4 to 8 treatments

2) Frequency: 2-3 times per week

3) Optimum duration: 4 to 6 weeks

4) Maximum duration: 2 months

13. Restriction of Activities

Continuation of normal daily activities is the recommendation for Cumulative Trauma Disorders with or without neurologic symptoms. Complete work-cessation should be avoided, if possible, since it often further aggravates the pain presentation. Modified return-to-work is almost always more efficacious and rarely contraindicated in the vast majority of injured workers with CTD. 14. Vocational Rehabilitation

Vocational rehabilitation is a generally accepted intervention, but Colorado limits its use as a result of Senate Bill 87-79. Initiation of vocational rehabilitation requires adequate evaluation of patients for quantification of highest functional level, motivation and achievement of maximum medical improvement. Vocational rehabilitation may be as simple as returning to the original job or as complicated as being retrained for a new occupation.

G. OPERATIVE TREATMENT:

THE FOLLOWING SURGICAL GUIDELINES ARE NOT INTENDED TO REPLACE THE SURGEON'S JUDGMENT.

Over a decade's experience has demonstrated that operative treatment of most CTD conditions is not usually necessary. Operative treatment may be indicated when the individual component diagnoses that make up CTD prove unresponsive to the full complement of non-operative options, including work site analysis and modification over four to six months. Physical exam findings should be well localized and consistent with the diagnosis. Severe neurologic findings are an exception to these indications, and may suggest earlier surgical intervention. Surgical results must anticipate objective functional gains and improved activities of daily living.

Surgery in CTD usually falls into two broad categories: peripheral nerve decompression and muscle or tendon sheath release or debridement. The treating surgeon must determine the appropriate procedure and timing for the individual case. The most common surgical procedures that are performed in CTD patients are listed below; other procedures may be indicated in certain cases.

Since CTD often involves several areas in an upper extremity, surgical treatment of one problem should be performed in conjunction with conservative treatment of other problems in the upper extremity.

1. Peripheral Nerve Decompression:

Surgery may be considered when findings on history and physical exam correlate specifically with the diagnosis being considered. Subjective complaints should be localized and appropriate to the diagnosis, neurologic complaints should be consistent with the nerve distribution in question, and physical exam findings should correlate with the history. Surgery may be considered as an initial therapy in situations where there is clinical and electrodiagnostic evidence of severe or progressive neuropathy. Objective evidence should be present in all cases in which surgery is contemplated. Objective evidence may include: electrodiagnostic (EDX) studies, diagnostic peripheral nerve block which eradicates the majority of the patient's symptoms, or a motor deficit commensurate with the suspected neurologic lesion. Refer to Physical Examination Findings Reference Table in the Physical Examination section of this guideline for objective diagnostic findings. Job modification should be considered prior to surgery. Refer to the “Job Site Alteration” section for additional information on job modification.

When no objective evidence is present and the patient continues to have signs and symptoms consistent with the diagnosis after six months of conservative treatment including a psychological evaluation, a second opinion should be obtained before operative treatment is considered.

Specific procedures and their indications are outlined below: a. Median Nerve Decompression at the Wrist (carpal tunnel release)

Please refer to Rule XVII, Exhibit B., Upper Extremity Medical Treatment Guidelines, Section II. Occupational Carpal Tunnel Syndrome. b. Median Nerve Decompression in the Forearm (pronator teres or flexor digitorum superficialis release)

Please refer to Physical Examination Findings Table in Physical Examination section of this guideline. Electrodiagnostic (EDX) studies may show delayed median nerve conduction in the forearm. If nerve conduction velocity is normal with suggestive clinical findings, the study may be repeated after a 3-6 month period of continued conservative treatment. If the study is still normal, the decision on treatment is made on the consistency of clinical findings and the factors noted above. c. Ulnar Nerve Decompression at the Wrist (ulnar tunnel release or Guyon's canal release)

Please refer to Physical Examination Findings Reference Table in the Physical Examination section of this guideline. Electrodiagnostic testing may confirm the diagnosis and differentiate from ulnar entrapment neuropathy at the elbow. d. Ulnar Nerve Decompression/Transposition at the Elbow

Please refer to Physical Examination Findings Reference Table in the Physical Examination section of this guideline. Electrodiagnostic studies (EDX) may indicate an ulnar neuropathy at the elbow. In general, patients with minimal symptoms or without objective findings of weakness tend to respond better to conservative treatment than patients with measurable pinch or grip strength weakness. If objective findings persist despite conservative treatment, surgical options include: simple decompression, medial epicondylectomy with decompression, anterior subcutaneous transfer, and submuscular or intramuscular transfer. e. Radial Sensory Nerve Decompression at the Wrist

Please refer to Physical Examination Findings Reference Table in the Physical Examination section of this guideline. Electrodiagnostic (EDX) studies can be useful in establishing a diagnosis. f. Radial Nerve Decompression at the Elbow

Please refer to Physical Examination Findings Reference Table in the Physical Examination section of this guideline. Electrodiagnostic (EDX) studies are helpful when positive, but negative studies do not exclude the diagnosis. g. Thoracic Outlet Syndrome

Please refer to Rule XVII, Exhibit B., Upper Extremity Medical Treatment Guidelines, Section III, Thoracic Outlet Syndrome.

2. Tendon Decompression or Debridement

Surgery may be considered when several months of appropriate treatment have failed, and findings on history and physical exam correlate specifically with the diagnosis being considered. Subjective complaints should be localized and appropriate to the diagnosis, and physical exam findings should correlate with the history. Refer to the Physical Examination Findings Table in the Physical Examination section of this guideline. Job modification should be considered prior to surgery. Refer to the “Job Site Alteration” section for additional information on job modification.

Specific procedures and their indications are outlined below: a. Subacromial Decompression

Please refer to Rule XVII, Exhibit B., Upper Extremity Medical Treatment Guidelines, Section IV, Shoulder Injury. b. Medial or Lateral Epicondyle Release/Debridement

Please refer to Physical Examination Findings Reference Table in the Physical Examination section of this guideline. It is generally accepted that 80% of cases improve with conservative therapy. Intermittent discomfort may recur over six months to one year after initial conservative treatment. Surgery should only be performed to achieve functional gains on those with significant ongoing impaired activities of daily living. X-rays may be normal or demonstrate spur formation over the involved epicondyle. c. First Extensor Compartment Release (de Quervain's Tenosynovitis)

Please refer to Physical Examination Findings Reference Table in the Physical Examination section of this guideline. Surgery should be performed to achieve functional gains on those with significant ongoing impaired activities of daily living. d. Trigger Finger/Thumb Release

3. Considerations for post-operative therapy are: a. Immobilization

Controlled mobilization, and/or formal physical/occupational therapy should begin as soon as possible following surgery at the discretion of the treating surgeon. Final decisions regarding the need for splinting post-operatively should be left to the discretion of the treating physician based upon his/her understanding of the surgical technique used and the specific conditions of the patient. b. Home Program

It is generally accepted that all patients should receive a home therapy protocol involving stretching, ROM, scar care, and resistive exercises. Once they have been cleared for increased activity by the surgeon, patients should be encouraged to use the hand as much as possible for daily activities, allowing pain to guide their level of activity. c. Supervised Therapy Program

May be helpful in patients who do not show functional improvements post-operatively or in patients with heavy or repetitive job activities. The therapy program may include some of the generally accepted elements of soft tissue healing and return to function:

1) Soft tissue healing/remodeling:

May be used after the incision has healed. It may include any of the following: evaluation, whirlpool, electrical stimulation, soft tissue mobilization, scar compression pad, heat/cold application, splinting or edema control may be used as indicated. Following wound healing, ultrasound and iontophoresis with sodium chloride (NaCl) may be considered for soft tissue remodeling. Diathermy is not an acceptable adjunct.

2) Return to function:

Range-of-motion and stretching exercises, strengthening, activity of daily living adaptations, joint protection instruction, posture/body mechanics education. Worksite modifications may be indicated. (a) Time to produce effect: 2-4 weeks

(b) Frequency: 2-3 times/week

(d) Maximum duration: 8 weeks

RULE XVII, EXHIBIT C Lower Extremity Injury Medical Treatment Guidelines December 1, 2001

(Previously Adopted March 2, 1995, Revised March 15, 1998)

Presented By:

State of Colorado

Department of Labor and Employment

DIVISION OF WORKERS' COMPENSATION

TABLE OF CONTENTS

Lower Extremity Injury

Medical Treatment Guideline SECTION DESCRIPTION

A. INTRODUCTION B. GENERAL GUIDELINE PRINCIPLES 1. Application of Guidelines 2. Education 3. Treatment Parameter Duration 4. Active Interventions 5. Active Therapeutic Exercise Program 6. Positive Patient Response 7. Re-Evaluate Treatment Every 3 to 4 Weeks 8. Surgical Interventions 9. Six-Month Time Frame 10. Return-to-Work 11. Delayed Recovery 12. Guideline Recommendations and Inclusion of Medical Evidence 13. Care Beyond Maximum Medical Improvement (MMI) C. INITIAL DIAGNOSTIC PROCEDURES 1. History-taking and Physical Examination (Hx & PE) a. History of Present Injury: b. Past History: c. Physical Examination 2. Radiographic Imaging 3. Laboratory Tests 4. Other Procedures a. Joint Aspiration D. SPECIFIC LOWER EXTREMITY INJURY DIAGNOSIS, TESTING, AND TREATMENT 1. Foot and Ankle a. Ankle Sprain/Fracture b. Talar Fracture c. Calcaneal Fractures d. Midfoot (Lisfranc's) Fracture Dislocation e. Metatarsal-Phalangeal, Tarsal-Metatarsal, and Interphalangeal Joint Arthropathy f. Pilon Fracture g. Puncture Wounds of the Foot h. Achilles Tendon Injury/Rupture i. Ankle Osteoarthropathy j. Ankle or Subtalar Joint Dislocation k. Heel Spur Syndrome/Plantar Fasciitis l. Tarsal Tunnel Syndrome m. Neuroma 2. Knee a. Chondral Defects b. Aggravated Osteoarthritis c. Anterior Cruciate Ligament Injury d. Posterior Cruciate Injuries e. Meniscus Injury f. Patellar Subluxation g. Retropatellar Pain Syndrome h. Tendonitis/Tenosynovitis i. Bursitis of the Lower Extremity 3. Hip and Leg a. Hip Fracture b. Pelvic Fracture c. Acetabulum Fracture d. Hamstring Tendon Rupture e. Hip Dislocation f. Trochanteric Fracture g. Femur Fracture h. Tibia Fracture E. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES 1. Imaging Studies a. Magnetic Resonance Imaging (MRI) b. Computerized Axial Tomography (CT) c. Lineal Tomography d. Bone Scan (Radioisotope Bone Scanning) e. Other Radionuclide Scanning f. Arthrograms g. Diagnostic Arthroscopic Examination 2. Other Tests a. Personality/Psychological /Psychosocial Evaluations b. Electrodiagnostic Testing c. Doppler Ultrasonography/Plethys mography d. Venogram/Arteriogram e. Compartment Pressure Testing and Measurement Devices 3. Special Tests a. Computer Enhanced Evaluations b. Functional Capacity Evaluation (FCE) c. Jobsite Evaluation d. Vocational Assessment e. Work Tolerance Screening F. THERAPEUTIC PROCEDURES — NON-OPERATIVE 1. Acupuncture a. Acupuncture b. Acupuncture with Electrical Stimulation c. Other Acupuncture Modalities 2. Biofeedback 3. Injections — Therapeutic a. Joint Injections b. Soft Tissue Injections c. Trigger Point Injections d. Prolotherapy e. Intra-Capsular Acid Salts 4. Medications a. Acetaminophen b. Minor Tranquilizer/Muscle Relaxants c. Narcotics d. Nonsteroidal Anti- Inflammatory Drugs (NSAIDs) e. Oral Steroids f. Psychotropic/Anti- anxiety/Hypnotic Agents g. Tramadol h. Topical Drug Delivery 5. Occupational Rehabilitation Programs a. Non-Interdisciplinary b. Interdisciplinary 6. Orthotics and Prosthetics a. Fabrication/Modification of Orthotics b. Orthotic/Prosthetic Training c. Splints or Adaptive Equipment 7. Patient Education 8. Personality/Psychological/Psychosocial Intervention 9. Restriction of Activity 10. Return-To-Work a. Establishment of A Return-To-Work Status b. Establishment of Activity Level Restrictions c. Compliance with Activity Restrictions 11. Therapy — Active a. Activities of Daily Living (ADL) b. Functional Activities c. Functional Electrical Stimulation d. Gait Training e. Neuromuscular Re- Education f. Therapeutic Exercise g. Wheelchair Management and Propulsion 12. Therapy — Passive a. Continuous Passive Movement (CPM) b. Contrast Baths c. Electrical Stimulation (Unattended) d. Fluidotherapy e. Infrared Therapy f. Iontophoresis g. Manipulation h. Manual Electrical Stimulation i. Massage — Manual or Mechanical j. Mobilization (Joint) k. Mobilization (Soft Tissue) l. Paraffin Bath m. Superficial Heat And Cold Therapy n. Short-wave Diathermy o. Traction p. Transcutaneous Electrical Nerve Stimulation (TENS) q. Ultrasound r. Vasopneumatic Devices s. Whirlpool/Hubbard Tank 13. Vocational Rehabilitation G. THERAPEUTIC PROCEDURES — OPERATIVE a. Ankle and Subtalar Fusion b. Knee Fusion c. Total Knee Replacement d. Total Hip Replacement e. Amputation f. Manipulation Under Anesthesia g. Bursectomy h. Osteotomy i. Hardware Removal j. Release of Contracture

A. INTRODUCTION

To properly utilize this document, the reader should not skip nor overlook any sections.

B. GENERAL GUIDELINE PRINCIPLES

1. Application of Guidelines

The Division provides procedures to implement medical treatment guidelines and to foster communication to resolve disputes among the provider, payer and patient through the Workers' Compensation Rules of Procedure, Rule XVII and Rule VIII. In lieu of more costly litigation, parties may wish to seek administrative dispute resolution services through the Division.

2. Education

Education of the patient and family, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of lower extremity pain and disability. Currently, practitioners often think of education last, after medications, manual therapy and surgery. Practitioners must develop and implement an effective strategy and skills to educate patients, employers' insurance systems, policy makers and the community as a whole. An education-based paradigm should always start with inexpensive communication providing reassuring information to the patient. More in-depth education currently exists within a treatment regime employing functional restorative and innovative programs of prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of facilitating self-management of symptoms and prevention.

3. Treatment Parameter Duration

4. Active Interventions Interventions emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment, are generally emphasized over passive modalities, especially as treatment progresses. Generally, passive interventions are viewed as a means to facilitate progress in an active rehabilitation program with concomitant attainment of objective functional gains.

5. Active Therapeutic Exercise Program

Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and education. This includes functional application in vocational or community settings.

6. Positive Patient Response

7. Re-Evaluate Treatment Every 3 to 4 Weeks

8. Surgical Interventions

9. Six-Month Time Frame

10. Retum-to-Work

Retum-to-work is therapeutic, assuming the work is not likely to aggravate the basic problem or increase long-term pain. The practitioner must provide specific physical limitations and the patient should never be released to “sedentary” or “light duty.” The following functions should be considered and modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, bending at the waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors. Even if there is residual chronic pain, return-to-work is not necessarily contraindicated.

The practitioner should understand all of the physical demands of the patient's job position before returning the patient to full duty and should request clarification of the patient's job duties Clarification should be obtained from the employer or, if necessary, including, but not limited to, an occupational health nurse, occupational therapist, vocational rehabilitation specialist, or an industrial hygienist. 11. Delayed Recovery

The Division recognizes that 3 to 10% of all industrially injured patients will not recover within the timelines outlined in this document despite optimal care. Such individuals may require treatments beyond the limits discussed within this document, but such treatment will require clear documentation by the authorized treating practitioner focusing on objective functional gains afforded by further treatment and impact upon prognosis.

12. Guideline Recommendations and Inclusion of Medical Evidence

“Some” means the recommendation considered at least one adequate scientific study, which reported that a treatment was effective.

13. Care Bevond Maximum Medical Improvement (MMI)

The remainder of this document should be interpreted within the parameters of these guideline principles that may lead to more optimal medical and functional outcomes for injured workers.

C. INITLAL DIAGNOSTIC PROCEDURES

History taking and physical examinations are generally accepted, well-established and widely used procedures that establish the foundation/basis for and dictates subsequent stages of diagnostic and therapeutic procedures. When findings of clinical evaluations and those of other diagnostic procedures are not complementing each other, the objective clinical findings should have preference. The medical records should reasonably document the following. a. History of Present Injury:

1) Mechanism of injury. This includes details of symptom onset and progression;

2) Relationship to work. This includes a statement of the probability that the illness or injury is work- related;

3) Prior occupational and non-occupational injuries to the same area including specific prior treatment and any prior bracing devices;

4) History of locking, clicking, giving way, acute or chronic swelling, crepitation, pain while ascending or descending stairs, or popping;

5) Ability to perform job duties and activities of daily living; and

6) Exacerbating and alleviating factors of the injury. b. Past History:

1) Past medical history includes neoplasm, gout, arthritis, and diabetes;

2) Review of systems includes symptoms of rheumatologic, neurologic, endocrine, neoplastic, and other systemic diseases;

3) Smoking history; and

4) Vocational and recreational pursuits. c. Physical Examination

Examination of a joint should include the joint above and below the affected area. Physical examinations should include accepted tests and exam techniques applicable to the joint or area being examined, including:

1) Visual inspection;

2) Palpation;

3) Range of motion/quality of motion;

4) Strength;

5) Joint stability;

6) If applicable to injury, integrity of distal circulation, sensory, and motor function; and

7) If applicable, full neurological exam including muscle atrophy and gait abnormality. 2. Radiographic Imaging

Radiographic imaging of the lower extremities is a generally accepted, well-established and widely used diagnostic procedure when specific indications based on history and/or physical examination are present. It should not be routinely performed. The mechanism of injury and specific indications for the radiograph should be listed on the request form to aid the radiologist and x-ray technician. For additional specific clinical indications, see Section IV, “Specific Diagnosis, Testing and Treatment Procedures.” Indications include:

1) The inability to transfer weight for four steps at the time of the initial visit, regardless of limping;

2) History of significant trauma, especially blunt trauma or fall from a height;

3) Age over 55 years;

4) Unexplained or persistent lower extremity pain over two weeks. (Occult fractures, especially stress fractures, may not be visible on initial x-ray. A follow-up radiograph and/or bone scan may be required to make the diagnosis);

5) History or exam suggestive of intravenous drug abuse or osteomyelitis; and

6) Pain with swelling and/or range of motion (ROM) limitation localizing to an area of prior fracture, internal fixation, or joint prosthesis.

3. Laboratory Tests

Laboratory tests are generally accepted, well established and widely used procedures. They are, however, rarely indicated at the time of initial evaluation, unless there is suspicion of systemic illness, infection, neoplasia, connective tissue disorder, or underlying arthritis or rheumatologic disorder based on history and/or physical examination. Laboratory tests can provide useful diagnostic information. Tests include, but are not limited to:

1) CBC with differential can detect infection, blood dyscrasias, and medication side effects;

2) Erythrocyte sedimentation rate, rheumatoid factor, ANA, HLA, and C-reactive protein (CRP) can be used to detect evidence of a rheumatologic, infection, or connective tissue disorder;

3) Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease;

4) Liver and kidney function may be performed for prolonged anti-inflammatory use or other medications requiring monitoring; and

5) Analysis of joint aspiration for bacteria, white cell count, red cell count, fat globules, crystalline birefringence and chemistry to evaluate joint effusion.

4. Other Procedures a. Joint Aspiration

Joint aspiration is a generally accepted, well-established and widely used procedure when specifically indicated and performed by individuals properly trained in these techniques. This is true at the initial evaluation when history and/or physical examination are of concern for a septic joint or bursitis. Particularly at the knee, aspiration of a large effusion can help to decrease pain and speed functional recovery. Persistent or unexplained effusions may be examined for evidence of infection, rheumatologic, or inflammatory processes. The presence of fat globules in the effusion strongly suggests occult fracture.

D. SPECIFIC LOWER EXTREMITY INJURY DIAGNOSIS, TESTING, AND TREATMENT

1. Foot and Ankle a. Ankle Sprain/Fracture

1) Description/Definition — An injury to the ankle joint due to abnormal motion of the talus that causes a stress on the malleoli and the ligaments. Instability can result from a fracture of a malleolus (malleolli), rupture of ligaments, or a combination. Circumstances surrounding the injury are of importance in consideration of other injuries and locations. Additionally, the position of the foot at the time of injury is helpful in determining the extent and type of injury. Grading of soft tissue injuries includes:

(a) Grade 1 injuries are those with microscopic tears of the ligament, minimal swelling, normal stress testing, and the ability to bear weight.

(b) Grade 2 injuries have partial disruption of the ligament, significant swelling, indeterminate results on stress testing, and difficulty bearing weight.

(c) Grade 3 injuries have a ruptured ligament, swelling and ecchymosis, abnormal results on stress testing, and the inability to bear weight.

2) Occupational Relationship — Sudden twisting, direct blunt trauma, and falls.

3) Specific Physical Findings — Varies with individual: normal-appearing ankle or minimal tenderness on examination, ability/inability to bear weight, pain, swelling, ecchymosis. If the patient is able to transfer weight from one foot and has normal physical findings, then likelihood of fracture is reduced.

4) Diagnostic Testing Procedures — Ankle x-rays for bone tenderness, inability to bear weight, or significant edema/ecchymosis.

5) Non-Operative Treatment — For patients able to bear weight: NSAIDs and RICE (rest, ice, compression, elevation) in first 24 hours. After the acute phase, isometric and range of motion exercises are recommended followed by strengthening exercises. Partial weight bearing and splinting may be used in the initial stage of treatment. Active and/or passive therapy may be utilized to achieve optimal function.

For patients unable to bear weight: Bracing plus NSAIDs and RICE.

For patients with a clearly unstable joint: immobilization may be necessary for 4 to 6 weeks, with active and/or passive therapy to achieve optimal function.

6) Surgical Indications — Severe instability, failure of conservative treatment, chronic instability, displaced fracture.

7) Operative Treatment — Soft tissue: primary repair for acute and severe instability, delayed primary repair for chronic instability. Osseous: Open reduction internal fixation.

8) Post-Operative Therapy — Casting, bracing, active and/or passive therapy. b. Talar Fracture 1) Description/Definition — Osseous fragmentation of talus confirmed by radiographic, CT or MRI evaluation.

2) Occupational Relationship — Usually occurs from a fall or crush injury.

3) Specific Physical Findings — Clinical findings consistent with fracture of talus: pain with range of motion, palpation, swelling, ecchymosis. Pain with weight-bearing attempt.

4) Diagnostic Testing Procedures — Radiographs, CT scans, MRI. CT scans preferred for spatial alignment.

5) Non-Operative Treatment — Active and/or passive therapy, casting, nonweight-bearing for 6 to 8 weeks for non-displaced fractures.

6) Surgical Indications — Osseous displacement, joint involvement and instability per physician discretion.

7) Operative Treatment — Open reduction internal fixation.

8) Post-Operative Therapy — Nonweight-bearing 6 to 8 weeks followed by weight-bearing cast. MRI follow-up if suspect avascular necrosis. Active and/or passive therapy. c. Calcaneal Fractures

1) Description/Definition — Osseous fragmentation/separation confirmed by diagnostic studies.

2) Occupational Relationship — Usually occurs by fall or crush injury.

3) Specific Physical Findings — Pain with range of motion and palpation of calcaneus. Inability to weight- bear, malpositioning of heel, possible impingement of sural nerve.

4) Diagnostic Testing Procedures—Radiographs/ CT scans.

5) Non-Operative Treatment — Active and/or passive therapy, nonweight-bearing 6 to 8 weeks, followed by weight-bearing cast at physician's discretion.

6) Surgical Indications — Displacement of fragments, joint depression, intra-articular involvement, malposition of heel.

7) Operative Treatment — Open reduction internal fixation.

8) Post-Operative Therapy — Nonweight-bearing for 6 to 8 weeks followed by weight-bearing for approximately 6 to 8 weeks at physician's discretion. Active and/or passive therapy. d. Midfoot (Lisfranc's) Fracture Dislocation

1) Description/Definition — Fracture/ligamentous disruption of the tarsal-metatarsal joints, i.e., metatarsal-cuneiform and metatarsal-cuboid bones.

2) Occupational Relationship—Usually occurs by a fall, crush, or sagittal plane hyperflexion/extension.

3) Specific Physical Findings — Fracture dislocation at Lisfranc's joint. CT scans usually needed to evaluate. Fracture at base of 2nd metatarsal commonly seen.

4) Diagnostic Testing Procedures — X-rays, CT scans, MRI, mid-foot stress x-rays. 5) Non-Operative Treatment — Active and/or passive therapy. If minimal or no displacement (soft tissue) then casting, nonweight-bearing 6 to 10 weeks.

6) Surgical Indications — If displacement of fragments or intra-articular. Most Lisfranc's fracture/dislocations are treated surgically.

7) Operative Treatment — Open reduction internal fixation with removal of hardware approximately 3 to 6 months afterwards, pending healing status.

8) Post-Operative Therapy—Active and/or passive therapy, foot orthoses, nonweight-bearing 6 to 12 weeks. e. Metatarsal-Phalangeal, Tarsal-Metatarsal, and Interphalangeal Joint Arthropathy

1) Description/Definition — Internal derangement of joint.

2) Occupational Relationship — Jamming, contusion, crush injury, or repetitive motion posttraumatic arthrosis.

3) Specific Physical Findings — Pain with palpation and ROM of joint, effusion.

4) Diagnostic Testing Procedures — Radiographs, diagnostic joint injection, MRI.

5) Non-Operative Treatment — Active and/or passive therapy, joint splinting, injection therapy.

6) Surgical Indications — Pain, unresponsive to conservative care. Surgery may include athroplasty, implant, and fusion.

7) Operative Treatment — Fusion, arthroplasty, joint debridement.

8) Post-Operative Therapy — Active and/or passive therapy, early range of motion with arthroplasty, bracing-protected, weight-bearing with fusion. f. Pilon Fracture

1) Description/Definition — Crush/comminution fracture of distal metaphyseal tibia that has intra-articular extensions into the weight-bearing surface of the tibio-talar joint.

2) Occupational Relationship—Usually from a fall.

3) Specific Physical Findings—Multiple fracture fragments at distal tibia with intra-articular extensions into the weight-bearing surface of the tibio-talar joint.

4) Diagnostic Testing Procedures—Radiographs, CT scans.

5) Non-Operative Treatment — Active and/or passive therapy. Prolonged nonweight-bearing at physician's discretion.

6) Surgical Indications — Displacement of fracture with viable attempt at joint salvage, severe comminution necessitating primary fusion.

7) Operative Treatment — Open reduction internal fixation, fusion, external fixation.

8) Post-Operative Therapy—Active and/or passive therapy. g. Puncture Wounds of the Foot

1) Description/Definition — Penetration of skin by foreign object.

2) Occupational Relationship — Usually by stepping on foreign object, open wound.

3) Specific Physical Findings — Site penetration by foreign object consistent with history. In early onset, may show classic signs of infection.

4) Diagnostic Testing Procedures — X-ray, MRI, ultrasound.

5) Non-Operative Treatment — Appropriate antibiotic therapy, tetanus toxoid booster, nonweight-bearing at physician's discretion.

6) Surgical Indications — Cellulitis, retained foreign body suspected, abscess, compartmental syndrome, and bone involvement.

7) Operative Treatment — Incision and drainage with cultures.

8) Post-Operative Therapy — Nonweight-bearing, antibiotic therapy based upon cultures, follow-up x- rays may be needed to evaluate for osseous involvement. Active and/or passive therapy. h. Achilles Tendon Injury/Rupture

1) Description/Definition — Rupture, tear, or strain of Achilles tendon.

2) Occupational Relationship — Related to a fall, twisting, jumping, or sudden load on ankle with dorsiflexion.

3) Specific Physical Findings — Swelling and pain at tendon, palpable deficit in tendon.

4) Diagnostic Testing Procedures — MRI, ultrasound.

5) Non-Operative Treatment — Cast, nonweight-bearing, active and/or passive therapy.

6) Surgical Indications — Total rupture.

7) Operative Treatment — Repair of tendon by various methods, therapy.

8) Post-Operative Therapy — Nonweight-bearing cast for 6 to 8 weeks followed by active and/or passive therapy. i. Ankle Osteoarthropathy

1) Description/Definition — Internal joint pathology of ankle.

2) Occupational Relationship — Chronic: work activities exacerbating a pathologic condition. Acute: internal derangement of joint caused by trauma (twisting, fall).

3) Specific Physical Findings — Pain within joint, swelling.

4) Diagnostic Testing Procedures — X-ray, CT, MRI, diagnostic injection.

5) Non-Operative Treatment — Injection therapy, bracing, active and/or passive therapy. 6) Surgical Indications — Pain and loss of joint function. Unresponsive to conservative care.

7) Operative Treatment — Arthroscopy, arthrotomy, fusion.

8) Post-Operative Therapy — Active and/or passive therapy. j. Ankle or Subtalar Joint Dislocation

1) Description/Definition — Dislocation of ankle or subtalar joint.

2) Occupational Relationship — Usually occurs by fall, twist.

3) Specific Physical Findings — Disruption of articular arrangements of ankle, subtalar joint.

4) Diagnostic Testing Procedures — Radiographs, CT scans.

5) Non-Operative Treatment — Closed reduction under anesthesia with pre and post-reduction neurovascular assessment.

6) Surgical Indications — Inability to reduce closed fracture, association with unstable fractures.

7) Operative Treatment — Open reduction of dislocation.

8) Post-Operative Therapy — Immobilization, followed by active and/or passive therapy. k. Heel Spur Syndrome/Plantar Fasciitis

1) Description — Pain along the inferior aspect of the heel at the attachment of the plantar fascia.

2) Occupational Relationship — Condition may be exacerbated by prolonged standing on hard surfaces. Acute injury may be caused by trauma. This may include jumping from a height or hyperextension of the forefoot upon the rear foot.

3) Specific Physical Findings — Pain with palpation at the inferior attachment of the plantar fascia to the os calcis. May be associated with calcaneal spur.

4) Diagnostic Testing — Standard radiographs to rule out fracture, identify spur after conservative therapy. Bone scans may be utilized to rule out stress fractures in chronic cases.

5) Non-Operative Treatment — This condition usually responds to conservative management consisting of active and/or passive therapy, taping, injection therapy, non-steroidal anti-inflammatory drugs, and custom foot orthoses.

6) Surgical Indications — Surgery is usually employed only after failure of conservative management (3 to 6 months).

7) Operative Treatment — Plantar fascial release with or without calcaneal spur removal.

8) Post-Operative Therapy — Nonweight-bearing 7 to 10 days followed by weight-bearing cast or shoe for four weeks. Active and/or passive therapy. l. Tarsal Tunnel Syndrome

1) Description — Pain and paresthesias along the medial aspect of the ankle and foot due to nerve irritation and entrapment of the tibial nerve or its branches. 2) Occupational Relationship — Acute injuries may occur after blunt trauma along the medial aspect of the foot. Non-traumatic occurrences are determined at physician's discretion after review of environmental and biomechanical risk factors. Examples may include abnormal foot mechanics and excessive weight bearing.

3) Specific Physical Findings — Positive Tinel's sign. Pain with percussion of the tibial nerve radiating distally or proximally. Pain and paresthesias with weight-bearing activities.

4) Diagnostic Testing Procedures — Nerve conduction velocity studies, MRI.

5) Non-Operative Treatment — Active and/or passive therapy, injection therapy, cast immobilization, foot orthoses, non-steroidal anti-inflammatories.

6) Surgical Indications — Failure of condition to respond to conservative management (3 to 6 months).

7) Operative Treatment — Tarsal tunnel release.

8) Post-Operative Therapy — Active and/or passive therapy. m. Neuroma

1) Description — This condition is a perineural fibrosis of the intermetatarsal nerve creating pain and/or paresthesias in the forefoot region. Symptoms appear with weight-bearing activities. Usually occurs between the third and fourth metatarsals or between the second and third metatarsals.

2) Occupational Relationship — Acute injuries may include excessive loading of the forefoot region caused from jumping or pushing down on the ball the foot. Non-traumatic occurrences are determined at physician's discretion after review of environmental and biomechanical risk factors. Examples may include excessive weight-bearing on hard surfaces in conjunction with abnormal foot mechanics.

3) Specific Physical Findings — Paresthesias and or pain with palpation of the intermetatarsal nerve (Mulder's sign) diagnostic testing-radiographs to rule out osseous involvement. Diagnostic and therapeutic injections. Diagnosis is usually made upon clinical judgment; however MRI and ultrasound imaging have also been employed in difficult cases.

4) Diagnostic Testing — Radiographs to rule out osseous involvement. Diagnostic and therapeutic injections. Diagnosis is usually made upon clinical judgment; however MRI and ultrasound imaging have also been employed in difficult cases.

5) Non-Operative Treatment — Injection therapy, nonsteroidal anti-inflammatories, foot orthoses, active and/or passive therapy.

6) Surgical Indications — Failure of conservative management (2 to 3 months).

7) Operative Treatment — Excision of the neuroma.

8) Post-Operative Therapy — Active and/or passive therapy. May involve a period of nonweight-bearing up to two weeks followed by gradual protected weight-bearing 4 to 6 weeks.

2. Knee a. Chondral Defects

1) Description/Definition — Cartilage or cartilage and bone defect at the articular or meniscal surface of a joint.

2) Occupational Relationship — Usually caused by a traumatic knee injury.

3) Specific Physical Findings — Knee effusion, pain in joint.

4) Diagnostic Testing Procedures — MRI may show bone bruising, osteochondral lesion, or possibly articular cartilage injury. Radiographs, contrast radiography, CT may also be used.

5) Non-Operative Treatment — Limited indications. The size and extent of the injury should be determined first. This form of therapy is reserved for non-displaced, stable lesions. Immobilization (for acute injury), active and/or passive therapy.

6) Surgical Indications — Symptoms not responsive to conservative therapy. Identification of an osteochondral lesion by diagnostic testing procedures should be done to determine the size of the lesion and stability of the joint.

a. Cartilage Grafts and or Transplantations remain controversial and have some scientific evidence. These procedures are technically difficult and require specific physician expertise. Cartilage transplantation requires the harvesting and growth of patients' cartilage cells in a highly specialized lab and may incur extraneous laboratory charges.

Indications – They may be effective in patients less than 40 years of age, with a singular, traumatically caused grade III or IV femoral condyle deficit, and who plan to maintain an active lifestyle. The diameter of the deficit should not exceed 20 mm for osteochondral autograft transplant procedure.

Contraindications – Grafts and transplants are not recommended for individuals with obesity, inflammatory or osteoarthritis, or other chondral defects, associated ligamentous or meniscus pathology, or who are greater than 55 years of age. For cartilage grafts or transplants, prior authorization is required.

b. Cartilage Repair involves the repair and or removal of torn cartilage.

7) Operative Treatment — Arthroscopy with debridement or shaving of cartilage, microfracture, mosiacplasty, fixation of loose osteochondral fragments and cartilage transplantation.

8) Post-Operative Therapy — May include restricted weight bearing, bracing, active and/or passive therapy. Continuous passive motion is suggested after microfracture. b. Aggravated Osteoarthritis

1) Description/Definition — Swelling and/or pain in a joint due to an aggravating activity in a patient with pre-existing degenerative change in a joint.

2) Occupational Relationship — May be caused by repetitive activity or constant position.

3) Specific Physical Findings — Increased pain and swelling in a joint.

4) Diagnostic Testing Procedures — Radiographs, MRI to rule out degenerative menisci tear.

5) Non-Operative Treatment — NSAIDs, ice, bracing, active and/or passive therapy, therapeutic injections, restricted activity.

6) Surgical Indications — Symptoms not responsive to conservative therapy. 7) Operative Treatment — Arthroscopic joint lavage, debridement, removal of loose bodies. For symptoms not responsive to conservative measures, treatment may involve total joint replacement.

8) Post-Operative Therapy — Active and/or passive therapy. c. Anterior Cruciate Ligament Injury

1) Description/Definition — Rupture or partial rupture of the anterior cruciate ligament; may be associated with other internal derangement of the knee.

2) Occupational Relationship — May be caused by virtually any traumatic force to the knee but most often caused by a twisting or a hyperextension force.

3) Specific Physical Findings — Findings on physical exam include effusion or hemarthrosis, instability, Lachman's test, pivot shift test, and anterior drawer test.

4) Diagnostic Testing Procedures — MRI. Radiographs may show avulsed portion of tibial spine but this is a rare finding.

5) Non-Operative Treatment — Active and/or passive therapy, bracing, therapeutic injection.

6) Surgical Indications — Physically active individual less than 50 years old or any individual with complaints of recurrent instability.

7) Operative Treatment — Diagnostic/surgical arthroscopy followed by ACL reconstruction using autograft. If meniscus repair is performed, an ACL repair should be performed concurrently.

8) Post-Operative Therapy — Active and/or passive therapy, bracing. d. Posterior Cruciate Injuries

1) Description/Definition — Rupture of posterior cruciate ligament; may have concurrent ACL rupture.

2) Occupational Relationship — Most often caused by a posterior directed force to flexed knee.

3) Specific Physical Findings — Findings on physical exam include acute effusion, instability, reverse Lachman's test, reverse pivot shift, posterior drawer test.

4) Diagnostic Testing Procedures — MRI, radiographs may reveal avulsed bone.

5) Non-Operative Treatment — Active and/or passive therapy, bracing, therapeutic injection.

6) Surgical Indications — Complaints of instability. Carefully consider the patients' normal daily activity level before initiation of surgical intervention. Most commonly done when the PCL rupture is accompanied by multiligament injury.

7) Operative Treatment — Autograft or allograft reconstruction.

8) Post-Operative Therapy — Active and/or passive therapy, bracing. e. Meniscus Injury

1) Description/Definition — A tear, disruption, or avulsion of medial or lateral meniscus tissue. 2) Occupational Relationship — Trauma to the menisci from rotational, shearing, torsion, and/or impact injuries.

3) Specific Physical Findings — Patient describes a popping, tearing, or catching sensation. Findings on physical exam may include joint line tenderness, locked joint, or occasionally, effusion.

4) Diagnostic Testing Procedures — Radiographs including standing PA, lateral, tunnel, and Skyline views.

5) Non-Operative Treatment — Active and/or passive therapy, bracing.

6) Surgical Indications — Symptoms not responsive to conservative therapy. Sustained marked reduction of ROM of joint; acute effusion with positive ligament laxity; recurrent effusions; infection; loose bodies.

7) Operative Treatment — Debridement of meniscus, repair of meniscus, partial or complete excision of meniscus. Complete excision of meniscus should only be performed when clearly indicated due to the long-term risk of arthritis in these patients.

8) Post-Operative Therapy — Active and/or passive therapy, bracing. f. Patellar Subluxation

1) Description/Definition — An incomplete subluxation or dislocation of the patella. Recurrent episodes can lead to subluxation syndrome that can cause frank dislocation of the patella.

2) Occupational Relationship — Primarily associated with contusion, lateral force direct contact. Secondary causes associated with shearing forces on the patella.

3) Specific Physical Findings — Patient may report buckling sensation. Findings on physical exam may include retinacular weakness, swelling, effusion, marked pain with patellofemoral tracking/compression and glides. In addition, other findings include atrophy of muscles, positive patellar apprehension test, patella alta.

4) Diagnostic Testing Procedures — CT or Radiographs including Merchant views, Q-angle versus congruents.

5) Non-Operative Treatment — Active and/or passive therapy, bracing, therapeutic injection.

6) Surgical Indications — Symptoms not responsive to conservative therapy, fracture, recurrent subluxation or recurrent effusion.

7) Operative Treatment — Diagnostic arthroscopy with possible arthrotomy; debridement of soft tissue and articular cartilage disruption; open reduction internal fixation with fracture. Retinacular release, quadriceps reefing, and patellar tendon transfer should only be considered after 6 to 9 months of conservative therapy.

8) Post-Operative Therapy — Active and/or passive therapy, bracing. g. Retropatellar Pain Syndrome

1) Description/Definition — A retropatellar pain syndrome lasting over three months. Retropatellar pathologies are associated with resultant weakening instability, and pain of the patellofemoral mechanism. Can include malalignment, persistent quadriceps tendonitis, distal patellar tendonitis, patellofemoral arthrosis, and symptomatic plica syndrome. 2) Occupational Relationship — Usually associated with contusion; repetitive patellar compressive forces, shearing articular injuries associated with subluxation or dislocation of patella, fractures, infection, and connective tissue disease.

3) Specific Physical Findings — Patient complains of pain, instability and tenderness that interfere with daily living and work functions. Findings on physical exam may include retinacular tenderness, pain with patellar compressive ranging, positive patellar glide test, atrophy of quadriceps muscles, positive patellar apprehensive test. Associated anatomical findings may include increased Q angle; rotational lower extremity joints; ligament laxity, and effusion.

4) Diagnostic Testing Procedures — Radiographs including tunnel, Merchant, or Laurin views. MRI rarely identifies pathology. Occasionally CT or Bone scan.

5) Non-Operative Treatment — Active and/or passive therapy, bracing, orthotics, therapeutic injections.

6) Surgical Indications — Symptoms not responsive to conservative therapy, patellar tendon disruption, quadriceps tendon rupture/avulsion, fracture.

7) Operative Treatment — Arthroscopic debridement of articular surface, plica, synovial tissue, loose bodies, arthrotomy, open reduction internal fixation with fracture, patellar button (prosthesis) with grade III-IV OA, and possible patellectomy. Retinacular release, quadriceps reefing, and tibial transfer procedures should only be considered after 6 to 9 months of conservative therapy.

8) Post-Operative Therapy — Active and/or passive therapy; bracing. h. Tendonitis/Tenosynovitis

1) Description/Definition — Inflammation of the lining of the tendon sheath or of the enclosed tendon. Usually occurs at the point of insertion into bone or a point of muscular origin. Can be associated with bursitis or calcium deposits or systemic connective diseases.

2) Occupational Relationship — Extreme or repetitive trauma, strain, or excessive unaccustomed exercise or work.

3) Specific Physical Findings — Involved tendons may be visibly swollen with possible fluid accumulation and inflammation; popping or crepitus; and decreased ROM.

4) Diagnostic Testing Procedures — Rarely indicated.

5) Non-Operative Treatment — Active and/or passive therapy, including ergonomic changes at work station(s), NSAIDs, therapeutic injections.

6) Surgical Indications — Suspected avulsion fracture, severe functional impairment unresponsive to conservative therapy.

7) Operative Treatment — Rarely indicated and only after extensive conservative therapy.

8) Post-Operative Therapy — Active and/or passive therapy. i. Bursitis of the Lower Extremity

1) Description/Definition — Inflammation of bursa tissue. Can be precipitated by tendonitis, bone spurs, foreign bodies, gout, arthritis, muscle tears, or infection.

2) Occupational Relationship — Sudden change in work habits, frequent repetitive motions in non-routine work profile, postural changes, contusion, frequent climbing, soft tissue trauma, fracture, continuous work on uneven surfaces, sustained compression force.

3) Specific Physical Findings — Palpable, tender and enlarged bursa, decreased ROM, warmth. May have increased pain with ROM.

4) Diagnostic Testing Procedures — Bursal fluid aspiration with testing for connective tissue, rheumatic disease, and infection. Radiographs, CT, MRI are rarely indicated.

5) Non-Operative Treatment — Active and/or passive therapy, ice, therapeutic injection, treatment of an underlying infection, if present.

6) Surgical Indications — Bursa excision after failure of conservative therapy.

7) Operative Treatment — Surgical excision of the bursa.

8) Post-Operative Therapy — Active and/or passive therapy.

3. Hip and Leg a. Hip Fracture

1) Description/Definition — Fractures of the neck and peritrochanteric regions of the proximal femur.

2) Occupational Relationship — Usually from a traumatic injury such as a fall or crush. Patients with intracapsular femoral fractures have a risk of developing avascular necrosis of the femoral head requiring treatment months to years after the initial injury.

3) Specific Physical Findings — Often a short, and externally rotated lower extremity.

4) Diagnostic Testing Procedures — Radiographs. Occasional use of tomography, CT scanning or MRI.

5) Non-Operative Treatment — Rarely indicated. May be considered in a stable, undisplaced fracture.

6) Surgical Indications — Unstable peritrochanteric fractures with potential for displacement; femoral neck fracture to be considered for pinning or prosthetic replacement based upon pattern and displacement of fracture. Open fracture.

7) Operative Treatment — Prosthetic replacement for displaced neck fractures. Closed reduction, and internal fixation for peri-trochanteric fractures and undisplaced or minimally displaced neck fractures.

8) Post-Operative Therapy — Active and/or passive therapy. Weight-bearing progression based upon fracture pattern and stability. In all cases, communication between the physician and physical therapist is important to the timing of weight-bearing and exercise progressions. b. Pelvic Fracture

1) Description/Definition — Fracture of one or more components of the pelvic ring (sacrum and iliac wings).

2) Occupational Relationship — Usually from a traumatic injury such as a fall or crush.

3) Specific Physical Findings — Displaced fractures may cause pelvic deformity and shortening or rotation of the lower extremities. 4) Diagnostic Testing Procedures — Radiographs, CT scanning. Occasionally MRI, angiogram, urethrogram.

5) Non-Operative Treatment — For stable, undisplaced or minimally displaced fractures. May include analgesics, a limited period of bed rest, limited weight-bearing and passive therapy.

6) Surgical Indications — Unstable fracture pattern, open fracture.

7) Operative Treatment — External or internal fixation dictated by fracture pattern.

8) Post-Operative Therapy — Graduated weight-bearing according to fracture healing. Active and/or passive therapy for gait, pelvic stability and strengthening and restoration of joint and extremity function. c. Acetabulum Fracture

1) Description/Definition — Subgroup of pelvic fractures with involvement of the hip articulation.

2) Occupational Relationship — Usually from a traumatic injury such as a fall or crush.

3) Specific Physical Findings — Displaced fractures may have short and/or abnormally rotated lower extremity.

4) Diagnostic Testing Procedures — Radiographs, CT scanning.

5) Non-Operative Treatment — May be considered for undisplaced fractures or minimally displaced fractures that do not involve the weight-bearing surface of the acetabular dome.

6) Surgical Indications — Displaced or unstable fracture pattern associated femoral head fracture, open fracture.

7) Operative Treatment — Usually open reduction internal fixation.

8) Post-Operative Therapy — Active and/or passive therapy for early range-of-motion and weight-bearing progression, strengthening, flexibility, and neuromuscular training. In all cases, communication between the physician and physical therapist is important to the timing of weight-bearing and exercise progressions. d. Hamstring Tendon Rupture

1) Description/Definition — Most commonly, a disruption of the muscular portion of the hamstring. Extent of the tear is variable. Occasionally a proximal tear or avulsion. Rarely a distal injury.

2) Occupational Relationship — Excessive tension on the hamstring either from an injury or from to a rapid, forceful contraction of the muscle.

3) Specific Physical Findings — Local tenderness, swelling, ecchymosis.

4) Diagnostic Testing Procedures — Occasionally radiographs or MRI for proximal tears/possible avulsion.

5) Non-Operative Treatment — Usual treatment is local ice followed by heat in 24 to 48 hours, protected weight-bearing, active and/or passive therapy, nonsteroidal anti-inflammatory drugs.

6) Surgical Indications — Usually for proximal or distal injuries only if significant functional impairment is expected without repair, open fracture.

7) Operative Treatment — Occasionally re-attachment of proximal avulsions and repair of distal tendon disruption.

8) Post-Operative Therapy — Active and/or passive therapy, protected weight-bearing. e. Hip Dislocation

1) Description/Definition — Disengagement of the femoral head from the acetabulum.

2) Occupational Relationship — Usually from a traumatic injury such as a fall or crush.

3) Specific Physical Findings — Most commonly a short, internally rotated, adducted lower extremity with a posterior dislocation. A short externally rotated extremity with an anterior dislocation.

4) Diagnostic Testing Procedures — Radiographs, occasionally CT scanning.

5) Non-Operative Treatment — Urgent closed reduction. Sedation or general anesthesia usually required.

6) Surgical Indications — Failure of closed reduction. Associated fracture of the acetabulum or femoral head, open fracture.

7) Operative Treatment — Open reduction of the femoral head.

8) Post-Operative Therapy — Active and/or passive therapy for early range of motion, protected weight- bearing. f. Trochanteric Fracture

1) Description/Definition — Fracture of the greater trochanter of the proximal femur.

2) Occupational Relationship — Usually from a traumatic injury such as a fall or crush.

3) Specific Physical Findings — Local tenderness over the greater trochanter. Sometimes associated swelling, ecchymosis.

4) Diagnostic Testing Procedures — Radiographs. Occasionally tomograms or CT scans.

5) Non-Operative Treatment — Active and/or passive therapy for protected weight-bearing.

6) Surgical Indications — Large, displaced fragment, open fracture.

7) Operative Treatment — Open reduction, internal fixation.

8) Post-Operative Therapy — Active and/or passive therapy for protected weight-bearing. Full weight- bearing with radiographic and clinical signs of healing. g. Femur Fracture

1) Description/Definition — Fracture of the femur distal to the lesser trochanter.

2) Occupational Relationship — Usually from a traumatic injury such as a fall or crush. 3) Specific Physical Findings — May have a short, abnormally rotated extremity. Effusion if the knee joint involved.

4) Diagnostic Testing Procedures — Radiographs. Occasionally tomography or CT scanning, particularly if the knee joint is involved.

5) Non-Operative Treatment — Active and/or passive therapy for functional bracing, protected weight bearing.

6) Surgical Indications — Unstable fracture pattern, displaced fracture, especially if the knee joint is involved, open fracture.

7) Operative Treatment — Often closed, rodding for shaft fractures. Open reduction and internal fixation more common for fractures involving the knee joint.

8) Post-Operative Therapy — Active and/or passive therapy for protected weight-bearing, early range of motion if joint involvement. h. Tibia Fracture

1) Description/Definition — Fracture of the tibia proximal to the malleoli.

2) Occupational Relationship — Usually from a traumatic injury such as a fall or crush.

3) Specific Physical Findings — May have a short, abnormally rotated extremity. Effusion if the knee joint involved.

4) Diagnostic Testing Procedures — Radiographs. Occasionally tomography or CT scanning, particularly if the knee joint is involved.

5) Non-Operative Treatment — Active and/or passive therapy for functional bracing, protected weight- bearing.

6) Surgical Indications — Unstable fracture pattern, displaced fracture (especially if the knee joint is involved), open fracture.

7) Operative Treatment — Often closed rodding for shaft fractures. Open reduction and internal fixation more common for fractures involving the knee joint.

8) Post-Operative Therapy — Active and/or passive therapy for protected weight-bearing, early range of motion if joint involvement.

E. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES

All diagnostic imaging procedures have a significant percentage of specificity and sensitivity for various diagnoses. None is specifically characteristic of a certain diagnosis. Clinical information obtained by history taking and physical examination should be the basis for selection and interpretation of imaging procedure results. When a diagnostic procedure, in conjunction with clinical information, provides sufficient information to establish an accurate diagnosis, the second diagnostic procedure will become a redundant procedure. At the same time, a subsequent diagnostic procedure can be a complementary diagnostic procedure if the first or preceding procedures, in conjunction with clinical information, cannot provide an accurate diagnosis. Usually, preference of a procedure over others depends upon availability, a patient's tolerance and/or the treating practitioner's familiarity with the procedure.

1. Imaging Studies

Imaging studies are generally accepted, well established and widely used diagnostic procedures. When indicated, the following additional imaging studies can be utilized for further evaluation of the lower extremity, based upon the mechanism of injury, symptoms, and patient history. For specific clinical indications, see “Specific Diagnosis, Testing and Treatment Procedures.” The studies below are listed in frequency of use, not importance. a. Magnetic Resonance Imaging (MRI)

MRI provides a more definitive visualization of soft tissue structures, including ligaments, tendons, joint capsule, menisci and joint cartilage structures, than x-ray or Computerized Axial Tomography in the evaluation of traumatic or degenerative injuries. The addition of intravenous or intra-articular contrast can enhance definition of selected pathologies.

In general, the high field, conventional, MRI provides better resolution. A lower field scan may be indicated when a patient cannot fit into a high field scanner or is too claustrophobic despite sedation. Inadequate resolution on the first scan may require a second MRI using a different technique. All questions in this regard should be discussed with the MRI center and/or radiologist. b. Computerized Axial Tomography (CT)

CT provides excellent visualization of bone and is used to further evaluate bony masses and suspected fractures not clearly identified on radiographic window evaluation. Instrument scatter-reduction software provides better resolution when metallic artifact is of concern. c. Lineal Tomography

Lineal tomography is infrequently used, yet may be helpful in the evaluation of joint surfaces and bone healing. d. Bone Scan (Radioisotope Bone Scanning)

Bone scanning is more sensitive but less specific than MRI. It is useful for the investigation of traurna, infection, stress fracture, occult fracture, Charcot joint, Complex Regional Pain Syndrome, and suspected neoplastic conditions of the lower extremity. e. Other Radionuclide Scanning

Arthograms may be useful in the evaluation of internal derangement of a joint, including when MRI or other tests are contraindicated or not available. Potential complications of this more invasive technique include pain, infection, and allergic reaction. Arthrography gains additional sensitivity when combined with CT in the evaluation of internal derangement, loose bodies, and articular cartilage surface lesions. Diagnostic arthroscopy should be considered before arthrogram with strong clinical correlation. g. Diagnostic Arthroscopic Examination

Diagnostic arthroscopic (DA) examination allows direct visualization of the interior of a joint, enabling the diagnosis of conditions when other diagnostic tests have failed to reveal an accurate diagnosis. DA may also be employed in the treatment of joint disorders. In some cases, the mechanism of injury and physical examination findings will strongly suggest the presence of a surgical lesion. In those cases, it is appropriate to proceed directly with the interventional arthroscopy.

2. Other Tests

The studies below are listed by frequency of use, not importance. a. Personality/Psychological/Psychosocial Evaluations

Personality/psychological/psychosocial evaluations are generally accepted and well-established diagnostic procedures with selective use in the acute lower extremity population, but have more widespread use in sub-acute and chronic lower extremity populations.

Formal psychological or psychosocial evaluation should be performed on patients not making expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests. In addition to the customary initial exam, the evaluation of the injured worker should specifically address the following areas:

1) Employment history;

2) Interpersonal relationships — both social and work;

3) Leisure activities;

4) Current perception of the medical system;

5) Results of current treatment;

6) Perceived locus of control; and

7) Childhood history, including abuse and family history of disability.

Results should provide clinicians with a better understanding of the patient, thus allowing for more effective rehabilitation.

The evaluation will determine the need for further psychosocial interventions, and in those cases, a DSM IV diagnosis should be determined and documented. An individual with a PhD, PsyD, or Psychiatric MD/DO credentials may perform initial evaluations, which are generally completed within one to two hours. When issues of chronic pain are identified, the evaluation should be more extensive and follow testing procedures as outlined in “Psychosocial Evaluation,” in Division Rule XVII, Exhibit F, Chronic Pain Disorder Medical Treatment Guideline.

Electrodiagnostic tests include, but are not limited to, Electromyography (EMG), Nerve Conduction Studies (NCS) and Somatosensory Evoked Potentials (SSEP). These are generally accepted, well- established and widely used diagnostic procedures. The SSEP study, although generally accepted, has limited use. Electrodiagnostic studies may be useful in the evaluation of patients with suspected involvement of the neuromuscular system, including disorder of the anterior horn cell, radiculopathies, peripheral nerve entrapments, peripheral neuropathies, neuromuscular junction and primary muscle disease.

Doppler ultrasonography/plethysmography is useful in establishing the diagnosis of arterial and venous disease in the lower extremity and should be considered prior to the more invasive venogram or arteriogram study. Doppler is less sensitive in detecting deep-vein thrombosis in the calf muscle area. If the test is initially negative, an ultrasound should be repeated 7 days post initial symptoms to rule out popliteal thrombosis. It is also useful for the diagnosis of popliteal mass when MRI is not available or contraindicated. d. Venogram/Arteriogram

Venogram/arteriogram is useful for investigation of vascular injuries or disease, including deep-venous thrombosis. Potential complication may include pain, allergic reaction, and deep-vein thrombosis. e. Compartment Pressure Testing and Measurement Devices

Compartment pressure testing and measurement devices, such as pressure manometer, are useful in the evaluation of patients who present symptoms consistent with a compartment syndrome.

3. Special Tests

Special tests are generally well-accepted tests and are performed as part of a skilled assessment of the patient's capacity to return to work, his/her strength capacities, and physical work demand classifications and tolerances. a. Computer Enhanced Evaluations

(1) Frequency: One time for evaluation. Can monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations. b. Functional Capacity Evaluation (FCE)

(1) Frequency: One time with additional visits as needed for follow-up per job site. d. Vocational Assessment

Once an authorized practitioner has reasonably determined and objectively documented that a patient will not be able to return to her/her former employment and can reasonably prognosticate final restrictions, implementation of a timely vocational assessment can be performed. The vocational assessment should provide valuable guidance in the determination of future rehabilitation program goals. It should clarify rehabilitation goals, which optimize both patient motivation and utilization of rehabilitation resources. If prognosis for return to former occupation is determined to be poor, except in the most extenuating circumstances, vocational assessment should be implemented within 3 to 12 months post-injury. Declaration of Maximum Medical Improvement should not be delayed solely due to lack of attainment of a vocational assessment.

(1) Frequency: One time with additional visits as needed for follow-up e. Work Tolerance Screening

Work tolerance screening is a determination of an individual's tolerance for performing a specific job based on a job activity or task. It may include a test or procedure to specifically identify and quantify work- relevant cardiovascular, physical fitness and postural tolerance. It may also address ergonomic issues affecting the patient's return-to-work potential. May be used when a full FCE is not indicated.

(1) Frequency: One time for evaluation. May monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations.

F. THERAPEUTIC PROCEDURES — NON-OPERATIVE Before initiation of any therapeutic procedure, the authorized treating provider, employer and insurer must consider these important issues in the care of the injured worker.

First, patients undergoing therapeutic procedure(s) should be released or returned to modified, restricted or full duty during their rehabilitation at the earliest appropriate time. Refer to “Return-to-Work” in this section for detailed information.

The following procedures are listed in alphabetical order.

1. Acupuncture

(1) Time to produce effect: 3 to 6 treatments

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 1 to 2 months

(4) Maximum duration: 14 treatments b. Acupuncture with Electrical Stimulation

Acupuncture with electrical stimulation is the use of electrical current (micro-amperage or milli-amperage) on the needles at the acupuncture site. It is used to increase effectiveness of the needles by continuous stimulation of the acupoint. Physiological effects (depending on location and settings) can include endorphin release for pain relief, reduction of inflammation, increased blood circulation, analgesia through interruption of pain stimulus, and muscle relaxation. It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.

(1) Time to produce effect: 3 to 6 treatments

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 1 to 2 months

(4) Maximum duration: 14 treatments c. Other Acupuncture Modalities

(1) Time to produce effect: 3-6 treatments

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 1 to 2 months

(4) Maximum duration: 14 treatments

2. Biofeedback

Treatment is individualized to the patient's work-related diagnosis and needs. Home practice of skills is required for mastery and may be facilitated by the use of home training tapes. The ultimate goal in biofeedback treatment is normalizing the physiology to the pre-injury status to the extent possible and involves transfer of learned skills to the workplace and daily life. Candidates for biofeedback therapy or training must be motivated to learn and practice biofeedback and self-regulation techniques. Indications for biofeedback include individuals who are suffering from musculoskeletal injury where muscle dysfunction or other physiological indicators of excessive or prolonged stress response affects and/or delays recovery. Other applications include training to improve self-management of emotional stress/pain responses such as anxiety, depression, anger, sleep disturbance, and other central and autonomic nervous system imbalances. Biofeedback is often utilized along with other treatment modalities.

(1) Time to produce effect: 3 to 4 sessions

(2) Frequency: 1 to 2 times per week

(3) Optimum duration: 5 to 6 sessions

(4) Maximum duration: 10 to 12 sessions. Treatment beyond 12 sessions must be documented with respect to need, expectation, and ability to facilitate positive symptomatic or functional gains.

3. Injections — Therapeutic

Description — Therapeutic injection procedures are generally accepted, well-established procedures that may play a significant role in the treatment of patients with lower extremity pain or pathology. Therapeutic injections involve the delivery of anesthetic and/or anti-inflammatory medications to the painful structure. Therapeutic injections have many potential benefits. Ideally, a therapeutic injection will: (a) reduce inflammation in a specific target area; (b) relieve secondary muscle spasm; (c) allow a break from pain; and (d) support therapy directed to functional recovery. Diagnostic and therapeutic injections should be used early and selectively to establish a diagnosis and support rehabilitation. If injections are overused or used outside the context of a monitored rehabilitation program, they may be of significantly less value.

Indications — Diagnostic injections are procedures which may be used to identify pain generators or pathology. For additional specific clinical indications, see “Specific Diagnosis, Testing and Treatment Procedures.”

Special Considerations — The use of injections has become progressively sophisticated. Each procedure considered has an inherent risk, and risk versus benefit should be evaluated when considering injection therapy. In addition, all injections must include sterile technique.

Contraindications — General contraindications include local or systemic infection, bleeding disorders, allergy to medications used and patient refusal. Specific contraindications may apply to individual injections. a. Joint Injections

Joint injections are generally accepted, well-established procedures that can be performed as analgesic or anti-inflammatory procedures.

(1) Frequency: Not more than 3 to 4 times annually. Usually 1 or 2 injections adequate.

(2) Time to produce effect: Immediate with local anesthesia, or within 3 days if no anesthesia

(3) Optimum/Maximum duration: Varies b. Soft Tissue Injections

Soft tissue injections include bursa and tendon insertions. When performing tendon insertion injections, the risk of tendon rupture should be discussed with the patient and the need for restricted duty emphasized. (1) Frequency: Not more than 3 to 4 times annually. Usually 1 or 2 injections adequate.

(2) Time to produce effect: Immediate with local anesthesia, or within 3 days if no anesthesia

(3) Optimum/Maximum duration: Varies c. Trigger Point Injections

Trigger-point injections, although generally accepted, have only rare indications in the treatment of lower extremity disorders. Therefore, the Division does not recommend their routine use in the treatment of lower extremity injuries. d. Prolotherapy

Prolotherapy (also known as sclerotherapy) consists of intra-articular injections of hypertonic dextrose with or without phenol with the goal of inducing an inflammatory response that will recruit cytokine growth factors involved in the proliferation of connective tissue. Advocates of prolotherapy propose that these injections will alleviate complaints related to joint laxity by promoting the growth of connective tissue and stabilizing the involved joint.

Laboratory studies may lend some biological plausibility to claims of connective tissue growth, but high quality published clinical studies are lacking. The dependence of the therapeutic effect on the inflammatory response is poorly defined, raising concerns about the use of conventional anti-inflammatory drugs when proliferant injections are given. The evidence in support of prolotherapy is insufficient and therefore, its use is not recommended in lower extremity injuries. e. Intra-Capsular Acid Salts

Intra-capsular acid salts, or viscosupplementation, are an accepted form of treatment for osteoarthritis or degenerative changes in the knee joint. While there is good scientific evidence to support their use, studies have not included patients with severe (Grade 4) degenerative changes. It is recommended that these injections can be considered a therapeutic alternative in patients who have failed non- pharmacological and analgesic treatment, and particularly, if non-steroidal anti-inflammatory drug treatment is contraindicated or surgery is not an option. The utility of viscosupplementation in severe osteoarthritis and its efficacy beyond 6 months is not well known.

(1) Time to produce effect: After 1 or 2 series of injections

(2) Frequency: 1 series (3 to 5 injections, generally spaced 1 week apart)

(3) Optimum/maximum duration: Varies. Efficacy beyond 6 months is not well known.

4. Medications

Medication use in the treatment of lower extremity injuries is appropriate for controlling acute pain and inflammation. Use of medications will vary widely due to the spectrum of injuries from simple strains to complicated fractures. All drugs should be used according to patient needs. A thorough medication history, including use of alternative and over the counter medications, should be performed at the time of the initial visit and updated periodically.

Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are useful in the treatment of injuries associated with degenerative joint disease and/or inflammation. These same medications can be used for pain control.

Narcotic medications should be prescribed with strict time, quantity and duration guidelines, and with definitive cessation parameters. Pain is subjective in nature and should be evaluated using a scale to rate effectiveness of the narcotic prescribed. Severe pain associated with fractures and other major joint derangements should be treated with narcotics pending a surgical evaluation. Tramadol, a centrally acting non-narcotic, can be useful to provide pain relief. Other medications, including antidepressants, may be useful in selected patients with chronic pain.

Topical agents can be beneficial for pain management in lower extremity injuries. This includes topical capsaicin, nonsteroidals, as well as topical iontphoretics/phonophoretics, such as steroid creams and lidocaine.

Glucosamine and chondroitin, dietary supplements, may have potential in the treatment of degenerative joint conditions of the knee but high quality, long-term studies demonstrating objective improvement or side effects are lacking at this time. Long-term side effects of these dietary supplements are unknown.

The following are listed in alphabetical order. a. Acetaminophen

Acetaminophen is an effective analgesic with antipyretic but not antiinflammatory activity. Acetaminophen is generally well tolerated, causes little or no gastrointestinal irritation and is not associated with ulcer formation. Acetaminophen has been associated with liver toxicity in overdose situations or in chronic alcohol use.

(1) Optimal duration: 7 to 10 days

(2) Maximum duration: Chronic use as indicated on a case-by-case basis b. Minor Tranquilizer/Muscle Relaxants

Minor tranquilizer/muscle relaxants are appropriate for muscle spasm, mild pain and sleep disorders.

(1) Optimal duration: 1 week

(2) Maximum duration: 4 weeks c. Narcotics

Narcotics should be primarily reserved for the treatment of severe lower extremity pain. There are circumstances where prolonged use of narcotics is justified based upon specific diagnosis, and in these cases, it should be documented and justified. In mild to moderate cases of lower extremity pain, narcotic medication should be used cautiously on a case-by-case basis. Adverse effects include respiratory depression, the development of physical and psychological dependence, and impaired alertness.

(1) Optimal duration: 3 to 7 days

(2) Maximum duration: 2 weeks. Use beyond two weeks is acceptable in appropriate cases. d. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

1) Nonselective Nonsteroidal Anti-Inflammatory Drugs

Due to the cross-reactivity between aspirin and NSAIDs, NSAIDs should not be used in aspirin- sensitive patients, and should be used with caution in all asthma patients. NSAIDs are associated with abnormal renal function, including renal failure, as well as abnormal liver function. Certain NSAIDs may have interactions with various other medications. Individuals may have adverse events not listed above.

(1) Optimal duration: 1 week

(2) Maximum duration: 1 year

1) Selective Cyclo-oxygenase-2 (COX-2) Inhibitors

(1) Optimal duration: 7 to 10 days

(2) Maximum duration: Chronic use is appropriate in individual cases. e. Oral Steroids

Oral steroids have limited use but are accepted in cases requiring potent anti-inflammatory drug effect in carefully selected patients. A one-week regime of steroids may be considered in the treatment of patients who have arthritic flare-ups with significant inflammation of the joint. The physician must be fully aware of potential contraindications for the use of all steroids such as hypertension, diabetes, glaucoma, peptic ulcer disease, etc., which should be discussed with the patient.

(1) Optimal duration: 3 to 7 days

(2) Maximum duration: 7 days f. Psychotropic/Anti-anxiety/Hypnotic Agents Psychotropic/anti-anxiety/hypnotic agents may be useful for treatment of mild and chronic pain, dysesthesias, sleep disorders, and depression. Antidepressant medications, such as tricyclics and Selective Serotonin Reuptake Inhibitors (SSRIs), are useful for affective disorder and chronic pain management. Tricyclic antidepressant agents, in low dose, are useful for chronic pain but have more frequent side effects.

(1) Optimal Duration: 1 to 6 months

(2) Maximum duration: 6 to 12 months, with monitoring g. Tramadol

Tramadol is useful in relief of lower extremity pain and has been shown to provide pain relief equivalent to that of commonly prescribed NSAIDs. Although Tramadol may cause impaired alertness, it is generally well tolerated, does not cause gastrointestinal ulceration, or exacerbate hypertension or congestive heart failure. Tramadol should be used cautiously in patients who have a history of seizures or who are taking medication that may lower the seizure threshold, such as MAO inhibiters, SSRIs, and tricyclic antidepressants. This medication has physically addictive properties and withdrawal may follow abrupt discontinuation and is not recommended for patients with prior opoid addiction.

(1) Optimal Duration: 3 to 7 days

(2) Maximum Duration: 2 weeks. Use beyond 2 weeks is acceptable in appropriate cases. h. Topical Drug Delivery

Topical drug delivery may be an alternative treatment of localized musculoskeletal disorders. It is necessary that all topical agents be used with strict instructions for application as well as maximum number of applications per day to obtain the desired benefit and avoid potential toxicity. As with all medications, patient selection must be rigorous to select those patients with the highest probability of compliance. Refer to “Iontophoresis” in the Passive Therapy section for information regarding topical iontophoretic agents.

1) Topical Salicylates and Nonsalicylates

Topical salicylates and nonsalicylates have been shown to be effective in relieving pain in acute and chronic musculoskeletal conditions. Topical salicylate and nonsalicylates achieve tissue levels that are potentially therapeutic, at least with regard to COX inhibition. Other than local skin reactions, the side effects of therapy are minimal, although not nonexistent, and the usual contraindications to use of these compounds needs to be considered. Local skin reactions are rare and systemic effects were even less common. Their use in patients receiving warfarin therapy may result in alterations in bleeding time. Overall, the low level of systemic absorption can be advantageous; allowing the topical use of these medications when systemic administration is relatively contraindicated such as is the case in patients with hypertension, cardiac failure, or renal insufficiency.

(1) Optimal duration: 1 week

(2) Maximal duration: 2 weeks per episode 2) Capsaicin

Capsaicin is another medication option for topical drug use in lower extremity injury. Capsaicin offers a safe and effective alternative to systemic NSAID therapy. Although it is quite safe, effective use of capsaicin is limited by the local stinging or burning sensation that typically dissipates with regular use, usually after the first 7 to 10 days of treatment. Patients should be advised to apply the cream on the affected area with a plastic glove or cotton applicator and to avoid inadvertent contact with eyes and mucous membranes.

(1) Optimal duration: 1 week

(2) Maximal duration: 2 weeks per episode

3) Other Agents

Other topical agents, including prescription drugs (i.e., lidocaine), prescription compound agents, and prescribed over-the-counter medications (i.e., blue ice), may be useful for pain and inflammation. These drugs should be used according to patient needs.

(1) Optimal duration: varies with drug or compound

(2) Maximal duration: varies with drug or compound

4) Iontophoretic Agents - Refer to “Iontophoresis,” under Passive Therapy section.

5. Occupational Rehabilitation Programs a. Non-Interdisciplinary

1) Work Conditioning

(1) Length of visit: 1 to 2 hours per day

(2) Frequency: 2 to 5 visits per week

(3) Optimum duration: 2 to 4 weeks

(4) Maximum duration: 6 weeks. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.

2) Work Simulation Work simulation is a program where an individual completes specific work-related tasks for a particular job and return to work. Use of this program is appropriate when modified duty can only be partially accommodated in the work place, when modified duty in the work place is unavailable, or when the patient requires more structured supervision. The need for work place simulation should be based upon the results of a Functional Capacity Evaluation and or Jobsite Analysis.

(1) Length of visit: 2 to 6 hours per day

(2) Frequency: 2 to 5 visits per week

(3) Optimum duration: 2 to 4 weeks

1) Work Hardening

This can include a highly structured program involving a team approach or can involve any of the components thereof. The interdisciplinary team should, at a minimum, be comprised of a qualified medical director who is board certified with documented training in occupational rehabilitation, team physicians having experience in occupational rehabilitation, occupational therapist, physical therapist, case manager, and psychologist. As appropriate, the team may also include: chiropractor, RN, or vocational specialist.

(1) Length of visit: Up to 8 hours each day

(2) Frequency: 2 to 5 visits per week

(3) Optimum duration: 2 to 4 weeks

(4) Maximum duration: 6 weeks. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.

6. Orthotics and Prosthetics a. Fabrication/Modification of Orthotics Fabrication/modification of orthotics would be used when there is need to normalize weight-bearing, facilitate better motion response, stabilize a joint with insufficient muscle or proprioceptive/reflex competencies, to protect subacute conditions as needed during movement, and correct biomechanical problems. For specific types of orthotics/prosthetics see Section IV, “Specific Diagnosis, Testing and Treatment Procedures.”

(1) Time to produce effect: 1 to 3 sessions (includes wearing schedule evaluation)

(2) Frequency: 1 to 2 times per week

(3) Optimum/maximum duration: 4 sessions of evaluation, casting, fitting, and re-evaluation b. Orthotic/Prosthetic Training

Orthotic/prosthetic training is the skilled instruction (preferably by qualified providers) in the proper use of orthotic devices and/or prosthetic limbs including stump preparation, donning and doffing limbs, instruction in wearing schedule and orthotic/prosthetic maintenance training. Training can include gait, mobility, transfer and self-care techniques.

(1) Time to produce effect: 2 to 6 sessions

(2) Frequency: 3 times per week

(3) Optimum/maximum duration: 2 to 4 months c. Splints or Adaptive Equipment

Splints or adaptive equipment design, fabrication and/or modification indications include the need to control neurological and orthopedic injuries for reduced stress during functional activities and modify tasks through instruction in the use of a device or physical modification of a device, which reduces stress on the injury. Equipment should improve safety and reduce risk of re-injury. This includes high and low technology assistive options such as workplace modifications, computer interface or seating, crutch or walker training, and self-care aids.

(1) Time to produce effect: Immediate

(2) Frequency: 1 to 3 sessions or as indicated to establish independent use

(3) Optimum/maximum duration: 1 to 3 sessions

7. Patient Education

No treatment plan is complete without addressing issues of individual and/or group patient education as a means of prolonging the beneficial effects of treatment, as well as facilitating self-management of symptoms and injury prevention. The patient should be encouraged to take an active role in the establishment of functional outcome goals. They should be educated on their specific injury, assessment findings, and plan of treatment. Instruction on proper body mechanics and posture, positions to avoid, self-care for exacerbation of symptoms, and home exercise should also be addressed.

(1) Time to produce effect: Varies with individual patient

(2) Frequency: Should occur at each visit

8. Personalitv/Psychological/Psvchosocial Intervention Psychosocial treatment is generally accepted, widely used and well established intervention. This group of therapeutic and diagnostic modalities includes, but is not limited to, individual counseling, group therapy, stress management, psychosocial crises intervention, hypnosis and meditation. Any screening or diagnostic workup should clarify and distinguish between preexisting versus aggravated versus purely causative psychological conditions. Psychosocial intervention is recommended as an important component in the total management program that should be implemented as soon as the problem is identified. This can be used alone or in conjunction with other treatment modalities. Providers treating patients with chronic pain should refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder Medical Treatment Guideline.

(1) Time to produce effect: 2 to 4 weeks

(2) Frequency: 1 to 3 times weekly for the first 4 weeks (excluding hospitalization, if required), decreasing to 1 to 2 times per week for the second month. Thereafter, 2 to 4 times monthly.

(3) Optimum duration: 6 weeks to 3 months

9. Restriction of Activity

Complete work cessation should be avoided, if possible, since it often further aggravates the pain presentation. Modified return-to-work is almost always more efficacious and rarely contraindicated in the vast majority of injured workers with lower extremity injuries.

10. Return-To-Work

Retum-to-work is defined as any work or duty that the patient is able to perform safely, and it may not be the patient's regular work. Due to the large spectrum of injuries of varying severity and varying physical demands in the work place, it is not possible to make specific return-to-work guidelines for each injury. Therefore, the Division recommends the following: a. Establishment of A Return-To-Work Status

Ascertaining a return-to-work status is part of medical care, should be included in the treatment and rehabilitation plan, and addressed at every visit. A description of daily activity limitations is part of any treatment plan and should be the basis for restriction of work activities. In most cases the patient should be able to return to work in some capacity or in an alternate position consistent with medical treatment within two weeks unless there are extenuating circumstances. Injuries requiring more than two weeks off work should be thoroughly documented. (Some of these diagnoses are listed in Section IV, “Specific Diagnosis, Testing, and Treatment”). b. Establishment of Activity Level Restrictions Communication is essential between the patient, employer and provider to determine appropriate restrictions and return-to-work dates. It is the responsibility of the physician to provide clear concise restrictions, and it the employer's responsibility to determine if temporary duties can be provided within the restrictions. For lower extremity injuries, the following should be addressed when describing the patient's activity level:

1) Lower body postures such as squatting, kneeling, crawling, stooping, or climbing should include duration and frequency.

2) Ambulatory level for distance, frequency and terrain should be specified.

3) Standing duration and frequency with regard to balance issues.

4) Use of adaptive devices or equipment for proper ergonomics to enhance capacities can be included. c. Compliance with Activity Restrictions

11. Therapy — Active

Most of the following active therapies have some evidence and are widely used and accepted methods of care for a variety of work-related injuries. They are based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion, and can alleviate discomfort. Active therapy requires an internal effort by the individual to complete a specific exercise or task. This form of therapy requires supervision from a therapist or medical provider such as verbal, visual and/or tactile instruction(s). At times, the provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is predominately executed by the patient.

The following active therapies are listed in alphabetical order: a. Activities of Daily Living (ADL)

(1) Time to produce effect: 4 to 5 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks b. Functional Activities

Functional activities are the use of therapeutic activity to enhance mobility, body mechanics, employability, coordination, and sensory motor integration. (1) Time to produce effect: 4 to 5 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks c. Functional Electrical Stimulation

(1) Time to produce effect: 2 to 6 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 8 weeks.

(4) Maximum duration: 8 weeks. If beneficial, provide with home unit. d. Gait Training

Gait training is crutch walking, cane or walker instruction to a person with lower extremity injury or surgery. Indications include the need to promote normal gait pattern with assistive devices; instruct in the safety and proper use of assistive devices; instruct in progressive use of more independent devices (i.e., platform-walker, to walker, to crutches, to cane); instruct in gait on uneven surfaces and steps (with and without railings) to reduce risk of fall, or loss of balance; and or instruct in equipment to limit weight- bearing for the protection of a healing injury or surgery.

(1) Time to produce effect: 2 to 6 treatments

(2) Frequency: 2 to 3 times per week

(3) Optimum duration: 2 weeks

(4) Maximum duration: 2 weeks e. Neuromuscular Re-Education

Neuromuscular re-education is the skilled application of exercise with manual, mechanical or electrical facilitation to enhance strength, movement patterns, neuromuscular response, proprioception, kinesthetic sense, coordination, education of movement, balance and posture. Indications include the need to promote neuromuscular responses through carefully timed proprioceptive stimuli to elicit and improve motor activity in patterns similar to normal neurologically developed sequences, and improve neuromotor response with independent control.

(1) Time to produce effect: 2 to 6 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 4 to 8 weeks (4) Maximum duration: 8 weeks f. Therapeutic Exercise

(1) Time to produce effect: 2 to 6 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 8 weeks

(4) Maximum duration: 8 weeks g. Wheelchair Management and Propulsion

Wheelchair management and propulsion are the instruction and training of self-propulsion and proper use of a wheelchair. This includes transferring and safety instruction. This is indicated in individuals who are not able to ambulate due to bilateral lower extremity injuries, inability to use ambulatory assistive devices, and in cases of multiple traumas.

(1) Time to produce effect: 2 to 6 treatments

(2) Frequency: 2 to 3 times per week

(3) Optimum duration: 2 weeks

(4) Maximum duration: 2 weeks

12. Therapy — Passive

Most of the following passive therapies and modalities are generally well-accepted methods of care for a variety of work-related injuries. Passive therapy includes those treatment modalities that do not require energy expenditure on the part of the patient. They are principally effective during the early phases of treatment and are directed at controlling symptoms such as pain, inflammation and swelling and to improve the rate of healing soft tissue injuries. They should be use adjunctively with active therapies to help control swelling, pain and inflammation during the rehabilitation process. They may be used intermittently as a therapist deems appropriate or regularly if there are specific goals with objectively measured functional improvements during treatment.

The following passive therapies and modalities are listed in alphabetical order. a. Continuous Passive Movement (CPM) CPM is a form of passive motion using specialized machinery that acts to move a joint and may also pump blood and edema fluid away from the joint and periarticular tissues. CPM is effective in preventing the development of joint stiffness if applied immediately following surgery. It should be continued until the swelling that limits motion of the joint no longer develops. ROM for the joint begins at the level of patient tolerance and is increased twice a day as tolerated. Use of this equipment may require home visits.

(1) Time to produce effect: Immediate

(2) Frequency: Up to 4 times a day

(3) Optimum duration: Up to 3 weeks post surgical

(4) Maximum duration: 3 weeks b. Contrast Baths

Contrast baths can be used for alternating immersion of extremities in hot and cold water. Indications include edema in the sub-acute stage of healing, the need to improve peripheral circulation and decrease joint pain and stiffness.

(1) Time to produce effect: 3 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 4 weeks

(4) Maximum duration: 1 month c. Electrical Stimulation (Unattended)

Electrical stimulation, once applied, requires minimal on-site supervision by the physician or non- physician provider. Indications include pain, inflammation, muscle spasm, atrophy, decreased circulation, and the need for osteogenic stimulation.

(1) Time to produce effect: 2 to 4 treatments

(2) Frequency: Varies, depending upon indication, between 2 to 3 times per day to 1 time a week. Provide home unit if frequent use.

(3) Optimum duration: 1 to 3 months

(4) Maximum duration: 3 months d. Fluidotherapy

Fluidotherapy employs a stream of dry, heated air that passes over the injured body part. The injured body part can be exercised during the application of dry heat. Indications include the need to enhance collagen extensibility before stretching, reduce muscle guarding or reduce inflammatory response.

(1) Time to produce effect: 1 to 4 treatments

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 4 weeks (4) Maximum duration: 1 month e. Infrared Therapy

Infrared therapy is a radiant form of heat application. Indications include the need to elevate the pain threshold before exercise and to alleviate muscle spasm to promote increased movement.

(1) Time to produce effect: 2 to 4 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 3 weeks as primary, or up to 2 months if used intermittently as an adjunct to other therapeutic procedures

(4) Maximum duration: 2 months f. Iontophoresis

Iontophoresis is the transfer of medication, including, but not limited to, steroidal anti-inflammatory and anesthetics, through the use of electrical stimulation. Indications include pain (Lidocaine), inflammation (hydrocortisone, salicylate), edema (mecholyl, hyaluronidase, salicylate), ischemia (magnesium, mecholyl, iodine), muscle spasm (magnesium, calcium), calcific deposits (acetate), scars and keloids (chlorine, iodine, acetate).

(1) Time to produce effect: 1 to 4 treatments

(2) Frequency: 3 times per week with at least 48 hours between treatments

(3) Optimum duration: 8 to 10 treatments

(4) Maximum duration: 10 treatments g. Manipulation

Manipulation is manual therapy that moves a joint beyond the physiologic range-of-motion but not beyond the anatomic range-of-motion. It is indicated for pain and adhesions.

(1) Time to produce effect: Immediate or up to 10 treatments

(2) Frequency: 1 to 5 times per week as indicated by the severity of involvement and the desired effect

(3) Optimum duration: 10 treatments

(4) Maximum duration: 10 treatments h. Manual Electrical Stimulation

Manual electrical stimulation is used for peripheral nerve injuries or pain reduction that require continuous application, supervision, or involve extensive teaching. Indications include muscle spasm (including TENS), atrophy, decreased circulation, osteogenic stimulation, inflammation, and the need to facilitate muscle hypertrophy, muscle strengthening, muscle responsiveness in SCI/BI, and peripheral neuropathies.

(1) Time to produce effect: Variable, depending upon use. (2) Frequency: 3 to 7 times per week

(3) Optimum duration: 8 weeks

(4) Maximum duration: 2 months i. Massage — Manual or Mechanical

(1) Time to produce effect: Immediate

(2) Frequency: 1 to 2 times per week

(3) Optimum duration: 6 weeks

(4) Maximum duration: 2 months j. Mobilization (Joint)

Mobilization is passive movement, which may include passive range of motion performed in such a manner (particularly in relation to the speed of the movement) that it is, at all times, within the ability of the patient to prevent the movement if they so choose. It may include skilled manual joint tissue stretching. Indications include the need to improve joint play, improve intracapsular arthrokinematics, or reduce pain associated with tissue impingement/maltraction.

(1) Time to produce effect: 6 to 9 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 6 weeks

(4) Maximum duration: 2 months k. Mobilization (Soft Tissue)

(1) Time to produce effect: 2 to 3 weeks

(2) Frequency: 2 to 3 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks l. Paraffin Bath A paraffin bath is a superficial heating modality that uses melted paraffin (candle wax) to treat irregular surfaces such as the foot or ankle. Indications include the need to enhance collagen extensibility before stretching, reduce muscle guarding, or reduce inflammatory response.

(1) Time to produce effect: 1 to 4 treatments

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 4 weeks

(4) Maximum duration: 1 month m. Superficial Heat And Cold Therapy

Superficial heat and cold therapies are thermal agents applied in various manners that lower or raise the body tissue temperature for the reduction of pain, inflammation, and/or effusion resulting from injury or induced by exercise. It may be used acutely with compression and elevation. Indications include acute pain, edema and hemorrhage, need to increase pain threshold, reduce muscle spasm and promote stretching/flexibility. Includes portable cryotherapy units and application of heat just above the surface of the skin at acupuncture points.

(1) Time to produce effect: immediate

(2) Frequency: 2 to 5 times per week

(3) Optimum duration: 3 weeks as primary, or up to 2 months if used intermittently as an adjunct to other therapeutic procedures

(4) Maximum duration: 2 months n. Short-wave Diathermy

(1) Time to produce effect: 2 to 4 treatments

(2) Frequency: 2 to 3 times per week up to 3 weeks

(3) Optimum duration: 3 to 5 weeks

(4) Maximum duration: 5 weeks o. Traction

(1) Time to produce effect: 1 to 3 sessions

(2) Frequency: 2 to 3 times per week

(3) Optimum duration: 30 days (4) Maximum duration: 1 month p. Transcutaneous Electrical Nerve Stimulation (TENS)

(1) Time to produce effect: Immediate

(2) Frequency: Variable

(3) Optimum duration: 3 sessions

(4) Maximum duration: 3 sessions. If beneficial, provide with home unit or purchase if effective. q. Ultrasound

Ultrasound includes: Ultrasound with electrical stimulation and Phonophoresis. Ultrasound uses sonic generators to deliver acoustic energy for therapeutic thermal and/or non-thermal soft tissue effects. Indications include scar tissue, adhesions, collagen fiber and muscle spasm, and the need to extend muscle tissue or accelerate the soft tissue healing.

Ultrasound with electrical stimulation is concurrent delivery of electrical energy that involves a dispersive electrode placement. Indications include muscle spasm, scar tissue, pain modulation and muscle facilitation.

Phonophoresis is the transfer of medication to the target tissue to control inflammation and pain through the use of sonic generators. These topical medications include, but are not limited to, steroidal anti- inflammatory and anesthetics.

(1) Time to produce effect: 6 to 15 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 4 to 8 weeks

(4) Maximum duration: 2 months r. Vasopneumatic Devices

Vasopneumatic devices are mechanical compressive devices used in both in-patient and outpatient settings to reduce various types of edema. Indications include pitting edema, lymphedema and venostasis. Maximum compression should not exceed minimal diastolic blood pressure. Use of a unit at home should be considered if expected treatment is greater than two weeks.

(1) Time to produce effect: 1 to 3 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 1 month

(4) Maximum duration: 1 month. If beneficial, provide with home unit. s. Whirlpool/Hubbard Tank The whirlpool/Hubbard Tank is conductive exposure to water at temperatures that best elicits the desired effect (cold vs. heat). It generally includes massage by water propelled by a turbine or Jacuzzi jet system and has the same thermal effects as hot packs if higher than tissue temperature. It has the same thermal effects as cold application if comparable temperature water used. Indications include the need for analgesia, relaxing muscle spasm, reducing joint stiffness, enhancing mechanical debridement and facilitating and preparing for exercise.

(1) Time to produce effect: 2 to 4 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 3 weeks as primary, or up to 2 months if used intermittently as an adjunct to other therapeutic procedures

(4) Maximum duration: 2 months

13. Vocational Rehabilitation

G. THERAPEUTIC PROCEDURES — OPERATIVE

Structured rehabilitation interventions should be strongly considered post-operative in any patient not making expected functional progress within three weeks post-operative.

Return to work restrictions should be specific according to the recommendation in the section “Return to Work” under Therapeutic Procedures – Non-Operative. a. Ankle and Subtalar Fusion

1) Description/Definition — Surgical fusion of the ankle or subtalar joint.

2) Occupational Relationship — Usually post-traumatic arthritis or residual deformity.

3) Specific Physical Findings — Painful, limited range of motion of the joint(s). Possible fixed deformity.

4) Diagnostic Testing Procedures — Radiographs. Sometimes tomography, CT scan, bone scan. 5) Non-Operative Treatment — Active and/or passive therapy for bracing, NSAIDs.

6) Surgical Indications — All reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. Patient has disabling pain or deformity.

7) Operative Treatment — Usually open reduction, grafting and internal fixation. External fixation may be used in some cases.

8) Post-Operative Therapy — Protected weight-bearing. Active and/or passive therapy for gait training, ADLs. May require nonweight-bearing and modified duty up to 4 to 6 months. b. Knee Fusion

1) Description/Definition — Surgical fusion of femur to tibia at the knee joint.

2) Occupational Relationship — Usually from post-traumatic arthritis or deformity.

3) Specific Physical findings — Stiff, painful, sometime deformed limb at the knee joint.

4) Diagnostic Testing Procedures — Radiographs.

5) Non-Operative Treatment — Active and/or passive therapy for weight sharing braces, NSAIDs.

6) Surgical Indications — All reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. Fusion is a consideration particularly in the young patient who desires a lifestyle that would subject the knee to high mechanical stresses.

7) Operative Treatment — Usually open reduction, grafting, internal fixation. External fixation or intramedullary rodding may also be used.

8) Post-Operative Therapy — Active and/or passive therapy for protected weight-bearing. c. Total Knee Replacement

1) Description/Definition — Prosthetic replacement of the articulating surfaces of the knee joint.

2) Occupational Relationship — Usually from post-traumatic arthritis.

3) Specific Physical Findings — Stiff, painful knee.

4) Diagnostic Testing Procedures — Radiographs.

5) Non-Operative Treatment — Active and/or passive therapy, NSAIDs.

6) Surgical Indications — Severe arthritis plus all reasonable conservative measures have been exhausted and other reasonable surgical options have been considered or implemented.

7) Operative Treatment — Prosthetic replacement of the articular surfaces of the knee.

8) Post-Operative Therapy — Active and/or passive therapy for graduated weight-bearing, range-of- motion. d. Total Hip Replacement 1) Description/Definition — Prosthetic replacement of the articulating surfaces of the hip joint.

2) Occupational Relationship — Usually from post-traumatic arthritis. Patients with intracapsular femoral fractures have a risk of developing avascular necrosis of the femoral head requiring treatment months to years after the initial injury.

3) Specific Physical Findings — Stiff, painful hip.

4) Diagnostic Testing Procedures — Radiographs.

5) Non-Operative Treatment — Active and/or passive therapy, NSAIDs.

6) Surgical Indications — All reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. Severe arthritis.

7) Operative Treatment — Prosthetic replacement of the articular surfaces of the hip.

8) Post-Operative Therapy — Active and/or passive therapy for graduated weight-bearing, range of motion. e. Amputation

1) Description/Definition — Surgical removal of a portion of the lower extremity.

2) Occupational Relationship — Usually secondary to post traumatic bone, soft tissue, vascular or neurologic compromise of part of the extremity.

3) Specific Physical Findings — Non-useful or non-viable portion of the lower extremity.

4) Diagnostic Testing Procedures — Radiographs, vascular studies.

5) Non-Operative Treatment — None.

6) Surgical Indications — Non-useful or non-viable portion of the extremity.

7) Operative Treatment — Amputation.

8) Post-Operative Therapy — Active and/or passive therapy for prosthetic fitting, construction and training, protected weight-bearing. f. Manipulation Under Anesthesia

1) Description/Definition — Passive range of motion of a joint under anesthesia.

2) Occupational Relationship — Joint stiffness that usually results from a traumatic injury, compensation related surgery, or other treatment.

3) Specific Physical Findings — Joint stiffness in both active and passive modes.

4) Diagnostic Testing Procedures — Radiographs.

5) Non-Operative Treatment — Active and/or passive therapy for active and passive range of motion exercises.

6) Surgical Indications — Consider if routine therapeutic modalities, including physical therapy and/or dynamic bracing, do not restore the degree of motion that should be expected after a reasonable period of time, usually at least 12 weeks.

7) Operative Treatment — Not applicable.

8) Post-Operative Therapy — Active and/or passive therapy for active and passive range of motion. g. Bursectomy

1) Description/Definition — Surgical removal of peri-articular bursa.

2) Occupational Relationship — Usually a traumatic local injury or repetitive minor local irritation.

3) Specific Physical Findings — Swelling, tenderness over the bursa.

4) Diagnostic Testing Procedures — Radiographs.

5) Non-Operative Treatment — Active and/or passive therapy for splinting, rest, NSAIDs, steroid injection.

6) Surgical Indications — Persistent pain, swelling despite treatment.

7) Operative Treatment — Surgical removal of the bursa.

8) Post-Operative Therapy — Active and/or passive therapy for graduated range-of-motion exercises. h. Osteotomy

1) Description/Definition — A reconstructive procedure involving the surgical cutting of bone for realignment and is useful in patients that would benefit from realignment in lieu of total joint replacement.

2) Occupational Relationship — Post-traumatic arthritis or deformity.

3) Specific Physical Findings — Painful decreased range of motion and/or deformity.

4) Diagnostic Testing Procedures — Radiographs, MRI scan, CT scan.

5) Non-Operative Treatment — Active and/or passive therapy for activity modification, bracing, NSAIDs.

6) Surgical Indications — Failure of non-surgical treatment. Avoidance of total joint arthroplasty desirable.

7) Operative Treatment — Peri-articular opening or closing wedge of bone, usually with grafting and internal or external fixation.

8) Post-Operative Therapy — Active and/or passive therapy for protected weight-bearing, progressive range-of-motion. i. Hardware Removal

1) Description/Definition — Surgical removal of internal or external fixation device.

2) Occupational Relationship — Usually following healing of a post-traumatic injury that required fixation or reconstruction using instrumentation. 3) Specific Physical Findings — Local pain to palpation, swelling, erythema.

4) Diagnostic Testing Procedures — Radiographs, tomography, CT scan, MRI.

5) Non-Operative Treatment — Active and/or passive therapy for local modalities, activity modification. NSAIDs.

6) Surgical Indications — Persistent local pain, irritation around hardware.

7) Operative Treatment — Removal of instrumentation. Some instrumentation (e.g., Ilizarof) may be removed in the course of standard treatment without local irritation.

8) Post-Operative Therapy — Active and/or passive therapy for progressive weight-bearing, range of motion. j. Release of Contracture

1) Description/Definition — Surgical incision or lengthening of contracted tendon or peri-articular soft tissue.

2) Occupational Relationship — Usually following a posttraumatic injury.

3) Specific Physical Findings — Shortened tendon or stiff joint.

4) Diagnostic Testing Procedures — Radiographs, CT scan, MRI scan.

5) Non-Operative Treatment — Active and/or passive therapy for stretching, range of motion exercises.

6) Surgical Indications — Persistent shortening or stiffness associated with pain and/or altered function.

7) Operative Treatment — Surgical incision or lengthening of involved soft tissue.

8) Post-Operative Therapy — Active and/or passive therapy for stretching, range-of-motion exercises.

RULE XVII, EXHIBIT D Complex Regional Pain Syndrome/ Reflex Sympathetic Dystrophy Medical Treatment Guidelines July 30, 2003 (Previously Adopted December 30, 1996 and Revised March 15, 1998)

Presented By: State of Colorado Department of Labor and Employment DIVISION OF WORKERS' COMPENSATION

TABLE OF CONTENTS

A. INTRODUCTION

B. GENERAL GUIDELINE PRINCIPLES

1. APPLICATION OF GUIDELINES

2. EDUCATION

3. TREATMENT PARAMETER DURATION

4. ACTIVE INTERVENTIONS 5. ACTIVE THERAPEUTIC EXERCISE PROGRAM

6. POSITIVE PATIENT RESPONSE

7. RE-EVALUATION TREATMENT EVERY 3 TO 4 WEEKS

8. SURGICAL INTERVENTIONS

9. SIX-MONTH TIME FRAME

10. RETURN-TO-WORK

11. DELAYED RECOVERY

12. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE

13. TREATMENT OF PREEXISTING CONDITIONS

C. INTRODUCTION TO COMPLEX REGIONAL PAIN SYNDROME

D. DEFINITIONS

E. INITIAL EVALUATION

1. HISTORY AND PHYSICAL EXAMINATION (HX & PE)

F. DIAGNOSTIC PROCEDURES

1. DIAGNOSTIC IMAGING

2. INJECTIONS — DIAGNOSTIC SYMPATHETIC

3. THERMOGRAPHY (INFRARED STRESS THERMOGRAPHY)

4. AUTONOMIC TEST BATTERY

5. OTHER DIAGNOSTIC TESTS NOT SPECIFIC FOR CRPS

G. DIAGNOSIS OF CRPS

1. DIAGNOSTIC COMPONENTS OF CRPS-I (RSD):

2. DIAGNOSTIC CRITERIA FOR CRPS

H. THERAPEUTIC PROCEDURES – NON-OPERATIVE

1. ACUPUNCTURE

2. BIOFEEDBACK

3. COMPLEMENTARY ALTERNATIVE MEDICINE (CAM)

4. SLEEP DISTURBANCES

5. INJECTIONS — THERAPEUTIC a. Sympathetic Injections

b. Trigger Point Injections

c. Peripheral Nerve Blocks

d. Intravenous Lidocaine

6. INTERDISCIPLINARY REHABILITATION PROGRAMS

7. MEDICATIONS

a. Anticonvulsants

b. Antidepressants

c. Hypnotics and Sedatives

d. Opioids

e. Topical Drug Delivery

f. Other Agents

8. ORTHOTICS/PROSTHETICS/EQUIPMENT

9. PATIENT EDUCATION

10. PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION

11. RESTRICTION OF ACTIVITIES

12. RETURN-TO-WORK

13. THERAPY — ACTIVE

a. Activities of Daily Living (ADL)

b. Aquatic Therapy

c. Gait Training

d. Neuromuscular Re-education

e. Stress Loading

f. Therapeutic Exercise

14 THERAPY — PASSIVE

a. Continuous Passive Motion

b. Fluidotherapy

c. Orthotics/Splinting d. Paraffin Bath

e. Desensitization

f. Superficial Heat Therapy

I. THERAPEUTIC PROCEDURES – OPERATIVE

1. INTRATHECAL DRUG DELIVERY

2. NEUROSTIMULATION

3. SYMPATHECTOMY

J. MAINTENANCE MANAGEMENT

1. HOME EXERCISE PROGRAMS AND EXERCISE EQUIPMENT

2. EXERCISE PROGRAMS REQUIRING SPECIAL FACILITIES

3. PATIENT EDUCATION MANAGEMENT

4. PSYCHOLOGICAL MANAGEMENT

5. NON-NARCOTIC MEDICATION MANAGEMENT

6. NARCOTIC MEDICATION MANAGEMENT

7. THERAPY MANAGEMENT

8. INJECTION THERAPY

9. PURCHASE OR RENTAL OF DURABLE MEDICAL EQUIPMENT

A. INTRODUCTION

Although the primary purpose of this document is advisory and educational, these guidelines are enforceable under the Workers' Compensation Rules of Procedure, 7 CCR 1101-3. The Division recognizes that acceptable medical practice may include deviations from these guidelines, as individual cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of professional care.

To properly utilize this document, the reader should not skip nor overlook any sections.

B. GENERAL GUIDELINE PRINCIPLES

2. Education

Education of the patient and family, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of chronic pain spine injuries and disability. Currently, practitioners often think of education last, after medications, manual therapy and surgery. Practitioners must develop and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers and the community as a whole. An education-based paradigm should always start with inexpensive communication providing reassuring information to the patient. More in-depth education currently exists within a treatment regime employing functional restorative and innovative programs of prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of facilitating self-management of symptoms and prevention.

3. Treatment Parameter Duration

4. Active Interventions

5. Active Therapeutic Exercise Program

Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and education. This includes functional application in vocational or community settings.

6. Positive Patient Response

7. Re-Evaluation Treatment Every 3 to 4 Weeks

8. Surgical Interventions Surgery should be contemplated within the context of expected functional outcome and not purely for the purpose of pain relief. The concept of “cure” with respect to surgical treatment by itself is generally a misnomer. All operative interventions must be based upon positive correlation of clinical findings, clinical course and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with positive identification of pathologic conditions.

9. Six-Month Time Frame

10. Return-to-Work

Return-to-work is therapeutic, assuming the work is not likely to aggravate the basic problem or increase long-term pain. The practitioner must provide specific written physical limitations and the patient should never be released to “sedentary” or “light duty.” The following physical limitations should be considered and modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, overhead work, bending at the waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors. Even if there is residual chronic pain, return-to-work is not necessarily contraindicated.

The practitioner should consider all of the physical demands of the patient's job position before returning the patient to full duty and should request clarification of the patient's job duties. Clarification should be obtained from the employer or, if necessary, including, but not limited to, an occupational health nurse, occupational therapist, vocational rehabilitation specialist, or an industrial hygienist.

11. Delayed Recovery

12. Guideline Recommendations and Inclusion of Medical Evidence

“Some” means the recommendation considered at least one adequate scientific study, which reported that a treatment was effective.

“Good” means the recommendation considered the availability of multiple adequate scientific studies or at least one relevant high-quality scientific study, which reported that a treatment was effective. “Strong” means the recommendation considered the availability of multiple relevant and high quality scientific studies, which arrived at similar conclusions about the effectiveness of a treatment.

All recommendations in the guideline are considered to represent reasonable care in appropriately selected cases, regardless of the level of evidence attached to it. Those procedures considered inappropriate, unreasonable, or unnecessary are designated in the guideline as “not recommended.”

13. Treatment of Preexisting Conditions

Conditions that preexisted the work injury/disease will need to be managed under two circumstances: (a) A preexisting condition exacerbated by a work injury/disease should be treated until the patient has returned to their prior level of functioning or MMI; and (b) A preexisting condition not directly caused by a work injury/disease but which may prevent recovery from that injury should be treated until its negative impact has been controlled. The focus of treatment should remain on the work injury/disease.

The remainder of this document should be interpreted within the parameters of these guideline principles that may lead to more optimal medical and functional outcomes for injured workers.

C. INTRODUCTION TO COMPLEX REGIONAL PAIN SYNDROME

Complex Regional Pain Syndrome (CRPS Types I and II) describes painful syndromes, which were formerly referred to as Reflex Sympathetic Dystrophy (RSD) and causalgia. CRPS conditions usually follow injury that appears regionally and have a distal predominance of abnormal findings, exceeding the expected clinical course of the inciting event in both magnitude and duration and often resulting in significant impairment of limb function.

CRPS-I (RSD) is a syndrome that usually develops after an initiating noxious event, is not limited to the distribution of a single peripheral nerve, and is apparently disproportionate to the inciting event. It is associated at some point with evidence of edema, changes in skin blood flow, abnormal sudomotor activity in the region of the pain, allodynia or hyperalgesia. The site is usually in the distal aspect of an affected extremity or with a distal to proximal gradient. The peripheral nervous system and possibly the central nervous system are involved.

CRPS-II (Causalgia) is the presence of burning pain, allodynia, and hyperpathia usually in the hand or foot after partial injury to a nerve or one of its major branches. Pain is within the distribution of the damaged nerve but not generally confined to a single nerve.

Stages seen in CRPS-I are not absolute and in fact, may not all be observed in any single patient. In some patients, stages may be missed or the patient may remain for long periods of time in one stage.

Stage 1 – Acute (Hyperemic)

Starts at the time of injury or even weeks later. Associated with spontaneous pain, aching, burning. Typically restricted to the distal extremity. Hyperpathia, allodynia, hypoesthesia or hyperesthesia may be present. Initially, hair and nail growth may be increased but later decrease. Skin may be warm or cold.

Stage 2 – Dystrophic (Ischemic)

Spontaneous burning and/or aching pain, more pronounced hyperpathia and or allodynia. Signs of chronic sympathetic overactivity include (a) reduced blood flow; (b) sudomotor changes; (c) increased edema; (d) cyanotic skin; (e) muscle wasting; (f) decreased hair and nail growth; and (g) osteoporosis.

Stage 3 – Atrophic Signs and symptoms of this stage include (a) pain may be less prominent; (b) decreased hyperpathia and/or allodynia; (c) reduction in blood flow; (d) skin temperature and sweating may be increased or decreased; (e) irreversible trophic changes in skin and integument; and (f) pronounced muscle atrophy with contractures.

D. DEFINITIONS

1. After sensation – Refers to the abnormal persistence of a sensory perception, provoked by a stimulus even though the stimulus has ceased.

2. Allodynia – Pain due to a non-noxious stimulus that does not normally provoke pain.

Mechanical Allodynia – Refers to the abnormal perception of pain from usually non-painful mechanical stimulation.

Static Mechanical Allodynia – Refers to pain obtained by applying a single stimulus such as light pressure to a defined area.

Dynamic Mechanical Allodynia – Obtained by moving the stimulus such as a brush or cotton tip across the abnormal hypersensitive area.

Thermal Allodynia – Refers to the abnormal sensation of pain from usually non-painful thermal stimulation such as cold or warmth.

3. Central Pain – Pain initiated or caused by a primary lesion or dysfunction in the central nervous system.

4. Central Sensitization – The experience of pain evoked by the excitation of non-nociceptive neurons or of nerve fibers that normally relay non-painful sensations to the spinal cord. This result when non- nociceptive afferent neurons act on a sensitized CNS.

5. Dystonia – State of abnormal (hypo or hyper) tonicity in any of the tissues.

6. Hyperalgesia – Refers to an exaggerated pain response from a usually painful stimulation.

7. Hyperemia – Presence of increased blood in a part or organ.

8. Hyperesthesia (Positive Sensory Phenomenon) – Includes allodynia, hyperalgesia, and hyperpathia. Elicited by light touch, pin prick, cold, warm vibration, joint position sensation or two-point discrimination, which is perceived as increased or more.

9. Hyperpathia – Refers to an abnormally painful and exaggerated reaction to stimulus, especially to a repetitive stimulus, in a patient who perceives the stimulus as less intense because of an increased threshold.

10. Hypoesthesia – (also hypesthesia), diminished sensitivity to stimulation.

11. Pain Behavior – The nonverbal actions (such as grimacing, groaning, limping, using visible pain relieving or support devices and requisition of pain medications, among others) that are outward manifestations of pain, and through which a person may communicate that pain is being experienced.

12. Sudomotor Changes – Alteration in function of sweat glands; sweat output may increase or decrease due to changes in autonomic input to the gland. 13. Sympathetically Maintained Pain – A pain that is maintained by sympathetic efferent innervations or by circulating catecholalmines.

14. Trophic Changes – Tissue alterations due to interruption of nerve or blood supply; may include changes in hair growth and texture of skin.

15. Vasomotor Changes – Alteration in regulation of dilation or constriction of blood vessels.

E. INITIAL EVALUATION

All potential pain generators should be thoroughly investigated by complete neurologic and musculoskeletal exam and diagnostic procedures. Because CRPS-I is commonly associated with other injuries, it is essential that all related diagnoses are defined and treated. These disturbances are typically restricted to one extremity, usually distally, but are variable in their expression.

1. History and Physical Examination (Hx & Pe)

The history and physical exam establish the basis for subsequent diagnostic and therapeutic procedures. When clinical evaluation findings do not complement the findings of other diagnostic procedures, clinical findings should have preference. Before the diagnosis of CRPS-I or CRPS-II is established, an experienced practitioner must perform a detailed neurological and musculoskeletal exam to exclude other potentially treatable pain generators or neurological lesions. a. Medical History

As in other fields of medicine, a thorough patient history is an important part of the evaluation of pain. In taking such a history, factors influencing a patients' current status can be made clear and taken into account when planning diagnostic evaluation and treatment. History should ascertain the following elements:

1) Causality: How did this injury occur? Was the problem initiated by a work-related injury or exposure?

2) Presenting symptoms:

a) Severe, generally unremitting burning and/or aching pain, and/or allodynia;

b) Swelling of the involved area;

c) Changes in skin color;

d) Asymmetry in nail and/or hair growth;

e) Abnormal sweat patterns of the involved extremity;

f) Dystonia; and/or

g) Subjective temperature changes of the affected area. b. Pain History

The patient's description of and response to pain is one of the key elements in treatment. Characterization of the patient's pain and of the patient's response to pain is one of the key elements in treatment. 1) Site of Pain – localization and distribution of the pain help determine the type of pain the patient has (i.e., central versus peripheral).

2) Pain Drawing/Visual Analog Scale (VAS)

3) Duration

4) Place of onset

5) Pain Characteristics – time of pain occurrence as well as intensity, quality and radiation give clues to the diagnosis and potential treatment.

6) Response of Pain to Activity

7) Associated Symptoms – Does the patient have numbness or paresthesia, dysesthesia, weakness, bowel or bladder dysfunction, decreased temperature, increased sweating, cyanosis or edema? Is there local tenderness, allodynia, hyperesthesia or hyperalgesia? c. Substance Use/Abuse

1) Alcohol use

2) Smoking History

3) History of drug use and abuse.

4) Caffeine or caffeine-containing beverages. d. Other Factors Affecting Treatment Outcome

1) Compensation/Disability/Litigation

2) Treatment Expectations – What does the patient expect from treatment: complete relief of pain or reduction to a more tolerable level? e. Medical Management History

Refer to the Chronic Pain guideline for detailed elements when performing a review of prior medical management. In addition, history may include:

1) Chronological review of medical records including previous medical evaluations and response to treatment interventions;

2) History of diagnostic tests and results including but not limited to any response to sympathetic nerve blocks, results of general laboratory studies, EMG and nerve conduction studies, radiological examinations, including triple phase bone scan or thermography with autonomic stress testing.

3) Medications, including prescription, over-the-counter and herbal/dietary supplements.

4) Review of Systems Check List – Determine if there is any interplay between the pain complaint and other medical conditions.

5) Psychosocial Functioning - Determine if the following are present: current symptoms of depression or anxiety, evidence of stressors in the workplace or at home, and past history of psychological problems. It is recommended that patients diagnosed with CRPS be referred for a psychosocial evaluation. All patients with CRPS have Chronic Pain, and are likely to suffer psychosocial consequences.

6) Preexisting Conditions – Treatment of these conditions is appropriate when the preexisting condition affects recovery from chronic pain. f. Physical Examination

Physical Examination should include examination techniques applicable to those portions of the body in which the patient is experiencing subjective symptomatology and should include:

1) Inspection – Changes in appearance of the involved area, to include trophic changes, changes in hair and nail growth, muscular atrophy, changes in skin turgor, swelling and color changes.

2) Temperature Evaluation – Palpable temperature changes may not be detectable in early disease stages, and the examiner will generally only be able to appreciate significant temperature variations. Thermography, or other objective testing may be necessary to display temperature asymmetries.

3) Motor Evaluation – Involuntary movements, dystonia or muscle weakness in the involved limb(s).

4) Sensory Evaluation – A detailed sensory examination is crucial in evaluating a patient with chronic pain complaints. Presence of allodynia. Anatomic pattern of any associated sensory abnormalities to light touch, deep touch, pain and thermal stimulation. Quantitative sensory testing may be useful.

5) Musculoskeletal Evaluation –Presence of associated myofascial problems, such as contractures, ROM or trigger points.

6) Evaluation of Nonphysiologic Findings – Determine the presence of the following: Variabilities on formal exam including variable sensory exam, inconsistent tenderness, and or swelling secondary to extrinsic sources; Inconsistencies between formal exam and observed abilities of range-of-motion, motor strength, gait and cognitive/emotional state; and/or, observation of consistencies between pain behavior, affect and verbal pain rating, and affect and physical re-examination.

F. DIAGNOSTIC PROCEDURES

The Division recommends the following diagnostic procedures be considered, at least initially, the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Standard procedures are listed below in order of their suggested usefulness. In addition, it is recommended that all patients diagnosed with CRPS have a full psychosocial evaluation.

1. Diagnostic Imaging

Imaging is a generally accepted, well established and widely used diagnostic procedure when specific indications, based on history and physical examination, are present. Physicians should refer to individual Division guidelines for specific information about specific testing procedures. a. Plain Film Radiography

Description - A radiological finding in CRPS may be unilateral osteoporosis; however, osteoporosis may be absent in many cases. In CRPS-I, the osteoporosis may be rapid in progression. The disorder typically affects the distal part of an extremity such as a hand or foot, yet intermediate joints such as the knee or elbow may be involved.

Results - The radiological appearance of osteoporosis has been characterized as spotty or patchy. Although CRPS-I may exist in the absence of osteoporosis, the diagnosis of CRPS-I cannot be made solely on the basis of radiographic appearance or the osteoporosis alone. b. Triple Phase Bone Scan

Description - Radionucleotide imaging scintigraphy employing radio-pharmaceutical technetium coupled to a phosphate complex has been used to help facilitate the diagnosis of CRPS-1. It was hoped that a three-phase radionucleotide study would be selective in the face of demineralization of the bone as seen in CRPS-I. However there are many different types of conditions that can produce osteoporosis, and a triple-phase bone scan does not distinguish between the causes of bone demineralization.

Results - Clinical information can be derived from each of the three phases of the bone scan following injection. In the early course of CRPS-I, there is an increased uptake seen during Phase 1. However, in the late course of the disease process, there can actually be a decreased uptake seen. In Phase 2, which reflects the soft tissue vascularity, an increased diffuse uptake may be appreciated during the early course of CRPS-I. During Phase 3, one will see a diffuse uptake of multiple bone involvement of the involved limb, reflecting the bone turnover secondary to osteoporosis. Negative bone scans may be found in up to 40 percent of patients clinically diagnosed with CRPS-I; however when positive it may help to confirm the diagnosis of CRPS-I.

2. Injections – Diagnostic Sympathetic

Description — Diagnostic sympathetic injections are generally accepted procedures to aid in the diagnosis of CRPS I & II and SMP. Sympathetic blocks lack specificity for CRPS I & II. Each diagnostic injection has inherent risk and risk versus benefit should always be evaluated when considering injection therapy. Since these procedures are invasive, less invasive or non-invasive procedures should be considered first. Selection of patients, choice of procedure, and localization of the level for injection should be determined by clinical information.

Special Considerations – Injections with local anesthetics of differing duration are required to confirm a diagnosis. In some cases, injections at multiple levels may be required to accurately diagnose pain. Refer to “Injections – Therapeutic” for information on specific injections.

Since fluoroscopic and/or CT guidance during procedures is recommended to document technique and needle placement, an experienced physician should perform the procedure. The practitioner should have experience in ongoing injection training workshops provided by organizations such as the International Spinal Injection Society (ISIS) and be knowledgeable in radiation safety. In addition, practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments of Radiology, as applicable.

Complications – Complications may include transient neurapraxia, nerve injury, inadvertent spinal injection, infection, venous or arterial vertebral puncture, laryngeal paralysis, respiratory arrest, vasovagal effects, as well as permanent neurologic damage.

Contraindications – Absolute contraindications of diagnostic injections include: (a) bacterial infection – systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d) possible pregnancy. Relative contraindications of diagnostic injections may include: ASA/antiplatelet therapy (drug may be held for at least 3 days prior to injection). Test Results – The interpretation of the test result is primarily based upon pain relief of 50 percent or greater. The diagnostic significance of the test result should be evaluated in conjunction with clinical information and further information can be obtained from functional reassessment performed by physical and/or occupational therapy or from results of other diagnostic procedures following a successful block.

Local anesthetics of different durations of action should be considered and could take the place of doing a “placebo” block (i.e. - procaine, lidocaine, marcaine). Pain relief should be at least 50 percent or greater for the duration of the local anesthetic. It should be noted that with CRPS-I it is not unusual for the relief to last longer than the duration of the local anesthetic. If a placebo block is done, the needle should not be placed down to the sympathetic chain nor should an injection of saline be done around the sympathetic chain. Contact with the sympathetic nerves by a needle or pressure on the chain by saline can cause a temporary sympathetic block and give a false positive placebo test. A “sham block” would be preferable to see if the patient is a placebo responder. Additionally, patients with definite CRPS-I can also be placebo responders. The fact that the patient responds positively to a placebo does not mean that he/she does not have CRPS-1. It merely means that the patient is a placebo responder. This increases the value of doing another confirmatory test a. Stellate Ganglion Block

For diagnosis and treatment of sympathetic pain involving the face, head, neck, and upper extremities secondary to CRPS-I and II. This block is commonly used for differential diagnosis and is the preferred treatment of CRPS-I pain involving the upper extremity. For diagnostic testing, use three blocks over a 3-14 day period. For a positive response, pain relief should be 50% or greater for the duration of the local anesthetic and pain relief should be associated with functional improvement. b. Lumbar Sympathetic Block

Useful for diagnosis and treatment of pain of the pelvis and lower extremity secondary to CRPS-I and II. This block is commonly used for differential diagnosis and is the preferred treatment of sympathetic pain involving the lower extremity. For diagnostic testing, use three blocks over a 3- 14 day period. For a positive response, pain relief should be 50% or greater for the duration of the local anesthetic and pain relief should be associated with functional improvement. c. Phentolamine Infusion Test

An intravenous infusion of phentoalmine, an alpha 2 blocker, which results in generalized systemic sympatholysis. The infusion begins with intravenous saline for placebo control. For a positive response, pain relief should be 50 percent or greater and associated with functional improvement. This test aids in the diagnosis of SMP.

3. Thermography (Infrared Stress Thermography)

Description – A generally accepted procedure with some evidence to support its limited use. Infrared thermography may be useful for patients with suspected CRPS-I and II, and Sympathetically Maintained Pain (SMP). Thermography can distinguish abnormal thermal asymmetry of 1.0 degree Celsius which is not distinguishable upon physical examination. It may also be useful in cases of suspected small caliber fiber neuropathy and to evaluate patient response to sympatholytic interventions.

Special Considerations – The practitioner who supervises and interprets the thermographic evaluation shall follow recognized protocols and be board certified by one of the examining boards of the American Academy of Medical Infrared Imaging, American Academy of Thermology, or American Chiropractic College of Thermology.

Medications with anticholinergic activity (tricyclics, cyclobenzaprine, antiemetics, antipsychotics) may interfere with autonomic testing. The pre-testing protocol which includes cessation of specific medications therapy must be followed for accurate test results. Results of autonomic testing may be affected by peripheral polyneuropathy, radiculopathy or peripheral nerve injury, peripheral vascular disease, generalized autonomic failure, or by Shy-Drager syndrome.

Thermographic Tests – Functional autonomic stress testing may include any of the following methods: a. Cold Water Stress Test (Cold Pressor Test) – Paroxysmal cooling is strongly suggestive of vasomotor instability. b. Warm Water Stress Test – Paroxysmal warming is strongly suggestive of vasomotor instability.

4. Autonomic Test Battery

Description – Resting skin temperature (RST), resting sweat output (RSO), and quantitative sudomotor axon reflex test (QSART) are a recently developed test battery with some evidence to support its limited use in the diagnosis of CRPS-I. Prior authorization is required.

Special Considerations - Medications with anticholinergic activity (tricyclics, cyclobenzaprine, antiemetics, antipsychotics) may interfere with autonomic testing. Results of autonomic testing may be affected by peripheral polyneuropathy, radiculopathy or peripheral nerve injury, peripheral vascular disease, generalized autonomic failure, or by Shy-Drager syndrome.

Test Battery – These tests measure asymmetries in physiologic manifestations of autonomic activity between an affected limb and an unaffected contralateral limb. Skin temperature reflects vasomotor activity and sweat output measures sudomotor activity. The results of the three test components must be combined and scored. The battery of tests must include a measurement of each component (RST, RSO, and QSART). a. Infrared Resting Skin Temperature (RST) – Provides thermographic measurements between the affected and unaffected limb. Generally, a 1 degree Celsius difference is significant. b. Resting Sweat Output (RSO) – Measures an increase or reduction of 50 percent between the affected and unaffected limb. c. Quantitative Sudomotor Axon Reflex Test (QSART) – Measures the sweat output elicited by iontophoretic application of acetylcholine. An increase or reduction of 50 percent between the affected and unaffected limb is significant.

5. Other Diagnostic Tests Not Specific for CRPS

The following tests and procedures are not used to establish the diagnosis of CRPS but may provide additional information. The following are listed in alphabetical order. a. Electrodiagnostic Procedures

Electromyography (EMG) and Nerve Conduction Studies (NCS) are generally accepted, well- established and widely used for localizing the source of the neurological symptoms and establishing the diagnosis of focal nerve entrapments, such as carpal tunnel syndrome or radiculopathy, which may contribute to or coexist with CRPS II (causalgia). Traditional electrodiagnosis includes nerve conduction studies, late responses, (F-Wave, H-reflex) and electromyographic assessment of muscles with needle electrode examination. As CRPS II occurs after partial injury to a nerve, the diagnosis of the initial nerve injury can be made by electrodiagnostic studies. The later development of sympathetically mediated symptomatology however, has no pathognomonic pattern of abnormality on EMG/NCS. When issues of diagnosis are in doubt, a referral or consultation with a physiatrist or neurologist trained in electrodiagnosis is appropriate. b. Laboratory Tests

Laboratory tests are generally accepted well established and widely used procedures and can provide useful diagnostic and monitoring information.

They may be used when there is suspicion of systemic illness, infection, neoplasia, or underlying rheumatologic disorder, connective tissue disorder, or based on history and/or physical examination. Tests include, but are not limited to:

1) CBC with differential can detect infection, blood dyscrasias, and medication side effects;

2) Erythrocyte sedimentation rate, rheumatoid factor, ANA, HLA, and Creactive protein can be used to detect evidence of a rheumatologic, infection, or connective tissue disorder, serum protein electrophoresis;

3) Thyroid, glucose and other tests to detect endocrine disorders;

4) Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease;

5) Urinalysis for calcium, phosphorus, hydroxyproline, or hematuria;

6) Liver and kidney function may be performed for baseline testing and monitoring of medications; and

7) Tox Screen and or Blood Alcohol Level if suspected drug or alcohol abuse. c. Peripheral Blood Flow (Laser Doppler or Xenon Clearance Techniques)

This is currently being evaluated as a diagnostic procedure in CRPS-I and is not recommended by the Division at this time. d. Personality/Psychosocial/Psychological Evaluation

Psychosocial assessment requires consideration of variations in pain experience and expression because of factors such as gender, age, race, ethnicity, national origin, religion, sexual orientation, disability, language or socioeconomic status. Psychometric Testing is a valuable component of a consultation to assist the physician in making a more effective treatment plan. There is strong evidence that psychometric testing provides unique and useful information, and that the validity of such tests is comparable to the validity of medical tests. All patients who are diagnosed as having chronic pain should be referred for a Psychosocial Evaluation as well as concomitant interdisciplinary rehabilitation treatment whenever appropriate.

1) Qualifications

a) A psychologist with a PhD, PsyD, EdD credentials, or a physician with Psychiatric MD/DO credentials may perform the initial comprehensive evaluations. It is preferable that these professionals have experience in diagnosing and treating chronic pain disorders in injured workers.

b) Psychometric tests may be administered by psychologists with a PhD, PsyD, or EdD, or by physicians with appropriate training. 2) Clinical Evaluation – All chronic pain patients should have a clinical evaluation that addresses the following areas:

a) History of Injury – The history of the injury should be reported in the patient's words or using similar terminology. Caution must be exercised when using translators.

(1) Nature of injury

(2) Psychosocial circumstances of the injury

(3) Current symptomatic complaints

(4) Extent of medical corroboration

(5) Treatment received and results

(6) Compliance with treatment

(7) Coping strategies used, including perceived locus of control

(8) Perception of medical system and employer

(9) History of response to prescription medications

b) Health History

(1) Nature of injury

(2) Medical history

(3) Psychiatric history

(4) History of alcohol or substance abuse

(5) Activities of daily living

(6) Mental status exam

(7) Previous injuries, including disability, impairment, and compensation

c) Psychosocial history

(1) Childhood history, including abuse

(2) Educational history

(3) Family history, including disability

(4) Marital history and other significant adulthood activities and events

(5) Legal history, including criminal and civil litigation

(6) Employment and military history

(7) Signs of pre-injury psychological dysfunction (8) Current interpersonal relations, support, living situation

(9) Financial history

d) Psychological test results, if performed

e) Danger to self or others.

f) Current psychiatric diagnosis consistent with the standards of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).

g) Preexisting psychiatric conditions. Treatment of these conditions is appropriate when the preexisting condition affects recovery from chronic pain.

h) Causality (to address medically probable cause and effect, distinguishing pre-existing psychological symptoms, traits and vulnerabilities from current symptoms).

i) Treatment recommendations with respect to specific goals, frequency, timeframes, and expected outcomes.

3) Tests of Psychological Functioning

Psychometric Testing is a valuable component of a consultation to assist the physician in making a more effective treatment plan. Psychometric testing is useful in the assessment of mental conditions, pain conditions, cognitive functioning, treatment planning, vocational planning and evaluation of treatment effectiveness. There is no general agreement as to which standardized psychometric tests should be specifically recommended for psychological evaluations of chronic pain conditions. It is appropriate for the mental health provider to use their discretion and administer selective psychometric tests within their expertise and within standards of care in the community. Some of these tests are available in Spanish and other languages, and many are written at a 6th grade reading level. Special Tests e. Special Tests

Special tests are generally well-accepted tests and are performed as part of a skilled assessment of the patients' capacity to return to work, strength capacity, and or physical work demands classifications and tolerance. Tests include Computer-Enhanced Evaluations, Functional Capacity Evaluation (FCE), Jobsite Evaluation, Vocational Assessment, and Work Tolerance Screening. Refer to the Chronic Pain guideline for detailed information and frequency of each special testing procedure.

G. DIAGNOSIS OF CRPS

1. Diagnostic Components of CRPS-I (RSD): a. Subjective Complaints

Complaint of pain, usually burning or aching pain and out of proportion to identified pathology. May be sharp or lancinating. Frequently is present without provocation or movement. b. Physical Findings

1) Swelling, generally unilateral and variable in presentation. 2) Vasomotor signs – Unilateral. Initial extremity warming early on, coldness of extremity as condition progresses. Discoloration of skin usually darker blue or purple, may be mottled, may be paler.

3) Sudomotor sign – Increased sweating of the involved extremity.

4) Trophic Changes – Coarse, thick hair, later may be sparse; nails brittle, ridged, may grow faster initially, later grow more slowly; skin is smooth, shiny; digits tapered (pencil pointing); joints stiff with decreased ROM; muscle wasting; motor disturbances; increased physiological tremor, dystonia. c. Diagnostic Testing Procedures

1) X-rays of both extremities;

2) Triple Phase Bone Scan;

3) Sympathetic Blocks

4) Infrared Thermogram;

5) Autonomic Test Battery

2. Diagnostic Criteria for CRPS a. CRPS-I (RSD)

1) Patient complains of pain, usually diffuse burning or aching;

2) Patient has physical findings on examination of at least vasomotor and/or sudomotor signs. Allodynia and/or trophic changes add strength to the diagnosis of CRPS-I; and

3) At least two diagnostic testing procedures are positive. Even the most sensitive tests can have false negatives. The patient can still have CRPS-I, if clinical signs are strongly present. In patients with continued signs and symptoms of CRPS-I, further diagnostic testing may be appropriate. b. CRPS-II (causalgia)

1) Patient complains of pain;

2) Documentation of peripheral nerve injury with pain initially in the distribution of the injured nerve;

3) Patient has physical findings on examination of at least vasomotor and/or sudomotor signs. Allodynia and/or trophic changes add strength to the diagnosis of CRPS-II; and

4) At least two diagnostic testing procedures are positive. Even the most sensitive tests can have false negatives. The patient can still have CRPS-II, if clinical signs are strongly present. In patients with continued signs and symptoms of CRPS-II, further diagnostic testing may be appropriate. c. Sympathetically Mediated Pain (SMP)

1) Patient complains of pain; 2) Usually does not have clinically detectable vasomotor or sudomotor signs; and

3) Has pain relief with sympathetic blocks. d. Not CRPS

1) Patient complains of pain;

2) May or may not have vasomotor or sudomotor signs;

3) No relief with sympathetic blocks; and

4) No more than one other diagnostic test procedure is positive.

H. THERAPEUTIC PROCEDURES – NON-OPERATIVE

Non-operative therapeutic rehabilitation is applied to patients with CRPS or SMP who experience chronic and complex problems of deconditioning and functional disability. Treatment modalities may be utilized sequentially or concomitantly depending on chronicity and complexity of the problem, and treatment plans should always be based on a diagnosis utilizing appropriate diagnostic procedures.

Before initiation of any therapeutic procedure, the authorized treating physician, employer and insurer must consider these important issues in the care of the injured worker: a. Patients undergoing therapeutic procedure(s) should be released or returned to modified or restricted duty during their rehabilitation at the earliest appropriate time. Refer to “Return-to-Work” in this section for detailed information. b. Reassessment of the patient's status in terms of functional improvement should be documented after each treatment. If patients are not responding within the recommended time periods, alternative treatment interventions, further diagnostic studies or consultations should be pursued. Continued treatment should be monitored using objective measures such as:

1) Return to work or maintaining work status.

2) Fewer restrictions at work or performing or limitations in activities of daily living (ADL).

3) Decrease in usage of medications.

4) Measurable functional gains, such as increased range of motion or documented increase in strength. c. Clinicians should provide and document education to the patient. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of facilitating self-management of symptoms. d. Psychological or psychosocial screening should be performed on all chronic pain patients.

The following procedures are listed in alphabetical order.

1. Acupuncture

Acupuncture is an accepted and widely used procedure for the relief of pain and inflammation and there is some scientific evidence to support its use. Credentialed practitioners must perform acupuncture evaluations, with experience in evaluation and treatment of chronic pain patients. The exact mode of action is only partially understood. Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the brain, promotes deep relaxation, and affects the release of neurotransmitters. Acupuncture is commonly used as an alternative or in addition to traditional Western pharmaceuticals. It is commonly used when pain medication is reduced or not tolerated. It may be used as an adjunct to physical rehabilitation, surgical intervention, and or as part of multidisciplinary treatment to hasten the return of functional activity. Acupuncture should be performed by licensed practitioners.

Refer to the Chronic Pain guideline for detailed information on acupuncture and timeframe parameters.

2. Biofeedback

Biofeedback is a generally well-accepted form of behavioral medicine that helps patients learn self- awareness and self-regulation skills for the purpose of gaining greater control of their physiology. Biofeedback treatment is intended to assist patients in managing stress-related psychophysiological reactions that may arise as a reaction to organic pain, or which may cause pain. The biofeedback specialist may utilize a variety of interventions for teaching physiological self-management. Biological feedback may then be provided through mechanisms ranging from simple devices to electronic instrumentation, and displayed or fed back to the patient visually, auditorially, or tactilely. This enables the patient to identify and refine effective interventions.

The application of biofeedback to patients with CRPS is not well researched. However, based on CRPS symptomology, temperature or skin conductance feedback modalities may be of particular interest. Refer to the Chronic Pain Guideline for detailed information on biofeedback and time parameters.

3. Complementary Alternative Medicine (CAM)

CAM is a term used to describe a broad range of treatment modalities, a number of which are generally accepted and supported by some scientific evidence, and others which still remain outside the generally accepted practice of conventional Western Medicine. In many of these approaches, there is attention given to the relationship between physical, emotional, and spiritual well-being. While CAM may be performed by a myriad of both licensed and non-licensed health practitioners with training in one or more forms of therapy, credentialed practitioners should be used when available or applicable.

Refer to Chronic Pain guideline for detailed information on CAM and timeframe parameters.

4. Sleep Disturbances

Disturbances of sleep are common in chronic pain. Although primary insomnia may accompany pain as an independent comorbid condition, it more commonly occurs secondary to the pain condition itself. Exacerbations of pain often are accompanied by exacerbations of insomnia; the reverse can also occur. Sleep laboratory studies have shown disturbances of sleep architecture in pain patients. Loss of deep slowwave sleep and increase in light sleep occur and sleep efficiency, the proportion of time in bed spent asleep, is decreased. These changes are associated with patient reports of non-restorative sleep.

Many chronic pain patients develop behavioral habits that exacerbate and maintain sleep disturbances. Excessive time in bed, irregular sleep routine, napping, low activity and worrying in bed are all maladaptive responses that can arise in the absence of any psychopathology. There is some evidence that behavioral modification, such as patient education and group or individual counseling, can be effective in reversing the effects of insomnia. Behavioral modifications are easily implemented and can include: a. Maintaining a regular sleep schedule, retiring and rising at approximately the same time on weekdays and weekends. b. Avoiding daytime napping. c. Avoiding caffeinated beverages after lunchtime d. Making the bedroom quiet and comfortable, eliminating disruptive lights, sounds television sets, and keeping a bedroom temperature of about 65°;F. e. Avoiding alcohol or nicotine within two hours of bedtime. f. Avoiding large meals within two hours of bedtime. g. Exercising vigorously during the day, but not within two hours of bedtime, since this may raise core temperature and activate the nervous system. h. Associating the bed with sleep and sexual activity only, using other parts of the home for television, reading and talking on the telephone. i. Leaving the bedroom when unable to sleep for more than 20 minutes, retuning to the bedroom when ready to sleep again.

These modifications should be undertaken before sleeping medication is prescribed.

5. Injections — Therapeutic

When considering the use of injections in CRPS management, the treating physician must carefully consider the inherent risks and benefits. First, it is understood that these injections are seldom meant to be “curative” but may have diagnostic or prognostic qualities and when used for therapeutic purposes they are employed in conjunction with other treatment modalities for maximum benefit. Second, education of the patient should include the proposed goals of the injections, expected gains, risks or complications, and alternative treatment. Lastly, reassessment of the patient's status in terms of functional improvement should be documented after each injection and/or series of injections. Any continued use of injections should be monitored using objective measures such as:

(1) Return to work or maintaining work status.

(2) Fewer restrictions at work or when performing activities of daily living (ADL).

(3) Decrease in usage of medications.

(4) Measurable functional gains, such as increased range of motion or documented increase in strength.

Visual analog scales (VAS) provide important subjective data but are not an appropriate measure of function.

The physician must be aware of the possible placebo effect as well as the long-term effects of injections related to the patient's physical and mental status. Strict adherence to contraindications, both absolute and relative, may prevent potential complications. Subjecting the patient to potential risks, i.e., needle trauma, infection, nerve injury, or systemic effects of local anesthetics and corticosteroids, must be considered before the patient consents to such procedures. a. Sympathetic Injections

Description – Sympathetic injections are generally accepted, well-established procedures. They include stellate ganglion blocks, lumbar sympathetic, and intravenous regional (Bier) blocks. Regional blocks frequently use bretylium with additional agents (narcotics and or anti-inflammatory drugs). There is some evidence that bretylium reduces pain intensity. It is recommended that all patients receiving therapeutic blocks participate in an appropriate exercise program that may include a functionally directed rehabilitation program.

Indications – Pain relief and functional improvement from previous diagnostic or therapeutic blocks.

Special Considerations – Except for Bier blocks, fluoroscopic and/or CT guidance during procedures is recommended to document technique and needle placement; an experienced physician should perform the procedure. The practitioner should participate in ongoing injection training workshops provided by organizations such as the International Spinal Injection Society (ISIS) and be knowledgeable in radiation safety. In addition, practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments of Radiology, as applicable.

Contraindications – Absolute contraindications of therapeutic injections include: (a) bacterial infection – systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d) possible pregnancy. Relative contraindications of therapeutic injections may include: ASA/antiplatelet therapy (drug may be held for at least 3 days prior to injection).

Treatment Parameters – To be effective as a treatment modality, the patient should be making measurable progress in their rehabilitation program and should be achieving an increasing or sustained duration of relief between blocks. If appropriate outcomes are not achieved, changes in treatment should be undertaken.

(1) Time to produce effect: 1 to 3 blocks

(2) Frequency: Variable, depending upon duration of pain relief and functional gains. During the first two weeks of treatment, blocks may be provided every 3 to 5 days, based on patient response. After the first two weeks, blocks may be given weekly with tapering for a maximum of 7 injections over 6 weeks.

(3) Optimum duration: 3 months.

(4) Maximum duration: 3 to 4 months for initial treatment. For the use of blocks during maintenance care, refer to the Maintenance Care section for treatment parameters. b. Trigger Point Injections

May be appropriate when myofascial trigger points are present on examination. Refer to chronic pain guidelines for treatment parameters. c. Peripheral Nerve Blocks

May be appropriate when peripheral nerve pathology is identified. Refer to chronic pain guidelines for treatment parameters. d. Intravenous Lidocaine

May be used as a prognostic indicator for the use of mexilitine. It is infrequently used as a therapeutic treatment.

6. Interdisciplinary Rehabilitation Programs

These programs should assess the impact of pain and suffering on the patient's medical, physical, psychological, social and/or vocational functioning. In general, interdisciplinary programs deal with irreversible, painful musculoskeletal, neurological, and other chronic painful disorders and psychological issues, including drug dependence, high levels of stress and anxiety, failed surgery and preexisting or latent psychopathology. The number of professions involved in the team in chronic pain program may vary due to the complexity of the needs of the person served. The Division recommends consideration of referral to an interdisciplinary program within 6 months post-injury in patients with delayed recovery unless surgical interventions or other medical complications intervene.

Refer to the Chronic Pain guideline for detailed information about these programs and timeframe parameters. Before treatment has been initiated, the patient, physician, and insurer should agree on treatment approach, methods and goals. Generally the type of outpatient program needed will depend on the degree of impact the pain has had on the patient's medical, physical, psychological, social and/or vocational functioning.

When referring a patient for formal outpatient interdisciplinary pain rehabilitation or Work Hardening programs, the Division recommends the programs be Commission on Accreditation of Rehabilitation Facilities (CARF) eligible and/or certified. CARF eligibility or certification ensures that programs meet specific care standards of design and efficacy.

Inpatient Pain Rehabilitation Programs are rarely needed but may be necessary for certain patients. Refer to Chronic Pain guideline for detailed conditions that may require inpatient pain rehabilitation.

Outpatient interdisciplinary pain programs, whether formal or informal, should be comprised of the following dimensions: a. Communication – To ensure positive functional outcomes, communication between the patient, insurer and all professionals involved must be coordinated and consistent. Any exchange of information must be provided to all professionals, including the patient. Care decisions would be communicated to all. b. Documentation – Through documentation by all professionals involved and or discussions with the patient, it should be clear that functional goals are being actively pursued and measured on a regular basis to determine their achievement or need for modification. c. Treatment Modalities – Use of modalities may be necessary early in the process to facilitate compliance with and tolerance to therapeutic exercise, physical conditioning, and increasing functional activities. Active treatments should be emphasized over passive treatments. Active treatments should encourage self-coping skills and management of pain, which can be continued independently at home or at work. Treatments that can foster a sense of dependency by the patient on the caregiver should be avoided. Treatment length should be decided based upon observed functional improvement. For a complete list of Active and Passive Therapies, refer to the Therapy sections of this guideline. All treatment timeframes may be extended, based upon the patient's positive functional improvement. d. Therapeutic Exercise Programs – There is strong evidence that these programs, including aerobic conditioning and strengthening, are superior to treatment programs that do not include exercise. There is no sufficient evidence to support the recommendation of any particular exercise regimen over any other exercise regimen. A Therapeutic Exercise program should be initiated at the start of any treatment rehabilitation. Such programs should emphasize education, independence, and the importance of an on-going exercise regime. e. Return to Work – The authorized treating physician should continually evaluate the patient for their potential to return to work. When return to work is an option, it may be appropriate to implement a Work Hardening Program (as described in this section). For patients currently employed, efforts should be aimed at keeping them employed. For more specific information regarding return to work, refer to the Return To Work section in this guideline. f. Patient Education – Patients with pain need to re-establish a healthy balance in lifestyle. All providers should educate patients on how to overcome barriers to resuming daily activity, including pain management, decreased energy levels, financial constraints, decreased physical ability and change in family dynamics. g. Psychosocial Evaluation and Treatment – Psychosocial evaluation should be initiated, if not previously done. Providers of care should have a thorough understanding of the patient's personality profile; especially if dependency issues are involved. Psychosocial treatment may enhance the patient's ability to participate in pain treatment rehabilitation, manage stress, and increase their problem- solving and self-management skills. h. Vocational Assistance – Vocational assistance can define future employment opportunities or assist patients in obtaining future employment. Refer to Return to Work section for detailed information.

7. Medications

There is no single formula for pharmacological treatment of patients with chronic nonmalignant pain. A thorough medication history, including use of alternative and over the counter medications, should be performed at the time of the initial visit and updated periodically. Appropriate application of pharmacological agents depends on the patient's age, past history (including history of substance abuse), drug allergies and the nature of all medical problems. It is incumbent upon the physician to thoroughly understand pharmacological principles when dealing with the different drug families and their respective side effect, bioavailability profiles and primary reason for each medication's usage.

All medications should be given an appropriate trial in order to test for therapeutic effect. Trials of medication requiring specific therapeutic drug levels may take several months to achieve, depending upon the half-life of the drug. It is recommended that patients with CRPS be maintained on drugs that have the least serious side effects. For example, patients need to be tried or continued on acetaminophen and or antidepressant medications whenever feasible as part of their overall treatment for chronic pain. It is recommended that use of opioid analgesic and sedative hypnotic medications in chronic pain patients be used in a very limited manner, with total elimination desirable whenever clinically feasible. For the clinician to interpret the following material, it should be noted that: (1) drug profiles listed are not complete; (2) dosing of drugs will depend upon the specific drug, especially for off-label use; and (3) not all drugs within each class are listed, and other drugs within the class may be appropriate. Clinicians should refer to informational texts or consult a pharmacist before prescribing unfamiliar medications or when there is a concern regarding drug interactions.

The following drug classes are listed in alphabetical order, not in order of suggested use. a. Anticonvulsants

Although the mechanism of action of anticonvulsant drugs in neuropathic pain states remains to be fully defined, they appear to act as nonselective sodium channel blocking agents. A large variety of sodium channels are present in nervous tissue, and some of these are important mediators of nociception, as they are found primarily in unmyelinated fibers and their density increases following nerve injury. While the pharmacodynamic effects of the various anticonvulsant drugs are similar, the pharmacokinetic effects differ significantly. Carbamazepine has important effects as an inducer of hepatic enzymes and may influence the metabolism of other drugs enough to present problems in patients taking more than one drug. Gabapentin and oxcarbazepine, by contrast, are relatively non-significant enzyme inducers, creating fewer drug interactions. Because anticonvulsant drugs may have more problematic side-effect profiles, their use should usually be deferred until antidepressant drugs have failed to relieve pain.

1) Gabapentin (Neurontin)

a) Description – Structurally related to GABA but does not interact with GABA receptors.

b) Indications – Neuropathic pain.

c) Relative Contraindications – Renal insufficiency.

d) Dosing and Time to Therapeutic Effect – Dosage may be increased over several days.

e) Major Side Effects – Confusion, sedation.

f) Drug Interactions – Oral contraceptives, cimetidine, antacids.

g) Recommended Laboratory Monitoring – Renal function. b. Antidepressants

Antidepressants are classified into a number of categories based on their chemical structure and their effects on neurotransmitter systems. Their effects on depression are attributed to their actions on disposition of norepinephrine and serotonin at the level of the synapse; although these synaptic actions are immediate, the symptomatic response in depression is delayed by several weeks. When used for chronic pain, the effects may in part arise from treatment of underlying depression, but may also involve additional neuromodulatory effects on endogenous opioid systems, raising pain thresholds at the level of the spinal cord.

Pain responses may occur at lower drug doses with shorter times to symptomatic response than are observed when the same compounds are used in the treatment of mood disorders. Neuropathic pain, diabetic neuropathy, post-herpetic neuralgia, and cancer-related pain may respond to antidepressant doses low enough to avoid adverse effects that often complicate the treatment of depression.

1) Tricyclics (e.g., amitruptiline [Elavil], nortriptyline [Pamelor, Aventyl], doxepin [Sinequan, Adapin])

a) Description – Serotonergics, typically tricyclic antidepressants (TCAs), are utilized for their serotonergic properties as increasing CNS serotonergic tone can help decrease pain perception in nonantidepressant dosages. Amitriptyline is known for its ability to repair Stage 4 sleep architecture, a frequent problem found in chronic pain patients and to treat depression, frequently associated with chronic pain.

b) Indications – Chronic musculoskeletal and/or neuropathic pain, insomnia. Second line drug treatment for depression.

c) Major Contraindications – Cardiac disease or dysrhythmia, glaucoma, prostatic hypertrophy, seizures, suicide risk.

d) Dosing and Time to Therapeutic Effect – Varies by specific tricyclic. Low dosages are commonly used for chronic pain and/or insomnia.

e) Major Side Effects – Anticholinergic side effects including, but not limited to, dry mouth, sedation, orthostatic hypotension, cardiac arrhythmia, weight gain.

f) Drug Interactions – Tramadol (may cause seizures), Clonidine, cimetidine, sympathomimetics, valproic acid, warfarin, carbamazepine, bupropion, anticholinergics, quinolones.

g) Recommended Laboratory Monitoring – Renal and hepatic function. EKG for those on high dosages or with cardiac risk. c. Hypnotics and Sedatives

Sedative and hypnotic drugs decrease activity, induce drowsiness, and moderate agitation. Many drugs produce these effects incidental to their usual intended effects, similar to the side effects of many antihistamines and antidepressants. Due to the habit-forming potential of the benzodiazepines and other drugs found in this class, they are not routinely recommended but may be useful in some patients with chronic pain.

Most insomnia in chronic pain patients should be managed primarily though behavioral interventions with medications as secondary measures (refer to “Disturbances of Sleep” section).

1) Zaleplon (Sonata)

a) Description – A nonbenzodiazepine hypnotic.

b) Indications – Insomnia.

c) Dosing and Time to Therapeutic Effect – Time of onset is 30 to 60 minutes. Due to rapid elimination, may be taken as little as 4 hours before awakening.

d) Major Side Effects – Dizziness, dose-related amnesia.

e) Drug Interactions – Increases sedative effect of other CNS depressant drugs. Use low dose if on cimetidine.

f) Recommended Laboratory Monitoring – Hepatic function.

2) Zolpidem (Ambien)

a) Description – A nonbenzodiazepine hypnotic, which does not appear to cause rebound insomnia. It has little respiratory depression and insignificant anxiolytic or muscle relaxant activity. b) Indications – Short-term use for insomnia

c) Time to Produce Therapeutic Effect – Onset of action is 30 to 60 minutes

d) Major Side Effects – Dizziness, dose-related amnesia.

e) Drug Interactions – Increases sedative effect of other CNS depressant drugs.

f) Recommended Laboratory Monitoring – Hepatic function. d. Opioids

Opioids are the most powerful analgesics. Their use in acute pain and moderate to severe cancer pain is well accepted. Their use in chronic nonmalignant pain, however, is fraught with controversy and lack of scientific research.

The central nervous system actions of these drugs account for much of their analgesic effect and for many of their other actions, such as respiratory depression, drowsiness, mental clouding, reward effects, and habit formation. With respect to the latter, it is crucial to distinguish between three distinct phenomena: tolerance, dependence, and addiction.

Tolerance refers to a state of adaptation in which exposure to a drug over time causes higher doses of that drug to be required in order to produce the same physiologic effect.

Dependence refers to a set of disturbances in body homeostasis that leads to withdrawal symptoms, which can be produced with abrupt discontinuation, rapid reduction, decreasing blood levels, and /or by administration of an antagonist.

Addiction is a primary, chronic, neurobiologic disease, with genetic, psychological, and environmental factors influencing its development and manifestations. It is a behavioral pattern of drug craving and seeking which leads to a preoccupation with drug procurement and use.

Tolerance and dependence are physiological phenomena, are expected with the continued administration of opioids, and should not deter physicians from their appropriate use.

The use of opioids is well accepted in treating cancer pain, where nociceptive mechanisms are generally present due to ongoing tissue destruction, expected survival may be short, and symptomatic relief is emphasized more than functional outcomes. In chronic non-malignant pain, by contrast, tissue destruction has generally ceased, meaning that central and neuropathic mechanisms frequently overshadow nociceptive processes. Expected survival in chronic pain is relatively long and return to a high level of function is a major goal of treatment. Therefore, approaches to pain developed in the context of malignant pain may not be transferable to chronic non-malignant pain.

In most cases, analgesic treatment should begin with acetaminophen, aspirin, and NSAIDs. While maximum efficacy is modest, they may reduce pain sufficiently to permit adequate function. When these drugs do not satisfactorily reduce pain, opioids for moderate to moderately severe pain may be added to (not substituted for) the less efficacious drugs.

Consultation or referral to a pain specialist should be considered when the pain persists but the underlying tissue pathology is minimal or absent and correlation between the original injury and the severity of impairment is not clear. Consider consultation if suffering and pain behaviors are present and the patient continues to request medication, or when standard treatment measures have not been successful or are not indicated.

1) General Indications — There must be a clear understanding that opioids are to be used for a limited term in the first instance (see trial indications below), that their use is contingent upon certain obligations or goals being met by the patient, e.g., return to work, and the patient understands that there may be drug screening to ensure compliance.

2) Therapeutic Trial Indications — A therapeutic trial of opioids should not be employed unless the patient has begun a rehabilitation program. Once this criterion has been met, opioids would be indicated when a patient meets the following:

a) The failure of pain management alternatives, including active therapies, cognitive behavioral therapy, pain self-management techniques, and other appropriate medical techniques.

b) Physical and psychosocial assessment, performed by two specialists with one being the authorized treating physician.

c) Informed, written, witnessed consent by the patient.

In addition, there should be documentation of sustained improvement of pain control and/or functional status, including return to work, with use of opioids. Frequent follow-up at least every 2 to 4 weeks may be necessary to titrate dosage and assess clinical efficacy.

3) On-Going, Long-Term Management — Actions Should Include:

a) Prescriptions from a single practitioner,

b) Ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects,

c) Ongoing effort to gain improvement of social and physical function as a result of pain relief,

d) Contract detailing reasons for termination of supply, with appropriate tapering of dose,

e) Use of random drug screening, as deemed appropriate by the prescribing physician,

f) Use of more than two opioids: a long acting opioid for maintenance of pain relief and a short acting opioid for limited rescue use when pain exceeds the routine level. If more than two opioids are prescribed for long-term use a second opinion from specialist who is Board Certified in Neurology, Physical Medicine and Rehabilitation, or Anesthesiology with recognized training and/or certification in pharmacological pain management is strongly recommended,

g) Use of acetaminophen-containing medications in patients with liver disease should be limited; and

h) Continuing review of overall situation with regard to nonopioid means of pain control,

i) Inpatient treatment in complex cases. Refer to Interdisciplinary Rehabilitation Programs for detailed information on in-patient criteria.

4) Relative Contraindications — Extreme caution should be used in prescribing controlled substances for workers with one or more “relative contraindications”:

a) History of alcohol or other substance abuse, or a history of chronic, high-dose benzodiazepine use;

b) Off work for more than six months;

c) Severe personality disorder

5) General Contraindications —

a) Active alcohol or other substance abuse.

b) Untreated mood or psychotic disorders (e.g., depression).

c) Decreased physical or mental function with continued opioid use.

d) Addictive behaviors. Warning signs include:

(1) Preoccupation with drugs;

(2) Refusal to participate in medication taper;

(3) Reporting that nothing but a specific opioid works;

(4) Strong preference for short-acting over long-acting opioids;

(5) Use of multiple prescribers and pharmacies;

(6) Use of street drugs or other patients drugs;

(7) Not taking medications as prescribed;

(8) Loss of medications more than once; and/or

(9) Criminal behaviors to obtain drugs, i.e., forged prescriptions.

6) Dosing and Time to Therapeutic Effect — Oral route is the preferred route of analgesic administration because it is the most convenient and cost-effective method of administration. When patients cannot take medications orally, rectal and transdermal routes should be considered because they are also relatively noninvasive.

7) Major Side Effects — There is great individual variation in susceptibility to opioid-induced side effects and clinicians should monitor for these potential side effects. Common initial side effects include nausea, vomiting, drowsiness, unsteadiness, and confusion. Occasional side effects include dry mouth, sweating, pruritus, hallucinations, and myoclonus. Rare side effects include respiratory depression and psychological dependence. Constipation and nausea/vomiting are common problems associated with long-term opioid administration and should be anticipated, treated prophylactically, and monitored constantly.

8) Drug Interactions — Patients receiving opioid agonists should not be given a mixed agonist-antagonist (pentazocine [Talwin], butorphanol [Stadol]) because doing so may precipitate a withdrawal syndrome and increase pain.

9) Recommended Laboratory Monitoring — Primary laboratory monitoring is recommended for acetaminophen/ASA/ibuprofen combinations (renal and liver function, blood dyscrasias). May perform urine and or blood drug screen if suspect use of other narcotics or lack of compliance with full medication regimen.

10) Patient Physician Contracts — All patients on chronic opioids should have an informed, written, witnessed consent. The contract should discuss side effects of opioids, results of use in pregnancy, inability to refill lost or missing medication, withdrawal symptoms, requirement for drug testing, and necessity of tapering.

11) Potentiating Agents — Some medications appear to potentiate the analgesic effects of opioids. Dextromethorphan is available as a nonopioid non-prescription antitussive agent in numerous cough and cold remedies. It antagonizes n-methyl-d-aspartate receptors involved in central sensitization of pain pathways. It may exert some morphine sparing effects in patients taking morphine, but its activity as an analgesic in neuropathic pain is likely to be weak. It is well tolerated in most patients. Because the patient profiles that might predict response to dextromethorphan are undefined, its use in chronic pain must be empirically tried on an individual basis. Diphenhydramine and hydroxyzine (atarax, vistaril) are antihistamines, which act at hl receptors to alleviate allergic symptoms and produce somnolence. Diphenhydramine is a component of some non-prescription sleeping preparations. Their use in potentiating the effects of analgesic drugs is not clearly defined, but it may be used empirically for this purpose. e. Topical Drug Delivery

1) Description — Topical medications, such as ketamine and capsacin, may be an alternative treatment for neuropathic disorders and is an acceptable form of treatment in selected patients although there is no literature addressing its use in patients with CRPS.

2) Indications — Pain. Patient selection must be rigorous to select those patients with the highest probability of compliance.

3) Dosing and Time to Therapeutic Effect — It is necessary that all topical agents be used with strict instructions for application as well as maximum number of applications per day to obtain the desired benefit and avoid potential toxicity.

4) Side Effects — Localized skin reactions may occur, depending on drug. f. Other Agents

1) Tramadol (Ultram)

a) Description — An opioid partial agonist that is generally well tolerated, does not cause GI ulceration, or exacerbate hypertension or congestive heart failure.

b) Indications — Mild to moderate pain relief. This drug has been shown to provide pain relief equivalent to that of commonly prescribed NSAIDs.

c) Contraindications — Use cautiously in patients who have a history of seizures or who are taking medication that may lower the seizure threshold, such as MAO inhibitors, SSRIs, and TCAs. Not recommended in those with prior opioid addiction.

d) Side Effects — May cause impaired alertness or nausea. This medication has physically addictive properties and withdrawal may follow abrupt discontinuation. e) Drug Interactions — Narcotics, sedating medications.

f) Recommended Laboratory Monitoring — Renal and hepatic function.

2) Agents not listed which may be useful in the treatment of CRPS and SMP include propranolol, nifedipine, calcitonin, bisphosphonates and short-term oral steroids, during the acute phase of the disease. Although propranolol, nifedipine, oral steroids, and calcitonin are used in practice, at this time there is a lack of well-designed studies to support their effectiveness compared to placebo. In individual patients, they may be effective. There is some evidence to support the use of intravenous bisphosphonate drugs, currently licensed for use in malignant bone disease and Paget's disease, in CRPS patients with abnormal bone scans. Oral use of bisphosphonates has not been studied in CRPS.

8. Orthotics/Prosthetics/Equipment

9. Patient Education

Patients should be educated on their specific injury, assessment findings, and plan of treatment and encouraged to take an active role in establishing functional outcome goals. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of prolonging the beneficial effects of rehabilitation, as well as facilitating self-management of symptoms and prevention of secondary disability. There is good evidence that patient education in self-management of asthma, anticoagulation, and other diseases improves appropriate use of medications, increases patient satisfaction with care, and reduces unscheduled physician visits for dealing with complications of treatment.

Patient education is an interactive process that provides an environment where the patient not only acquires knowledge but also gains an understanding of the application of that knowledge. Therefore, patients should be able to describe and/or will need to be educated on: a. The treatment plan; b. Indications for and potential side effects of medications; c. Their home exercise program; d. Expected results of treatment; e. Tests to be performed, the reasons for them and their results; f. Activity restrictions and return-to-work status; g. Home management for exacerbations of pain; h. Procedures for seeking care for exacerbations after office hours; i. Home self-maintenance program; j. Patient responsibility to communicate with all medical providers and the employer; and k. Patient responsibility to keep appointments.

Educational efforts should also extend to family and other support persons, the case manager, the insurer and the employer as indicated to optimize the understanding of the patient and the outcome. Professional translators should be provided for non-English speaking patients to assure optimum communication. All education, teaching, and instruction given to the patient should be documented in the medical record.

Effects of education weaken over time; continuing patient education sessions will be required to maximize the patient's function. The effectiveness of educational efforts can be enhanced through attention to the learning style and receptivity of the patient. Written educational materials may reinforce and prolong the impact of verbal educational efforts. Overall, patient education should emphasize health and wellness, return to work and return to a productive life.

(1) Time to produce effect: Varies with individual patient

(2) Frequency: At each visit

10. Personality/Psychological/Psychosocial Intervention

Psychosocial treatment is generally accepted, well-established therapeutic and diagnostic procedure with selected use in acute pain problems, but with more widespread use in sub-acute and chronic pain populations. Psychosocial treatment is recommended as an important component in the total management of a patient with chronic pain and should be implemented as soon as the problem is identified.

Once a diagnosis consistent with the standards of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) has been determined, the patient should be evaluated for the potential need for psychiatric medications. Use of any medication to treat a diagnosed condition may be ordered by the authorized treating physician or by the consulting psychiatrist. Visits for management of psychiatric medications are medical in nature and are not a component of psychosocial treatment. Therefore, separate visits for medication management may be necessary, depending upon the patient and medications selected.

The screening or diagnostic workup should have clarified and distinguished between preexisting, aggravated, and or purely causative psychological conditions. Therapeutic and diagnostic modalities include, but are not limited to, individual counseling, and group therapy. Treatment can occur within an individualized model, a multi-disciplinary model, or within a structured pain management program.

Refer to Chronic Pain guideline for detailed information on whom may perform the service and timeframe parameters.

11. Restriction of Activities

Patients should be educated to the detrimental effects of immobility versus the efficacious use of rest periods. Adequate rest allows the patient to comply with active treatment and benefit from the rehabilitation program. In addition complete work cessation should be avoided, if possible, since it often further aggravates the pain presentation and promotes disability. Modified return to work is almost always more efficacious and rarely contraindicated in the vast majority of injured workers with chronic pain. 12. Return-to-Work

Return-to-work is one of the major components in chronic pain management. Return to work is a subject that should be addressed by each workers' compensation provider at the first meeting with the injured employee, and be updated at each additional visit. A return to work format should be part of a company's health plan, knowing that return to work can decrease anxiety, reduce the possibility of depression and reconnect the worker with society.

Because a prolonged period of time off work will decrease the likelihood of return to work, the first weeks of treatment are crucial in preventing and/or reversing chronicity and disability mindset. In complex cases, experienced nurse case managers may be required to assist in return to work. Other services, including psychological evaluation and/or treatment and vocational assistance should be employed.

The following should be considered when attempting to return an injured worker with chronic pain to work. a. Job History Interview

The authorized treating physician should perform a job history interview at the time of the initial evaluation and before any plan of treatment is established. Documentation should include the workers' job demands, stressors, duties of current job, and duties of job at the time of the initial injury. In addition, cognitive and social issues should be identified and treatment of these issues should be incorporated into the plan of care. b. Coordination of Care

Management of the case is a significant part of return to work and may be the responsibility of the authorized treating physician, occupational health nurse, risk manager, or others. Case management is a method of communication between the primary provider, referral providers, insurer, employer and employee. Because case management may be coordinated by a variety of professionals, the case manager should be identified in the medical record. c. Communication

Communication is essential between the patient, authorized treating physician, employer and insurer. Employers should be contacted to verify employment status, job duties and demands, and policies regarding injured workers. In addition, availability of temporary and permanent restrictions, for what duration, as well as other placement options should be discussed and documented. d. Establishment of a Return-To-Work Status

Return to work for persons with chronic pain should be thought of as therapeutic, assuming that work is not likely to aggravate the basic problem or increase the discomfort. In most cases of chronic pain, the worker may not be currently working or even employed. The goal of return to work would be to implement a plan of care to return the worker to any level of employment with the current employer or to return them to any type of new employment. e. Establishment of Activity Level Restrictions

A formal job description for the injured/ill employee who is employed is necessary to identify physical demands at work and assist in the creation of modified duty. A Jobsite Evaluation may be utilized to identify tasks such as pushing, pulling, lifting, reaching above shoulder level, grasping, pinching, sitting, standing, posture, ambulatory distance and terrain, and if applicable, environment for temperature, air flow, noise and the number of hours that may be worked per day. Work restrictions assigned by the authorized treating physician may be temporary or permanent. The case manager should continue to seek out modified work until restrictions become less cumbersome or as the worker's condition improves or deteriorates. f. Rehabilitation and Return to Work

As part of rehabilitation, every attempt should be made to simulate work activities so that the authorized treating physician may promote adequate job performance. The use of ergonomic or adaptive equipment, therapeutic breaks, and interventional modalities at work may be necessary to maintain employment. g. Vocational Assistance

Formal vocational assistance is a generally accepted intervention and can assist disabled persons to return to viable employment. Assisting patients to identify vocational goals will facilitate medical recovery and aid in the maintenance of MMI by (1) increasing motivation towards treatment and (2) alleviating the patient's emotional distress. Chronic pain patients will benefit most if vocational assistance is provided during the interdisciplinary rehabilitation phase of treatment. To assess the patient's vocational capacity, a vocational assessment may be utilized to identify rehabilitation program goals, as well as optimize both patient motivation and utilization of rehabilitation resources.

Employers and employees of small businesses who are diagnosed with chronic pain may not be able to perform any jobs for which openings exist. Temporary employees may fill those slots while the employee functionally improves. Some small businesses hire other workers and if the injured employee returns to the job, the supervisor/owner may have an extra employee. To avoid this, it is suggested that case managers be accessed through their insurer or third party insurers. Case managers may assist with resolution of these problems, as well as assist in finding modified job tasks, or find jobs with reduced hours, etc., depending upon company philosophy and employee needs.

Employers and employees of mid-sized and large businesses are encouraged by the Division to identify modified work within the company that may be available to injured workers with chronic pain who are returning to work with temporary or permanent restrictions. To assist with temporary or permanent placement of the injured worker, it is suggested that a program be implemented that allows the case manager to access descriptions of all jobs within the organization.

13. Therapy — Active

Active therapy is based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion, and can alleviate discomfort.

Active therapy requires an internal effort by the individual to complete a specific exercise or task. This form of therapy requires supervision from a therapist or medical provider such as verbal, visual and/or tactile instruction(s). Active therapy is intended to promote independence and self-reliance in managing the physical pain as well as to improve the functional status in regard to the specific diagnosis and general conditioning and well-being. At times, a provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is predominately executed by the patient.

Since CRPS and SMP patients frequently have additional myofascial pain generators, other active therapies not listed may be used in treatment. Refer to the Chronic Pain guideline for therapies and timeframe parameters not listed. The following active therapies are listed in alphabetical order: a. Activities of Daily Living (ADL)

(1) Time to produce effect: 4 to 5 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks b. Aquatic Therapy

Aquatic therapy is the implementation of active therapeutic procedures (individual or group) in a swimming or therapeutic pool heated to 88-92 degrees. The water provides a buoyancy force that lessens the amount of force gravity applies to the body, and the pool should be large enough to allow full extremity range of motion and full erect posture. The decreased gravity effect allows the patient to have a mechanical advantage increases the likelihood of successful therapeutic exercise. Multiple limb involvement, weight bearing problems and vasomotor abnormalities are frequently treated with water exercise. Indications for individuals who may not tolerate active land-based or full weight bearing therapeutic procedures or who require augmentation of other therapy. Aquatic vests, belts and other devices can be used to provide stability, balance, buoyancy, and resistance.

(1) Time to produce effect: 5 to 10 sessions

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 Weeks. Multiple limb involvement may require longer intervention. c. Gait Training

Indications include the need to promote normal gait pattern with assistive devices and/or to reduce risk of fall or loss of balance. This may include instruction in safety and proper use of assistive devices and gait instruction on uneven surfaces and steps (with or without railings).

(1) Time to produce effect: 1 to 6 sessions

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 2 weeks. Could be needed intermittently as changes in functional status occur.

(4) Maximum duration: 1 month. d. Neuromuscular Re-education

(1) Time to produce effect: 6 treatments

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 4 to 8 weeks

(4) Maximum Duration: 8 to 12 weeks e. Stress Loading

Stress loading is considered a reflex and sensory integration technique involving the application of a compressive load and a carry load. It is carried out in a consistent, progressive manner and integrated as part of a home program. Use of this technique may increase symptoms initially, but symptoms generally subside with program consistency.

(1) Time to produce effect: 3 weeks

(2) Frequency: 2 to 3 times per week.

(3) Optimum duration: 4 to 6 weeks and concurrent with an active daily home exercise program.

(4) Maximum Duration: 6 to 10 weeks f. Therapeutic Exercise

Therapeutic exercise, with or without mechanical assistance or resistance, may include isoinertial, isotonic, isometric and isokinetic types of exercises. Stress loading exercises are recommended. Indications include the need for cardiovascular fitness, reduced edema, improved muscle strength, improved connective tissue strength and integrity, increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle recruitment, increased range-of-motion and are used to promote normal movement patterns. Can also include alternative/complementary exercise movement therapy. Therapeutic exercise programs should be tissue specific to the injury and address general functional deficits as identified in the diagnosis and clinical assessment. Patients should be instructed in and receive a home exercise program that progresses as their functional status improves. Upon discharge, the patient would be independent in the performance of the home exercise program and would have been educated in the importance of continuing such a program. Educational goals would be to maintain or further improve function and to minimize the risk for aggravation of symptoms in the future.

(1) Time to produce effect: 3 weeks

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 4 to 8 weeks and concurrent with an active daily home exercise program.

(4) Maximum Duration: 8 to 12 weeks of therapist oversight. Home exercise should continue indefinitely.

14 Therapy — Passive

Factors such as exacerbation of symptoms, re-injury, interrupted continuity of care, and comorbidities may extend durations of care. Having specific goals with objectively measured functional improvement during treatment can support extended durations of care. It is recommended that if after 6 to 8 visits no treatment effect is observed, alternative treatment interventions, further diagnostic studies or further consultations should be pursued.

Since CRPS and SMP patients frequently have additional myofascial pain generators, other passive therapies not listed may be used in treatment. Refer to the Chronic Pain guideline for therapies and timeframe parameters not listed. The following passive therapies are listed in alphabetical order: a. Continuous Passive Motion

CPM is rarely indicated in CRPS but may occasionally be warranted if the patient shows signs of contracture despite active therapy.

(1) Time to produce effect: 4 to 6 treatments

(2) Frequency: Varies, between 2 to 3 times per day and 1 time per week.

(3) Optimum duration: 4 treatments

(4) Maximum duration: 6 treatments. Provide home unit with improvement. b. Fluidotherapy

Used primarily for desensitization and to facilitate increased active range of motion. Thermal heat conduction and convection is advantageous for vasodilation, muscle relaxation and preparation for stress and activity (exercise).

(1) Time to produce effect: 3 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 2 months.

(4) Maximum duration: 2 months as a primary therapy or intermittently as an adjunct therapy to other procedures. c. Orthotics/Splinting

Static splinting is discouraged. Dynamic splinting may occasionally be useful in controlling proximal hypertonicity or for other concurrent pain generators.

(1) Time to produce effect: 1 week

(2) Frequency: varies depending upon application

(3) Optimum duration: 1 month

(4) Maximum duration: 2 months d. Paraffin Bath

Indications include the need to enhance collagen extensibility before stretching, reduce muscle guarding, and to prepare for functional restoration activities.

(1) Time to produce effect: 1 to 2 treatments

(2) Frequency: 1 to 3 times per week as an adjunct treatment to other procedures. May use daily if available at home.

(3) Optimum duration: 2 weeks

(4) Maximum duration: 3 to 4 weeks. If effective, purchase home unit. e. Desensitization

Desensitization is accomplished through sensory integration techniques. Concurrent desensitization techniques are generally accepted as a treatment for CRPS. Home techniques using soft cloths of various textures, massage, and vibrators may be beneficial in reducing allodynia and similar sensory abnormalities.

(1) Time to produce effect: 6 treatments

(2) Frequency: 3 times per week and concurrent with home exercise program.

(3) Optimum duration: 3 weeks with reinforcement of home program.

(4) Maximum duration: 1 month. f. Superficial Heat Therapy

Superficial heat is a thermal agent applied to raise the body tissue temperature. It is indicated before exercise to elevate the pain threshold, alleviate muscle spasm, and promote increased movement. Heat packs can be used at home as an extension of therapy in the clinic setting.

(1) Time to produce effect: Immediate

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 2 weeks as primary or intermittently as an adjunct to other therapeutic procedures

(4) Maximum duration: 2 weeks. Home use as a primary modality may continue at the providers' discretion.

I. THERAPEUTIC PROCEDURES - OPERATIVE

When considering operative intervention in chronic pain management, the treating physician must carefully consider the inherent risk and benefit of the procedure. All operative intervention should be based on a positive correlation with clinical findings, the clinical course, and diagnostic tests. A comprehensive assessment of these factors should have led to a specific diagnosis with positive identification of the pathologic conditions(s).

Surgical procedures are seldom meant to be curative and would be employed in conjunction with other treatment modalities for maximum functional benefit. Functional benefit should be objectively measured and includes the following: a. Return to work or maintaining work status b. Fewer restrictions at work or performing activities of daily living (ADL). c. Decrease in usage of medications d. Measurable functional gains, such as increased range of motion or documented increase in strength.

Education of the patient should include the proposed goals of the surgery, expected gains, risks or complications, and alternative treatment.

1. Intrathecal Drug Delivery

This mode of therapy delivers small doses of medications directly into the cerebrospinal fluid. Refer to the Chronic Pain guideline for detailed information and recommendations for its use in CRPS patients with chronic pain.

2. Neurostimulation

Neurostimulation is the delivery of low-voltage electrical stimulation to the spinal cord or peripheral nerves to inhibit or block the sensation of pain. Refer to the Chronic Pain guideline for detailed information and recommendations for its use in CRPS patients with chronic pain.

3. Sympathectomy

Description — Destruction of part of the sympathetic nervous system, which is not generally accepted or widely used. Long-term success with this pain relief treatment is poor. This procedure requires prior authorization.

Indications — Single extremity CRPS-I or SMP; distal pain only (should not be done if the proximal extremity is involved). Local anesthetic Stellate Ganglion Block or Lumbar Sympathetic Block consistently gives 90 to 100 percent relief each time a technically good block is performed (with measured rise in temperature). The procedure may be considered for individuals who have limited duration of relief from blocks. Permanent neurological complications are common.

J. MAINTENANCE MANAGEMENT

Successful management of chronic pain conditions results in fewer relapses requiring intense medical care. Failure to address long-term management as part of the overall treatment program may lead to higher costs and greater dependence on the health care system. Management of CRPS and SMP continues after the patient has met the definition of maximum medical improvement (MMI). MMI is declared when a patient's condition has plateaued and the authorized treating physician believes no further medical intervention is likely to result in improved function. When the patient has reached MMI, a physician must describe in detail the maintenance treatment.

Maintenance care in CRPS and SMP requires a close working relationship between the carrier, the providers and the patient. Providers and patients have an obligation to design a cost effective, medically appropriate program that is predictable and allows the carrier to set aside appropriate reserves. Carriers and adjusters have an obligation to assure that medical providers can plan medically appropriate programs. A designated primary physician for maintenance team management is recommended.

Maintenance Care will be based on principles of patient self-management. When developing a maintenance plan of care, the patient, physician and insurer should attempt to meet the following goals: a. Maximal independence will be achieved through the use of home exercise programs or exercise programs requiring special facilities (e.g., pool, health club) and educational programs; b. Modalities will emphasize self management and self-applied treatment; c. Management of pain or injury exacerbations will emphasize initiation of active therapy techniques and may occasionally require anesthetic injection blocks. d. Dependence on treatment provided by practitioners other than the authorized treating physician will be minimized; e. Periodic reassessment of the patient's condition will occur as appropriate. f. Patients will understand that failure to comply with the elements of the self-management program or therapeutic plan of care may affect consideration of other interventions.

Specific Maintenance Interventions and Parameters

1. Home Exercise Programs and Exercise Equipment

Most patients have the ability to participate in a home exercise program after completion of a supervised exercise rehabilitation program. Programs should incorporate an exercise prescription including the continuation of an age-adjusted and diagnosis-specific program for aerobic conditioning, flexibility, stabilization and strength. Some patients may benefit from the purchase or rental of equipment to maintain a home exercise program. Determination for the need of home equipment should be based on medical necessity to maintain MMI, compliance with an independent exercise program, and reasonable cost. Before the purchase or long-term rental of equipment, the patient should be able to demonstrate the proper use and effectiveness of the equipment. Effectiveness of equipment should be evaluated on its ability to improve or maintain functional areas related to activities of daily living or work activity. Occasionally, compliance evaluations may be made through a 4-week membership at a facility offering similar equipment. Home exercise programs are most effective when done 3 to 5 times a week.

2. Exercise Programs Requiring Special Facilities

Some patients may have higher compliance with an independent exercise program at a health club versus participation in a home program. All exercise programs completed through a health club facility should focus on the same parameters of an age-adjusted and diagnosis-specific program for aerobic conditioning, flexibility, stabilization and strength. Selection of health club facilities should be limited to those able to track attendance and utilization, and provide records available for physician and insurer review. Prior to purchasing a membership, a therapist and or exercise specialist who has treated the patient may visit the facility with the patient to assure proper use of the equipment.

(1) Frequency: 2 to 3 times per week.

(2) Optimal Duration: 1 to 3 months.

(3) Maximum Maintenance duration: 3 months. Continuation beyond 3 months should be based on functional benefit and patient compliance. Health club membership should not extend beyond 3 months if attendance drops below 2 times per week on a regular basis.

3. Patient Education Management

Educational classes, sessions, or programs may be necessary to reinforce self-management techniques. This may be performed as formal or informal programs, either group or individual.

(1) Maintenance duration: 2 to 6 educational sessions during one 12-month period. 4. Psychological Management

An ideal maintenance program will emphasize management options implemented in the following order: (a) individual self-management (pain control, relaxation and stress management, etc.), (b) group counseling, (c) individual counseling by a psychologist or psychiatrist, and (d) in-patient treatment. Aggravation of the injury may require more intense psychological treatment to restore the patient to baseline. In those cases, use treatments and timeframe parameters listed in the Biofeedback and Psychological Evaluation or Intervention sections.

(1) Maintenance duration: 6 to 10 visits during one 12-month period.

5. Non-Narcotic Medication Management

In some cases, self-management of pain and injury exacerbations can be handled with medications, such as those listed in the Medication Section. Physicians must follow patients who are on any chronic medication or prescription regimen for efficacy and side effects. Laboratory or other testing may be appropriate to monitor medication effects on organ function.

(1) Maintenance duration: Usually, four medication reviews within a 12-month period. Frequency depends on the medications prescribed. Laboratory and other monitoring as appropriate.

6. Narcotic Medication Management

As compared with other pain syndromes, there may be a role for chronic augmentation of the maintenance program with narcotic medications. In selected cases, scheduled medications may prove to be the most cost effective means of insuring the highest function and quality of life; however, inappropriate selection of these patients may result in a high degree of iatrogenic illness. A patient should have met the criteria in opioids section of these guidelines before beginning maintenance narcotics. Laboratory or other testing may be appropriate to monitor medication effects on organ function. The following management is suggested for maintenance narcotics: a. The medications should be clearly linked to improvement of function, not just pain control. All follow up visits should document the patient's ability to perform routine functions satisfactorily. Examples include the abilities to: perform work tasks, drive safely, pay bills or perform basic math operations, remain alert for 10 hours, or participate in normal family and social activities. If the patient is not maintaining reasonable levels of activity the patient should usually be tapered from the narcotic and tried on a different long acting opioid. b. A low dose narcotic medication regimen should be defined, which may minimally increase or decrease over time. Dosages will need to be adjusted based on side effects of the medication and objective function of the patient. A patient may frequently be maintained on additional non-narcotic medications to control side effects, treat mood disorders, or control neuropathic pain; however, only one long-acting narcotic and one short acting narcotic for rescue use should be prescribed in most cases. c. All patients on chronic narcotic medication dosages need to sign an appropriate narcotic contract with their physician for prescribing the narcotics. d. The patient must understand that continuation of the medication is contingent on their cooperation with the maintenance program. Use of non-prescribed drugs may result in tapering of the medication. The clinician may order random drug testing when deemed appropriate to monitor medication compliance. e. Patients on chronic narcotic medication dosages must receive them through one prescribing physician. (1) Maintenance duration: Up to 12 visits within a 12-month period to review the narcotic plan. Laboratory and other monitoring as appropriate.

7. Therapy Management

Some treatment may be helpful on a continued basis during maintenance care if the therapy maintains objective function and decreases medication use. Aggravation of the injury may require intensive treatment to get the patient back to baseline. In those cases, treatments and timeframe parameters listed in the Active and Passive Therapy sections apply.

(1) Active Therapy, Acupuncture, and Manipulation maintenance duration: 10 visits in a 12-month period.

8. Injection Therapy a. Sympathetic Blocks

These injections are considered appropriate if they maintain or increase function for a minimum of 4 to 8 weeks. Maintenance blocks are usually combined with and enhanced by the appropriate neuropharmacological medication(s) and other care. It is anticipated that the frequency of the maintenance blocks may increase in the cold winter months or with stress.

(1) Maintenance duration: Not to exceed 6 to 8 blocks in a 12-month period for a single extremity and to be separated by no less than 4 week intervals. Increased frequency may need to be considered for multiple extremity involvement or for acute recurrences of pain and symptoms. For treatment of acute exacerbations, consider 2 to 6 blocks with a short time interval between blocks. b. Trigger Point Injections

These injections may occasionally be necessary to maintain function in those with myofascial problems.

(1) Maintenance duration: Not more than 4 injections per session not to exceed 3 to 6 sessions per 12- month period.

9. Purchase or Rental of Durable Medical Equipment

It is recognized that some patients may require ongoing use of self-directed modalities for the purpose of maintaining function and or analgesic effect. Purchase or rental of modality based equipment should be done only if the assessment by the physician and or therapist has determined the effectiveness, compliance and improved or maintained function by its application. It is generally felt that large expense purchases such as spas, whirlpools and special mattresses are not necessary to maintain function beyond the areas listed above.

(1) Maintenance duration: Not to exceed 3 months for rental equipment. Purchase if effective.

RULE XVII, EXHIBIT E Cervical Spine Injury Medical Treatment Guidelines December 1, 2001

(Previously Adopted March 15, 1998) Presented By State of Colorado Department of Labor and Employment Division of Workers' Compensation

TABLE OF CONTENTS

Cervical Spine Injury Medical Treatment Guideline SECTION DESCRIPTION

A. INTRODUCTION B. GENERAL GUIDELINE PRINCIPLES 1. APPLICATION OF GUIDELINES 2. EDUCATION 3. TREATMENT PARAMATER DURATION 4. ACTIVE INTERVENTIONS 5. ACTIVE THERAPEUTIC EXERCISE PROGRAM 6. POSITIVE PATIENT RESPONSE 7. RE-EVALUATION TREATMENT EVERY 3 TO 4 WEEKS 8. SURGICAL INTER VENTIONS 9. SIX-MONTH TIME FRAME 10. RETURN-TO-WORK 11. DELAYED RECOVERY 12. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE 13. CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI) C. INITIAL DIAGNOSTIC PROCEDURES 1. HISTORY-TAKING AND PHYSICAL EXAMINATION (HX & PE) a. History of Present Injury b. Past History c. Physical Examination d. Spinal Cord Evaluation e. Soft Tissue Injury Evaluation 2. RADIOGRAPHIC IMAGING 3. LABORATORY TESTING D. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES 1. IMAGING STUDIES a. Magnetic Resonance Imaging (MRI) b. Computerized Axial Tomography (CT) c. Myelography d. CT Myelogram e. Lineal Tomography f. Bone Scan (Radioisotope Bone Scanning) g. Other Radionuclide Scanning 2. OTHER TESTS a. Personality/Psychological /Psychosocial/Evaluation b. Electrodiagnostic Testing c. Injections—Diagnostic d. Discography e. Thermography 3. SPECIAL TESTS a. Computer-Enhanced Evaluations b. Functional Capacity Evaluation (FCE) c. Jobsite Evaluation d. Vocational Assessment e. Work Tolerance Screening E. THERAPEUTIC PROCEDURES—NON-OPERATIVE 1. ACUPUNCTURE a. Acupuncture b. Acupuncture with Electrical Stimulation c. Other Acupuncture Modalities 2. BIOFEEDBACK 3. INJECTIONS—THERAPEUTIC a. Therapeutic Spinal Injections b. Facet Rhizotomy (Radio Frequency Medial Branch Neurotomy) c. Occipital Nerve Block a. Trigger Point Injections e. Prolotherapy 4. MEDICATIONS a. Acetaminophen b. Minor Tranquilizer/Muscle Relaxants c. Narcotics d. Nonsteroidal Anti- Inflammatory Drugs (NSAIDs) e. Oral Steroids f. Psychotropic/Anti- anxiety/Hypnotic Agents g. Tramadol h. Topical Drug Delivery 5. OCCUPATIONAL REHABILITATION PROGRAMS a. Non-Interdisciplinary b. Interdisciplinary 6. ORTHOTICS a. Cervical Collars b. Poster Appliances c. Cervicothoracic Orthosis d. Halo Devices e. Other Orthosis Devices and Equipment 7. PATIENT EDUCATION 8. PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCI AL INTERVENTION 9. RESTRICTION OF ACTIVITIES 10. RETURN-TO-WORK a. Establishment of a Return-To-Work Status b. Establishment of Activity Level Restrictions c. Compliance with Activity Restrictions 11. THERAPY—ACTIVE a. Activities of Daily Living (ADL) b. Functional Activities c. Functional Electrical Stimulation d. Cervical Lumbar Stabilization e. Neuromuscular Re- Education f. Therapeutic Exercise 12. THERAPY—PASSIVE a. Electrical Stimulation (Unattended) b. Infrared Therapy c. Iontophoresis d. Manipulation e. Massage—Manual or Mechanical f. Mobilization (Joint) g. Mobilization (Soft Tissue) h. Superficial Heat and Cold Therapy i. Short-Wave Diathermy j. Traction—Manual k. Traction—Mechanical l. Transcutaneous Electrical Nerve Stimulation (TENS) m. Ultrasound 13. VOCATIONAL REHABILITATION F. THERAPEUTIC PROCEDURES—OPERATIVE 1. ACUTE FRACTURES & DISLOCATIONS a. Halo Immobilization: b. Anterior or Posterior Decompression with Fusion 2. DISC HERNIATION AND OTHER CERVICAL CONDITIONS a. Cervical Discectomy with or without Fusion b. Cervical Corpectomy c. Cervical Laminectomy with or without Foraminotomy or Fusion d. Cervical Laminoplasty

A. INTRODUCTION

To properly utilize this document, the reader should not skip nor overlook any sections.

B. GENERAL GUIDELINE PRINCIPLES

1. Application of Guidelines

2. Education

Education of the patient and family, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of cervical spine injuries and disability. Currently, practitioners often think of education last, after medications, manual therapy and surgery. Practitioners must develop and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers and the community as a whole. An education-based paradigm should always start with inexpensive communication providing reassuring information to the patient. More in-depth education currently exists within a treatment regime employing functional restorative and innovative programs of prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of facilitating self-management of symptoms and prevention.

3. Treatment Paramater Duration

4. Active Interventions

5. Active Therapeutic Exercise Program

Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and education. This includes functional application in vocational or community settings.

6. Positive Patient Response

7. Re-Evaluation Treatment Every 3 to 4 Weeks

8. Surgical Interventions

9. Six-Month Time Frame

10. Return-to-Work

Return-to-work is therapeutic, assuming the work is not likely to aggravate the basic problem or increase long-term pain. The practitioner must provide specific written physical limitations and the patient should never be released to “sedentary” or “light duty.” The following physical limitations should be considered and modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, bending at the waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors. Even if there is residual chronic pain, return-to-work is not necessarily contraindicated.

11. Delayed Recovery

12. Guideline Recommendations and Inclusion of Medical Evidence

“Some” means the recommendation considered at least one adequate scientific study, which reported that a treatment was effective.

13. Care Beyond Maximum Medical Improvement (MMI) MMI should be declared when a patient's condition has plateaued to the point where the authorized treating physician no longer believes further medical intervention is likely to result in improved function. However, some patients may require treatment after MMI has been declared in order to maintain their functional state. The recommendations in this guideline are for pre-MMI care and are not intended to limit post-MMI treatment.

The remainder of this document should be interpreted within the parameters of these guideline principles that may lead to more optimal medical and functional outcomes for injured workers.

C. INITIAL DIAGNOSTIC PROCEDURES

The Division recommends the following diagnostic procedures be considered, at least initially, the responsibility of the workers' cornpensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Standard procedures, that should be utilized when initially diagnosing a work- reiated lower extremity complaint, are listed below.

1. History-Taking and Physical Examination (Hx & PE)

History taking and physical examinations are generally accepted, well established and widely used procedures that establish the foundation/basis for and dictate subsequent stages of diagnostic and therapeutic procedures. When findings of clinical evaluations and those of other diagnostic procedures are not complementing each other, the objective clinical findings should have preference. The medical records should reasonably document the following. a. History of Present Injury

1) Mechanism of injury. This includes details of symptom onset and progression;

2) Relationship to work. This includes a statement of the probability that the illness or injury is work- related;

3) Location of pain, nature of symptoms, and alleviating/exacerbating factors, especially if raising the arm over the head alleviates radicular-type symptoms;

4) Presence of upper and/or lower extremity numbness, weakness, or paresthesias, especially if precipitated by coughing or sneezing;

5) Prior occupational and non-occupational injuries to the same area including specific prior treatment, chronic or recurrent symptoms, and any functional limitations. Specific history regarding prior motor vehicles accidents may be helpful; and

6) Ability to perform job duties and activities of daily living. b. Past History

1) Past medical history includes neoplasm, arthritis, and diabetes;

2) Review of systems includes symptoms of rheumatologic, neurologic, endocrine, neoplastic, infectious, and other systemic diseases;

3) Smoking history, and

4) Vocational and recreational pursuits. c. Physical Examination This should include accepted tests and exam techniques applicable to the area being examined, including:

1) Visual inspection, including posture;

2) Cervical range of motion, quality of motion, and presence of muscle spasm. Motion evaluation of specific joints may be indicated. Range of motion should not be checked in acute trauma cases until fracture and instability have been ruled out on clinical examination, with or without radiographic evaluation;

3) Palpation of spinous processes, facets, and muscles noting myofascial tightness, tenderness, and trigger points;

4) Motor and sensory examination of the upper muscle groups with specific nerve root focus, as well as sensation to light touch, pin prick, temperature, position and vibration. More than 2 cm difference in the circumferential measurements of the two upper extremities may indicate chronic muscle wasting; and

5) Deep tendon reflexes. Asymmetry may indicate pathology. Inverted reflexes (e.g. arm flexion or triceps tap) may indicate nerve root or spinal cord pathology at the tested level. Pathologic reflexes include wrist, clonus, grasp reflex, and Hoffman's sign. d. Spinal Cord Evaluation

In cases where the mechanism of injury, history or clinical presentation suggests a possible severe injury, additional evaluation is indicated. A full neurological examination for possible spinal cord injury may include:

1) Sharp and light touch, deep pressure, temperature and proprioceptive sensory function;

2) Strength testing;

3) Anal sphincter tone and or perianal sensation;

4) Presence of pathological reflexes of the upper and lower extremities; or

5) Presence of an Incomplete Spinal Cord Injury Syndrome—

(a) Anterior Cord Syndrome is characterized by the loss of motor function and perception of pain and temperature below the level of the lesion with preservation of touch, vibration, and proprioception. This is typically seen after a significant compressive or flexion injury. Emergent CT or MRI is necessary to look for a possible reversible compressive lesion requiring immediate surgical intervention. The prognosis for recovery is the worst of the incomplete syndromes.

(b) Brown-Sequard Syndrome is characterized by ipsilateral motor weakness and proprioceptive disturbance with contralateral alteration in pain and temperature perception below the level of the lesion. This is usually seen in cases of penetrating trauma or lateral mass fracture. Surgery is not specifically required, although debridement of the open wound may be.

(c) Central Cord Syndrome is characterized by sensory and motor disturbance of all limbs, often upper extremity more than lower, and loss of bowel and bladder function with preservation of perianal sensation. This is typically seen in elderly patients with a rigid spine following hyperextension injuries. Surgery is not usually required. (d) Posterior Cord Syndrome, a rare condition, is characterized by loss of sensation below the level of the injury, but intact motor function. e. Soft Tissue Injury Evaluation

Soft tissue injuries are traumatic injuries to the muscles, ligaments, tendons, and/or connective tissue. The most common mechanism is sudden hyperextension and/or hyperflexion of the neck. Acceleration/deceleration on the lateral plane may also result in one of these syndromes. A true cervical strain is not associated with focal neurological symptoms or signs and pathophysiology of these injuries is not well understood. Soft tissue injuries may include cervical strain, myofascial syndromes, somatic dysfunction, and fractures. The Quebec Classification is used to categorize soft tissue and more severe cervical injuries:

1) Grade I — Neck complaints of pain, stiffness, or tenderness only, without physical signs. Lesion not serious enough to cause muscle spasm. Includes whiplash injury, minor cervical sprains or strains.

2) Grade II — Neck complaints with musculoskeletal signs, such as limited range of motion. Includes muscle spasm related to soft tissue injury, whiplash, cervical sprain, and cervicalgia with headaches, sprained cervical facet joints and ligaments.

3) Grade III — Neck complaints, such as limited range of motion, combined with neurologic signs. Includes whiplash, cervicobrachialgia, herniated disc, cervicalgia with headaches.

4) Grade IV — Neck complaints with fracture or dislocation.

2. Radiographic Imaging

Radiographic imaging of the cervical spine is generally accepted, well established and widely used diagnostic procedure. Basic views are the anterioposterior (AP), lateral, right and left obliques, and odontioid. Lateral flexion and extension views are done to evaluate instability but may have a limited role in the acute setting. The mechanism of injury and specific indications for the radiograph should be listed on the request form to aid the radiologist and x-ray technician. Suggested indications include:

1) History of significant trauma, especially blunt trauma, high impact motor vehicle accident, or fall from height where fracture, dislocation, instability, or neurologic deficit is suspected - Quebec Classification Grade III and IV. Alert, non-intoxicated patients who have isolated cervical complaints without palpable midline cervical tenderness or neurologic findings may not require radiographic imaging.

2) Age over 55 years.

3) Unexplained or persistent cervical pain for at least 6 weeks or that is worse with rest.

4) Localized pain, fever, constitutional symptoms, suspected tumor, or suspected systemic illness such as a rheumatic/rheumatoid disorder or endocrinopathy.

3. Laboratory Testing

2) Erythrocyte sedimentation rate, rheumatoid factor, ANA, HLA, and C-reactive protein can be used to detect evidence of a rheumatologic, infection, or connective tissue disorder;

3) Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease; and

4) Liver and kidney function may be performed for prolonged anti-inflammatory use or other medications requiring monitoring.

D. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES

Magnetic resonance imaging (MRI), myelography, or CT scanning following myelography may provide useful information for many spinal disorders. When a diagnostic procedure, in conjunction with clinical information, provides sufficient information to establish an accurate diagnosis, the second diagnostic procedure will become a redundant procedure. At the same time, a subsequent diagnostic procedure can be a complementary diagnostic procedure if the first or preceding procedures, in conjunction with clinical information, cannot provide an accurate diagnosis. Usually, preference of a procedure over others depends upon availability, a patient's tolerance and/or the treating practitioner's familiarity with the procedure.

1. Imaging Studies

Imaging studies are generally accepted, well established and widely used diagnostic procedures. In general, MRI is the preferred procedure for imaging of cervical nerve root compression or myelopathy. Imaging usually is not appropriate until conservative therapy has been tried and failed. Six-to-eight weeks of treatment are usually an adequate period of time before an imaging procedure is in order, but the clinician should use judgment in this regard. When the findings of the diagnostic imaging and testing procedures are not consistent with the clinical examination, the clinical findings should have preference. The studies below are listed in frequency of use, not importance: a. Magnetic Resonance Imaging (MRI)

MRI is the imaging study of choice for most abnormalities of the cervical spine. MRI is useful in suspected nerve root compression, in myelopathy to evaluate the spinal cord and/or masses, infections such as epidural abscesses or disc space infection, bone marrow involvement by metastatic disease, and/or suspected disc herniation or cord contusion following severe neck injury. MRI should be performed immediately if there is a question of infection or metastatic disease with cord compression. It is contraindicated in patients with certain implanted devices.

CT provides excellent visualization of bone and is used to further evaluate bony masses and suspected fractures not clearly identified on radiographic evaluation. It may sometimes be done as a complement to MRI scanning to better delineate bony osteophyte formation in the neural foramen. CT is usually utilized for suspected cervical spine fracture in a patient with negative plain films, or to further delineate a cervical fracture. CT scanning is also quite useful for congenital anomalies at the skull base and at the C1-2 levels. Plain CT scanning is poor for the C6-7 or C7-T1 levels because of shoulder artifact. Instrument- scatter reduction software provides better resolution when metallic artifact is of concern. c. Myelography

Lineal tomography is infrequently used, yet may be helpful in the evaluation of bone surfaces, bony fusion, or pseudoarthrosis. f. Bone Scan (Radioisotope Bone Scanning)

Bone scanning is generally accepted, well established and widely used. Bone scanning is more sensitive but less specific than MRI. 99MTechnecium diphosphonate uptake reflects osteoblastic activity and may be useful in metastatic/primary bone tumors, stress fractures, osteomyelitis, and inflammatory lesions, but cannot distinguish between these entities. In the cervical spine, the usual indication is for the evaluation of neoplastic conitions, but can also be used for occult fracture or infection. g. Other Radionuclide Scanning

2. Other Tests

The following studies are listed by frequency of use, not importance: a. Personality/Psychological/Psychosocial/Evaluation

Personality/psychological/psychosocial evaluations are generally accepted and well-established diagnostic procedures with selective use in the acute cervical spine injury population, but have more widespread use in sub-acute and chronic cervical spine populations.

1) Employment history;

2) Interpersonal relationships — both social and work;

3) Leisure activities;

4) Current perception of the medical system;

5) Results of current treatment;

6) Perceived locus of control; and

7) Childhood history, including abuse and family history of disability.

Electrodiagnostic tests include, but are not limited to, Electromyography (EMG), Nerve Conduction Studies (NCS) and Somatosensory Evoked Potentials (SSEP). These are generally accepted, well- established and widely used diagnostic procedures. The SSEP study, although generally accepted, has limited use. Electrodiagnostic studies may be useful for patients with suspected neural involvement whose symptoms are persistent or unresponsive to initial conservative treatments. They are used to differentiate peripheral neural deficits from radicular and spinal cord neural deficits and to rule out concomitant myopathy.

In general, these diagnostic procedures are complementary to imaging procedures such as CT, MRI, and/or myelography or diagnostic injection procedures. Electrodiagnostic studies may provide useful, correlative neuropathophysiological information that would be otherwise unobtainable from standard radiologic studies. c. Injections — Diagnostic 1) Description — Diagnostic cervical injections are generally accepted, well-established procedures. These injections may be useful for localizing the source of pain, and may have added therapeutic value when combined with injection of therapeutic medication(s). Each diagnostic injection has inherent risk and risk versus benefit should always be evaluated when considering injection therapy. Since these procedures are invasive, less invasive or non-invasive procedures should be considered first. Selection of patients, choice of procedure, and localization of the level for injection should be determined by clinical information indicating strong suspicion for pathologic condition(s) and the source of pain symptoms.

The interpretation of the test result is primarily based upon pain response; the diagnostic significance of the test result should be evaluated in conjunction with clinical information and the results of other diagnostic procedures. Injections with local anesthetics of differing duration are required to confirm a diagnosis. In some cases, injections at multiple levels may be required to accurately diagnose cervical pain. Refer to “Injections – Therapeutic” for information on specific injections.

2) Special Requirements for Diagnostic Injections — Since fluoroscopic, arthrographic and/or CT guidance during procedures is required to document technique and needle placement; an experienced physician should perform the procedure. The subspecialty disciplines of the physicians may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry. The practitioner should have experience in ongoing injection training workshops provided by organizations such as the International Spinal Injection Society (ISIS) and be knowledgeable in radiation safety. In addition, practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments of Radiology, as applicable.

3) Complications — General complications of diagnostic injections may include transient neurapraxia, nerve injury, infection, headache, vasovagal effects, as well as epidural hematoma, permanent neurologic damage, dural perforation and CSF leakage, and spinal meningeal abscess. Severe complications are remote but can include spinal cord damage, quadriplegia, and/or death.

(a) Medial Branch Blocks are primarily diagnostic, used to confirm the diagnosis of cervical facet pain. When used for diagnosis, two injections at different times with different duration of local anesthetic are recommended.

(b) Intra-Articular Facet injections are principally diagnostic yet some patients may obtain therapeutic response. If the patient demonstrates definite short-term but not long-term response, confirmatory medial branch blocks and possible medial branch neurotomy should be considered.

(c) Atlanto-Axial and Atlanto-Occipital injections are for diagnosis and treatment but do not lend themselves to denervation techniques owing to variable neuroanatomy. Injection of this articulation is complicated by the proximity of the vertebral artery. The vertebral artery may be tortuous at the level of the C0-C1 joint. Inadvertent injection of the vertebral artery may cause respiratory arrest, seizure, stroke, or permanent neurological sequelae. Only practitioners skilled in these injections should perform them. d. Discography

1) Description — Discography is a generally accepted, well-established invasive diagnostic procedure to identify a discogenic source of pain for patients who are surgical candidates. Discography should only be performed by physicians who are experienced and have been proctored in the technique.

2) Indications — Discography may be indicated when a patient has a history of unremitting cervical pain of greater than three months duration, with or without arm pain, which has been unresponsive to all conservative interventions. A patient who does not desire surgical intervention is not a candidate for an invasive nontherapeutic intervention, such as provocative discography. Discography may prove useful for the evaluation of the pre-surgical spine, such as pseudoarthrosis, discogenic pain at levels above or below a prior spinal fusion, annular tear, or internal disc disruption. Discography is not useful in previously operated discs. In addition, discography may prove useful in evaluation of the number of cervical spine levels that might require fusion. It has also been utilized to differentiate organic from psychogenic factors. CT- Discography provides further detailed information about morphological abnormalities of the disc and possible lateral disc herniations.

3) Preconditions for provocative discography include:

(a) A patient with unremitting neck and/or arm pain greater than 3 months duration in whom conservative treatment has been unsuccessful and in whom the specific diagnosis of the pain generator has not been made apparent on the basis of other noninvasive imaging studies (e.g., MRI, CT, plain films, etc.) and in whom a psychosocial evaluation has been considered.

4) Complications — Include, but are not limited to, discitis, nerve damage, retropharyngeal abscess, chemical meningitis, pain exacerbation and anaphylaxis may occur with discography. Therefore, prior to consideration of discography, the patient should undergo other diagnostic modalities in an effort to define the etiology of the patient's complaint including psychological screening, myelography, CT and MRI.

6) Special Considerations:

(a) Discography should not be done by the treating surgeon and the procedure should be carried out by an experienced individual who has received specialized training in the technique of provocative discography.

(b) Discography should be performed in a blinded format that avoids leading the patient with anticipated responses. The procedure should always include one or more disc levels thought to be normal or nonpainful in order to serve as an internal control. The patient should not know what level is being injected in order to avoid spurious results. Adjacent discs may be identified as pain generators in more than half of cases in which discogenic pain is identified at one level. Because surgery is likely to fail in multi-level discogenic pain, injection of as many levels as feasible can prevent many operative failures.

(d) Judicious use of sedation during the procedure is acceptable and represents the most common practice nationally at the current time and is recommended by most experts in the field.

(e) CT or MRI must have established cervical spinal dimensions and ruled out spinal stenosis.

(f) Intradiscal injection of local anesthetic should be carried out after the provocative portion of the examination and the patient's response.

(g) It is recommended that a post-discogram CT be considered as it frequently provides additional useful information about disc morphology or other pathology.

7) Reporting of Discography — In addition to a narrative report, the discography report should contain a standardized classification of (a) disc morphology and (b) the pain response. Both results should be clearly separated in the report from the narrative portion. Asymptomatic annular tears are common and the concordant pain response is an essential finding for a positive discogram. Alternative reporting techniques using pressure monitors are being investigated and may prove useful in identifying patients with discogenic pain.

Caution should be used when interpreting results from discography. In one study of patients without lumbar pathology, 10 percent of pain-free patients experienced pain with discography and 83 percent of patients with somatization disorder experienced pain with lumbar discography. No studies have yet been published which measure the frequency of false-positive discography of the cervical spine.

(a) Reporting disc morphology as visualized by the post-injection CT scan (when available) should follow the Modified Dallas Discogram Scale where:

Grade 0 = Normal Nucleus

Grade 1 = Annular tear confined to inner one-third of annulus fibrosis.

Grade 2 = Annular tear extending to the middle third of the annulus fibrosis.

Grade 3 = Annular tear extending to the outer one-third of the annulus fibrosis.

Grade 4 = A grade 3 tear plus dissection within the outer annulus to involve more than 30 degrees of the disc circumference.

Grade 5 = Full thickness tear with extra-annular leakage of contrast, either focal or diffuse.

(b) Reporting of pain response should be according to the modified Aprill Scheme. In this scheme, codes are assigned a response during the initial injection (“P” provocative response) and the response to an injection of the local anesthetic (“R” response) where:

P0 = No Pain P1 = Procedural pain, or pain that is nonconcordant with the patient's familiar pain

P2 = Concordant pain

R0 = No pain relief with injection of local anesthetic

R1 = Partial relief

R2 = Complete relief

N = Non-diagnostic, non-physiologic injection. The final category of “N” is suggested when the discographer concludes that the provocative portion of the injection is nondiagnostic. For example, a patient with a morphologically normal disc who responds when typical pain is reproduced is considered to have a non-diagnostic or nonphysiologic response. Other circumstances may occur that cause the discographer to conclude that the provocative portion of the injection is invalid. The category “N” should be used for these situations.

(1) Time to produce effect: Immediate

(2) Frequency: One time only

(3) Optimal duration: One time

(4) Maximum duration: Repeat discography is rarely indicated. e. Thermography

Thermography is an accepted and established procedure, but has limited use as a diagnostic test for cervical pain. It may be used to diagnose regional pain disorders and in these cases, refer to Division Rule XVII, Exhibit D, Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome Medical Treatment Guidelines.

3. Special Tests

(1) Frequency: One time for evaluation. Can monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations. b. Functional Capacity Evaluation (FCE)

(1) Frequency: One time with additional visits as needed for follow-up per job site. d. Vocational Assessment

(1) Frequency: One time with additional visits as needed for follow-up e. Work Tolerance Screening

(1) Frequency: One time for evaluation. May monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations.

E. THERAPEUTIC PROCEDURES — NON-OPERATIVE

Before initiation of any therapeutic procedure, the authorized treating provider, employer and insurer must consider these important issues in the care of the injured worker.

The following procedures are listed in alphabetical order.

1. Acupuncture

Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain.

(1) Time to produce effect: 3 to 6 treatments

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 1 to 2 months

(4) Maximum duration: 14 treatments b. Acupuncture with Electrical Stimulation

Acupuncture with electrical stimulation is the use of electrical current (micro-amperage or milli-amperage) on the needles at the acupuncture site. It is used to increase effectiveness of the needles by continuous stimulation of the acupoint. Physiological effects (depending on location and settings) can include endorphin release for pain relief, reduction of inflammation, increased blood circulation, analgesia through interruption of pain stimulus, and muscle relaxation. It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.

(1) Time to produce effect: 3 to 6 treatments

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 1 to 2 months

(4) Maximum duration: 14 treatments c. Other Acupuncture Modalities

(1) Time to produce effect: 3 to 6 treatments

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 1 to 2 months

(4) Maximum duration: 14 treatments

2. Biofeedback

Indications for biofeedback include individuals who are suffering from musculoskeletal injury where muscle dysfunction or other physiological indicators of excessive or prolonged stress response affects and/or delays recovery. Other applications include training to improve self-management of emotional stress/pain responses such as anxiety, depression, anger, sleep disturbance, and other central and autonomic nervous system imbalances. Biofeedback is often utilized along with other treatment modalities. (1) Time to produce effect: 3 to 4 sessions

(2) Frequency: 1 to 2 times per week

(3) Optimum duration: 5 to 6 sessions

(4) Maximum duration: 10 to 12 sessions. Treatment beyond 12 sessions must be documented with respect to need, expectation, and ability to facilitate positive symptomatic or functional gains.

3. Injections — Therapeutic a. Therapeutic Spinal Injections

Description — Therapeutic spinal injections are generally accepted, well-established procedures. They may be used after initial conservative treatment, such as physical and occupational therapy, medication, manual therapy, exercise, acupuncture etc., has been undertaken. Therapeutic injections should be used only after pathology has been demonstrated. Injections are invasive procedures that can cause catastrophic complications thus clinical indications and contraindications should be closely adhered to. A concomitant therapeutic exercise program should be considered or may be appropriate for patients receiving therapeutic spinal injections.

Special Considerations — For all cervical injections (excluding trigger point and occipital nerve blocks) fluoroscopic, arthrographic and/or CT guidance during procedures is required to document technique and needle placement, and should be performed by a physician experienced in the procedure. The subspecialty disciplines of the physicians may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry. The practitioner should participation in ongoing injection training workshops such as those sponsored by International Society for Injection Studies (ISIS) and be knowledgeable in radiation safety. In addition, practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments of Radiology, as applicable.

Complications — General complications of spinal injections may include (a) transient neurapraxia, local pain, nerve injury, infection, headache, vasovagal effects; (b) epidural hematoma, permanent neurologic damage, dural perforation and CSF leakage, spinal meningeal abscess; and or (c) suppression of the hypothalamic pituitary adrenal axis, which may be steroid dose dependent. Severe complications are remote but can include spinal cord damage, quadriplegia, and/or death.

Contraindications — Absolute contraindications of therapeutic injections include: (a) bacterial infection - systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d) possible pregnancy. Relative contraindications of diagnostic injections may include: (a) allergy to contrast, (b) poorly controlled Diabetes Mellitus or hypertension, (c) ASA/antiplatelet therapy (drug may be held for 3 days prior to injection), (d) shellfish allergy, if contrast to be used.

1) Cervical Epidural Steroid Injection (ESI)

(a) Description — Cervical ESIs are injections of corticosteroid into the epidural space. The purpose of ESI is to reduce pain and inflammation, restoring range of motion and thereby facilitating progress in more active treatment programs.

(b) Needle placernent — Radiographic guidance with epidurogram is indicated to document placement and ensure maximal efficacy. Spinal imaging is required for all epidural steroid injections. Contrast epidurograms allow one to verify the flow of medication into the epidural space.

(c) Indications — Cervical ESIs are useful in patients with symptoms of cervical radicular pain syndromes. They have less defined usefulness in non-radicular pain. There is some evidence that epidural steroid injections are effective for patients with radicular pain or radiculopathy (sensory or motor loss in a specific dermatome or myotome). Although there is no evidence regarding the effectiveness of ESI for non-radicular pain, it is a generally accepted intervention. MRI or CT scans are required before thoracic and cervical ESIs to assure adequate epidural space.

(1) Time to Produce Effect: Local anesthetic, approximately 30 minutes; corticosteroid, 48 to 72 hours for 80% of patients and 2 weeks for 20%.

(3) Optimal Duration: Usually 1 to 3 sessions of injection(s), depending upon each patient's response and functional gain.

(4) Maximum Duration: Up to 3 to 4 sessions of injections may be done as per the patient's response to pain and function. Patients should be reassessed after each injection session.

2) Zygoapophyseal (Facet) Injection

(a) Description — Intra-articular or pericapsular injection of local anesthetic and corticosteroid. There is conflicting evidence to support long-term therapeutic effect using facet injections.

(b) Indications — Facet injections may be considered in those patients whose history and examination are suggestive of a facet pain generator. The therapeutic value of facet injections provides short-term pain relief for patients to progress through a functionally directed rehabilitation program. Facet injections determine level(s) of facet involvement and the degree of pain coming from the posterior elements. If the patient demonstrates definite short-term but not long-term response confirmatory medial branch blocks and possible medial branch neurotomy should be considered.

(1) Time to Produce Effect: Approximately 30 minutes for local anesthetic; 48 to 72 hours for corticosteroid.

(2) Frequency: 1 to 3 sessions for each joint.

(3) Optimal Duration: 1 to 3 sessions of injections for each joint.

(4) Maximum Duration: 3 intra-synovial or medial branch nerve injections per joint can be done for facilitating a therapeutic exercise program. b. Facet Rhizotomy (Radio Frequency Medial Branch Neurotomy)

1) Description — A procedure designed to denervate the facet joint by ablating the periarticular facet nerve branches. Percutaneous radio-frequency is the method generally used. There is good evidence to support this procedure in the cervical spine but benefits beyond one year are not yet established.

2) Indications — Pain of well-documented facet origin, unresponsive to active and/or passive therapy, manual therapy, and psychosocial evaluation. This procedure is commonly used to provide a window of pain relief allowing for participation in active therapy. All patients must have a successful response to diagnostic medial nerve branch blocks. A successful response is considered to be a 90 percent or greater relief of pain for the length of time appropriate to the local anesthetic used (i.e., bupivacaine greater than lidocaine). Radio-frequency rhizotomy is the procedure of choice over alcohol, phenol, or cryoablation. Precise positioning of the probe under fluoroscopic guidance is recommended, since the maximum effective radius of the device is 2 mm.

3) Complications — Bleeding, infection, or neural injury. The clinician must be aware of the risk of developing a deafferentation centralized pain syndrome as a complication of this and other neuroablative procedures.

4) Post-Procedure Therapy — Active active and/or passive therapy. Implementation of a gentle reconditioning program within the first post-procedure week is recommended, barring complications. Instruction and participation in a long-term home-based program of ROM, strengthening, endurance and stability exercises should be done 3 to 4 weeks post-procedure. c. Occipital Nerve Block

1) Description — Occipital nerve blocks are used both diagnostically and therapeutically in the treatment of occipital neuralgia. Target is the greater occipital nerve.

2) Indications — Diagnosis and treatment of occipital neuralgia/cephalgia. Peripheral block of the grater occipital nerve may be appropriate as initial treatment. It may be indicated in patients unresponsive to peripheral nerve block or in need of additional diagnostic information may undergo this injection.

3) Complications — Bleeding, infection, neural injury. Post procedural ataxia is common and usually lasts 30 minutes post procedure. Because the occipital artery runs with the occipital nerve, inadvertent intravascular injection is a risk of this procedure and may lead to systemic toxicity and/or seizures.

(1) Time to Produce Effect: Approximately 30 minutes for local anesthetic; 48 to 72 hours for corticosteroid.

(2) Optimal Duration: 1 to 3 sessions for each joint.

(3) Maximum Duration: Continue up to 3 injections if progressive symptomatic and functional improvement can be documented. a. Trigger Point Injections

1) Description — Trigger point injection consists of dry needling or injection of local anesthetic with or without corticosteroid into highly localized, extremely sensitive bands of skeletal muscle fibers that produce local and referred pain when activated. Medication is injected in a four-quadrant manner in the area of maximum tenderness. Injection efficacy can be enhanced if injections are immediately followed by myofascial therapeutic interventions, such as vapo-coolant spray and stretch, ischemic pressure massage (myotherapy), specific soft tissue mobilization and physical modalities. The effectiveness of trigger point injection is uncertain, in part due to the difficulty of demonstrating advantages of active medication over injection of saline. Needling alone may be responsible for some of the therapeutic response.

2) Indications — Trigger point injections may be used to relieve myofascial pain and facilitate active therapy and stretching of the affected areas. They are to be used as an adjunctive treatment in combination with other treatment modalities such as functional restoration programs. Trigger point injections should be utilized primarily for the purpose of facilitating functional progress. Patients should continue in an aggressive aerobic and stretching therapeutic exercise program as tolerated throughout the time period they are undergoing intensive myofascial interventions. Myofascial pain is often associated with other underlying structural problems and any abnormalities need to be ruled out prior to injection.

3) Complications — Potential but rare complications of trigger point injections include infection, pneumothorax, anaphylaxis, penetration of viscera, neurapraxia and neuropathy. If corticosteroids are injected in addition to local anesthetic, there is a risk of local myopathy developing. Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be immediately repositioned.

(1) Time to Produce Effect: Local anesthetic 30 minutes; no anesthesia 24 to 48 hours.

(2) Frequency: Weekly, suggest no more than 4 injection sites per session per week to avoid significant post-injection soreness.

(3) Optimal Duration: 4 Weeks.

(4) Maximum Duration: 8 weeks. Occasional patients may require 2 to 4 repetitions of trigger point injection series over a 1 to 2 year period. e. Prolotherapy

Prolotherapy, also known as sclerotherapy, consists of a series of injections of hypertonic dextrose, with or without glycerine and phenol, into the ligamentous structures of the neck. There is no evidence that prolotherapy is effective in cervical pain. The injections are invasive, may be painful to the patient, are not generally accepted or widely used. Therefore, the use of prolotherapy for cervical pain is not recommended.

4. Medications

Medication use in the treatment of cervical injuries is appropriate for controlling acute and chronic pain and inflammation. Use of medications will vary widely due to the spectrum of injuries from simple strains to post-surgical healing. All drugs should be used according to patient needs. A thorough medication history, including use of alternative and over the counter medications, should be performed at the time of the initial visit and updated periodically.

Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are useful in the treatment of inflammation. These same medications can be used for pain control.

Narcotic medications should be prescribed with strict time, quantity and duration guidelines, and with definitive cessation parameters. Pain is subjective in nature and should be evaluated using a scale to rate effectiveness of the narcotic prescribed. Tramadol, a centrally acting non-narcotic, can be useful to provide pain relief. Other medications, including antidepressants, may be useful in selected patients with chronic pain. The following are listed in alphabetical order: a. Acetaminophen

(1) Optimal duration: 7 to 10 days

(2) Maximum duration: Chronic use as indicated on a case-by-case basis b. Minor Tranquilizer/Muscle Relaxants

Minor tranquilizer/muscle relaxants are appropriate for muscle spasm, mild pain and sleep disorders.

(1) Optimal duration: 1 week

(2) Maximum duration: 4 weeks c. Narcotics

Narcotics should be primarily reserved for the treatment of post-surgical or severe cervical pain. There are circumstances where prolonged use of narcotics is justified based upon specific diagnosis, and in these cases, it should be documented and justified. Adverse effects include respiratory depression, the development of physical and psychological dependence, and impaired alertness.

(1) Optimal duration: 3 to 7 days

(2) Maximum duration: 2 weeks. Use beyond two weeks is acceptable in appropriate cases. d. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

1) Non-Selective Nonsteroidal Anti-Inflammatory Drugs

Due to the cross-reactivity between aspirin and NSAIDs, NSAIDs should not be used in aspirin- sensitive patients, and should be used with caution in all asthma patients. NSAIDs are associated with abnormal renal function, including renal failure, as well as abnormal liver function. Certain NSAIDs may have interactions with various other medications. Individuals may have adverse events not listed above.

(1) Optimal duration: 1 week

(2) Maximum duration: 1 year

2) Selective Cyclo-oxygenase-2 (COX-2) Inhibitors

(1) Optimal duration: 7 to 10 days

(2) Maximum duration: Chronic use is appropriate in individual cases. e. Oral Steroids

Oral steroids have limited use but are accepted in cases requiring potent anti-inflammatory drug effect and should not be routinely recommended except in cases of suspected spinal cord compression. There is strong evidence to support the use of intravenous steroids in blunt spinal cord injury. The risks of permanent neurological damage from acute spinal cord compression generally outweigh the risks of pharmacologic side effects of steroids in an emergent situation. f. Psychotropic/Anti-anxiety/Hypnotic Agents

(1) Optimal Duration: 1 to 6 months

(2) Maximum duration: 6 to 12 months, with monitoring g. Tramadol

Tramadol is useful in relief of pain and has been shown to provide pain relief equivalent to that of commonly prescribed NSAIDs. Although Tramadol may cause impaired alertness, it is generally well tolerated, does not cause gastrointestinal ulceration, or exacerbate hypertension or congestive heart failure. Tramadol should be used cautiously in patients who have a history of seizures or who are taking medication that may lower the seizure threshold, such as MAO inhibiters, SSRIs, and tricyclic antidepressants. This medication has physically addictive properties and withdrawal may follow abrupt discontinuation and is not recommended for those with prior opoid addiction.

(1) Optimal Duration: 3 to 7 days

(2) Maximum Duration: 2 weeks. Use beyond 2 weeks is acceptable in appropriate cases. h. Topical Drug Delivery

Topical drug delivery may be an alternative treatment for localized musculoskeletal disorders and is an acceptable form of treatment in selected patients although there is no scientific evidence to support its use in cervical injury. It is necessary that all topical agents be used with strict instructions for application as well as maximum number of applications per day to obtain the desired benefit and avoid potential toxicity. As with all medications, patient selection must be rigorous to select those patients with the highest probability of compliance. Refer to “Iontophoresis” in the Passive Therapy section for information regarding topical iontophoretic agents.

5. Occupational Rehabilitation Programs a. Non-Interdisciplinary

1) Work Conditioning

(1) Length of visit: 1 to 2 hours per day

(2) Frequency: 2 to 5 visits per week

(3) Optimum duration: 2 to 4 weeks

(4) Maximum duration: 6 weeks. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.

2) Work Simulation

(1) Length of visit: 2 to 6 hours per day

(2) Frequency: 2 to 5 visits per week

(3) Optimum duration: 2 to 4 weeks

1) Work Hardening

(1) Length of visit: up to 8 hours/day

(2) Frequency: 2 to 5 visits per week

(3) Optimal duration: 2 to 4 weeks

(4) Maximum duration: 6 weeks. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.

3) Spinal Cord Programs

This can include a highly structured program involving a team approach or can involve any of the components thereof. The interdisciplinary team should, at a minimum, be comprised of a qualified medical director who is board certified and trained in rehabilitation, a case manager, occupational therapy, physical therapy, psychologist, rehabilitation RN and MD, and therapeutic recreation specialist. As appropriate, the team may also include: rehabilitation counselor, respiratory therapist, social worker, or speech-language pathologist.

Timeframe durations for any spinal cord program should be determined based upon the extent of the patient's injury and at the discretion of the rehabilitation physician in charge.

6. Orthotics

Primary principles and objectives of the application of cervical orthosis include: (a) control of the position through the use of control forces; (b) application of corrective forces to abnormal curvatures; (c) aid in spinal stability when soft tissues or osteoligamenteous structures cannot sufficiently perform their role as spinal stabilizers; and (d) restrict spinal segment movement after acute trauma or surgical procedure. In cases of traumatic cervical injury, the most important objective is the protection of the spinal cord and nerve root. a. Cervical Collars

1) Soft Collars are well tolerated by most patients but may not significantly restrict motion in any plane and are associated with delayed recovery. There is no evidence that their use promotes recovery from cervical sprain. In acute strain/sprain type injuries, use of cervical collars may prolong disability, limit early mobilization, promote psychological dependence, and limit self-activity. There is some evidence that patients encouraged to continue usual activity have less neck stiffness and headache than patients placed in cervical collars following motor vehicle crashes.

2) Rigid Collars, such as a Philadelphia Orthosis, are useful post-operative or in emergency situations. These collars restrict flexion and extension motion, and to a lesser degree, lateral bending and rotation. Duration of wear post-surgery is dependent upon the surgeon and degree of cervical healing but is generally not used beyond 8 weeks. b. Poster Appliances

Poster appliances, such as the Miami brace, restrict flexion and extension motion to about the same degree as a Philadelphia collar and to a greater degree, lateral bending and rotation. Not recommended in sprain or strain injuries. c. Cervicothoracic Orthosis

Cervicothoracic orthosis, such as Yale and SOMI type braces, restrict flexion and extension motion to a fuller degree than the Philadelphia collar and to a better degree lateral bending and rotation. Not recommended in sprain or strain type injuries. d. Halo Devices

Halo devices are used in the treatment of cervical fracture, dislocation, and instability at the discretion of the treating surgeon. Refer to Halo Devices in the Operative Treatment section. e. Other Orthosis Devices and Equipment

Special orthosis or equipment may have a role in the rehabilitation of a cervical injury such as those injuries to a cervical nerve root resulting in upper extremity weakness or a spinal cord injury with some degree of paraparesis or tetraparesis. Use of such devices would be in a structured rehabilitation setting as part of a comprehensive rehabilitation program.

7. Patient Education

(1) Time to produce effect: Varies with individual patient

(2) Frequency: Should occur at each visit

8. Personality/Psychological/Psychosocial Intervention

Psychosocial treatment is generally accepted, widely used and well established intervention. This group of therapeutic and diagnostic modalities includes, but is not limited to, individual counseling, group therapy, stress management, psychosocial crises intervention, hypnosis and meditation. Any screening or diagnostic workup should clarify and distinguish between preexisting versus aggravated versus purely causative psychological conditions. Psychosocial intervention is recommended as an important component in the total management program that should be implemented as soon as the problem is identified. This can be used alone or in conjunction with other treatment modalities. Providers treating patients with chronic pain should refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder Medical Treatment Guideline.

(1) Time to produce effect: 2 to 4 weeks

(2) Frequency: 1 to 3 times weekly for the first 4 weeks (excluding hospitalization, if required), decreasing to 1 to 2 times per week for the second month. Thereafter, 2 to 4 times monthly.

(3) Optimum duration: 6 weeks to 3 months

(4) Maximum duration: 3 to 12 months. Counseling is not intended to delay but to enhance functional recovery. For select patients, longer supervised treatment may be required, and if further counseling beyond 3 months is indicated, extensive documentation addressing which pertinent issues are preexisting versus aggravated versus causative, as well as projecting a realistic functional prognosis, should be provided by the authorized treating practitioner every 4 to 6 weeks during treatment.

9. Restriction of Activities

There is some evidence to support the continuation of normal daily activities as the recommended treatment for acute and chronic cervical injuries without neurologic symptoms. Complete work cessation should be avoided, if possible, since it often further aggravates the pain presentation. Modified return-to- work is almost always more efficacious and rarely contraindicated in the vast majority of injured workers with cervical spine injuries.

10. Return-to-Work

Communication is essential between the patient, employer and provider to determine appropriate restrictions and return-to-work dates. It is the responsibility of the physician to provide clear concise restrictions, and it the employer's responsibility to determine if temporary duties can be provided within the restrictions. For cervical spine extremity injuries, the following should be addressed when describing the patient's activity level:

1) Total body position including upper trunk, especially rotation and flexion. To include duration and frequency.

2) Upper extremity requirements including reaching above the shoulder, repetitive motions, and lifting or carrying requirements. Duration and frequency should be included.

3) Sitting duration and frequency with regard to posture, work height(s), and movements of the head and neck.

4) Visual field requirements in respect to limitations in head and neck movements.

5) Use of adaptive devices or equipment for proper office ergonomics or to enhance capacities can be included. c. Compliance with Activity Restrictions

11. Therapy — Active

The following active therapies are listed in alphabetical order: a. Activities of Daily Living (ADL)

(1) Time to produce effect: 4 to 5 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks b. Functional Activities

Functional activities are the use of therapeutic activity to enhance mobility, body mechanics, employability, coordination, and sensory motor integration.

(1) Time to produce effect: 4 to 5 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks c. Functional Electrical Stimulation

(1) Time to produce effect: 2 to 6 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 8 weeks.

(4) Maximum duration: 8 weeks. If beneficial, provide with home unit. d. Cervical Lumbar Stabilization

Cervicial Lumbar stabilization is a therapeutic program whose goal is to strengthen the spine in its neural and anatomic position. The stabilization is dynamic which allows whole body movements while maintaining a stabilized spine. It is the ability to move and function normally through postures and activities without creating undue vertebral stress.

(1) Time to produce effect: 4 to 8 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 8 weeks

(4) Maximum duration: 8 weeks e. Neuromuscular Re-Education

(1) Time to produce effect: 2 to 6 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 4 to 8 weeks

(4) Maximum duration: 8 weeks f. Therapeutic Exercise

(1) Time to produce effect: 2 to 6 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 8 weeks

(4) Maximum duration: 8 weeks

12. Therapy — Passive

Most of the following passive therapies and modalities are generally accepted methods of care for a variety of work-related injuries. Passive therapy includes those treatment modalities that do not require energy expenditure on the part of the patient. They are principally effective during the early phases of treatment and are directed at controlling symptoms such as pain, inflammation and swelling and to improve the rate of healing soft tissue injuries. They should be use adjunctively with active therapies to help control swelling, pain and inflammation during the rehabilitation process. They may be used intermittently as a therapist deems appropriate or regularly if there are specific goals with objectively measured functional improvements during treatment. While protocols for specific diagnoses and post-surgical conditions may warrant durations of treatment beyond those listed as “maximum,” factors such as exacerbation of symptoms, re-injury, interrupted continuity of care, and comorbidities may extend durations of care. Having specific goals with objectively measured functional improvement during treatment can support extended durations of care. It is recommended that if after 6 to 8 visits no treatment effect is observed, alternative treatment interventions, further diagnostic studies or further consultations should be pursued.

The following passive therapies are listed in alphabetical order: a. Electrical Stimulation (Unattended)

(1) Time to produce effect: 2 to 4 treatments

(2) Frequency: Varies, depending upon indication, between 2 to 3 times/day to 1 time/week. Provide home unit if frequent use.

(3) Optimum duration: 1 to 3 months

(4) Maximum duration: 3 months b. Infrared Therapy

Infrared therapy is a radiant form of heat application. Indications include the need to elevate the pain threshold before exercise and to alleviate muscle spasm to promote increased movement.

(1) Time to produce effect: 2 to 4 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 3 weeks as primary, or intermittently as an adjunct to other therapeutic procedures up to 2 months

(4) Maximum duration: 2 months c. Iontophoresis

(1) Time to produce effect: 1 to 4 treatments

(2) Frequency: 3 times per week with at least 48 hours between treatments

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks d. Manipulation Manipulation is a generally accepted, well-established and widely used therapeutic intervention. Manipulation can include high velocity, low amplitude (HVLA) technique, chiropractic manipulation, osteopathic manipulation, muscle energy techniques and non-force techniques. It is performed by taking a joint to its end range of motion and moving the articulation into the zone of accessory joint movement, well within the limits of anatomical integrity.

There is good scientific evidence to suggest that manipulation can be effective for relieving pain, decreasing muscle spasm, and to increase range of motion for patients with cervical pain. There is some evidence to show that manipulation of the cervical spine can be beneficial for relief of tension-type, cervicogenic, and migraine headaches. Contraindications include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthridites, and signs of progressive neurologic deficits, vertebrobasilar insufficiency, or carotid artery disease.

(1) Time to produce effect: 1 to 6 treatments.

(3) Optimum duration: 8 to 12 weeks

(4) Maximum duration: 3 months. Extended durations of care beyond what is considered “maximum” may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with comorbidities. Care beyond 3 months is indicated for certain chronic syndromes in which manipulation is helpful in improving function, decreasing pain and improving quality of life. Such care should be re-evaluated and documented on a monthly basis. Treatment may include visits 2 times a month through the 7th month post-injury, then on a monthly basis thereafter through the 10th month post-injury. Care beyond the 10th month should be reviewed and allowed on a case-by-case basis according to the unique needs of the patient with chronic and/or permanent injury. e. Massage — Manual or Mechanical

(1) Time to produce effect: Immediate

(2) Frequency: 1 to 2 times per week

(3) Optimum duration: 6 weeks

(4) Maximum duration: 2 months f. Mobilization (Joint)

(1) Time to produce effect: 6 to 9 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks g. Mobilization (Soft Tissue)

(1) Time to produce effect: 2 to 3 weeks

(2) Frequency: 2 to 3 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks h. Superficial Heat and Cold Therapy

(1) Time to produce effect: Immediate

(2) Frequency: 2 to 5 times per week

(3) Optimum duration: 3 weeks as primary or intermittently as an adjunct to other therapeutic procedures up to 2 months

(4) Maximum duration: 2 months i. Short-Wave Diathermy

(1) Time to produce effect: 2 to 4 treatments

(2) Frequency: 2 to 3 times per week up to 3 weeks

(3) Optimum duration: 3 to 5 weeks (4) Maximum duration: 5 weeks j. Traction — Manual

(1) Time to produce effect: 1 to 3 sessions

(2) Frequency: 2 to 3 times per week

(3) Optimum duration: 30 days

(4) Maximum duration: 1 month k. Traction — Mechanical

(1) Time to produce effect: 1 to 3 sessions up to 30 minutes. If response is negative after 3 treatments, discontinue this modality.

(2) Frequency: 2 to 3 times per week

(3) Optimum duration: 4 weeks

(4) Maximum duration: 1 month l. Transcutaneous Electrical Nerve Stimulation (TENS)

(1) Time to produce effect: Immediate

(2) Frequency: Variable

(3) Optimum duration: 3 sessions.

(4) Maximum duration: 3 sessions. If beneficial, provide with home unit or purchase if effective. m. Ultrasound

Ultrasound uses sonic generators to deliver acoustic energy for therapeutic thermal and/or nonthermal soft tissue effects. Indications include scar tissue, adhesions, collagen fiber and muscle spasm, and the need to extend muscle tissue or accelerate the soft tissue healing. Ultrasound with electrical stimulation is concurrent delivery of electrical energy that involves dispersive electrode placement. Indications include muscle spasm, scar tissue, pain modulation and muscle facilitation. Phonophoresis is the transfer of medication through the use of sonic generators to the target tissue to control inflammation and pain. These topical medications include, but are not limited to, steroidal anti-inflammatory and anesthetics.

(1) Time to produce effect: 6 to 15 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 4 to 8 weeks

(4) Maximum duration: 2 months

13. Vocational Rehabilitation

F. THERAPEUTIC PROCEDURES — OPERATIVE

All operative interventions should be based on a positive correlation with clinical findings, the natural history of the disease, the clinical course, and diagnostic tests. A comprehensive assimilation of these factors should have led to a specific diagnosis with positive identification of the pathologic condition(s). It is imperative for the clinician to rule out non-physiologic modifiers of pain presentation, or non-operative conditions mimicking radiculopathy or instability (peripheral compressive neuropathy, chronic soft tissue injuries, and psychological conditions), prior to consideration of elective surgical intervention. Patients who are not candidates for or refuse surgical treatment should be treated with non-operative therapy as indicated.

In situations requiring the possible need for re-surgery, a second opinion may be necessary. Psychological evaluation is strongly encouraged to determine if the patient will likely benefit from the treatment. Structured rehabilitation and psychological evaluation should be strongly considered in patients not making expected functional progress in the immediate post-operative period.

Return to work activity restrictions should be specific according to the recommendations in the section “Return to Work.” Most cervical non-fusion surgical patients can return to a limited level of duty between 3 to 6 weeks. Full activity is generally achieved between 6 weeks to 6 months, depending on the procedure and healing of the individual.

1. Acute Fractures & Dislocations

Decisions regarding the need for surgery in acute traumatic injury will depend on the specific injury type and possibility of long-term neurologic damage. a. Halo Immobilization:

1) Description — Intervention that restricts flexion-extension motion. Halo vest will provide significant but not complete rotational control and is the most effective device for treating unstable injuries to the cervical spine.

2) Complications — May include pin infection, pin loosening, and palsy of the sixth cranial nerve.

3) Surgical Indications — Cervical fractures requiring the need for nearly complete restriction of rotational control, and to prevent graft dislodgment, spine malalignment or pseudoarthrosis. Decision for use of halo is at the discretion of the surgeon based upon the patients' specific injury. Not indicated for unstable skull fractures or if skin overlying pin sites is traumatized.

4) Operative Treatment — Placement of the pins and apparatus.

5) Post-Operative Therapy — Traction may be required for realignment and or fracture reduction (amount to be determined by surgeon), active and/or passive therapy, pin care. b. Anterior or Posterior Decompression with Fusion

1) Description — To provide relief of pressure on the cervical spinal column and alignment and stabilization of the spine. May involve the use of bone grafts, sometimes combined with metal devices, to produce a rigid connection between two or more adjacent vertebrae.

2) Complications — Instrumentation failure such as screw loosening, plate failure, or dislodgement (more common in posterior instrumentation), bone graft donor site pain, in-hospital mortality, deep wound infection, superficial infection, graft extrusion, CSF leak, laryngeal nerve damage (anterior approach), and iatrogenic kyphosis.

3) Surgical Indications —When a significant or progressive neurological deficit exists in the presence of spinal canal compromise. Whether early decompression and reduction of neural structures enhances neurological recovery continues to be debated. Currently, a reasonable approach would be to treat non-progressive neurological deficits on a semiurgent basis, when the patient's systemic condition is medically stable.

4) Operative Treatment — Both anterior and posterior surgical decompression of the cervical spine are widely accepted. The approach is guided by location of the compressive pathology as well as the presence of other concomitant injuries. Posterior stabilization and fusion alone may be indicated for patients who have been realigned with traction and do not have significant canal compromise. The anterior approach is acceptable if there is disc and/or vertebral body anteriorly compromising the canal, or be performed posterioly if the compressive pathology arises posteriorly. The posterior approach is indicated in radiculopathy in the absence of myelopathy and with evidence of pseudoarthosis on radiographs.

The number of levels involved in the fracture pattern determines the choice between use of wire techniques versus spinal plates. In injuries treated with an anterior decompression procedure, anterior bone grafting alone does not provide immediate internal fixation and an anterior cervical plate is significantly beneficial. Patients who undergo surgery for significant fracture dislocations of the spine (three column injury) with canal compromise are best managed with anterior cervical decompression, fusion, and plating but in some cases posterior stabilization and fusion are also considered. Allografts may be used for single bone graft fusion; however autografts are generally preferable for multi-level fusions unless a strut graft is required.

5) Post-Operative Treatment — Active and/or passive therapy, cervical bracing. Referral to a formal rehabilitation program may be appropriate once participation in a home-based fitness program has been completed. Home programs should include instruction in ADL's, stretching, and sitting, and a daily walking program.

2. Disc Herniation and other Cervical Conditions

Operative treatment is indicated only when the natural history of a treatable problem is better than the natural history of benign neglect. All patients being considered for surgical intervention should undergo a comprehensive neuromuscular examination to identify pain generators that may respond to nonsurgical techniques or may be refractory to surgical intervention. Timely decision making for operative intervention is critical to avoid deconditioning, and increased disability of the cervical spine. General Recommendations — There is some evidence to suggest that recovery from cervical radiculopathy in patients without clinical signs of spinal cord compression at one year is similar with one- level fusion, physical therapy, or rigid cervical collar use. For patients with whiplash injury (Quebec Classification Grade Levels I or II), there is no evidence of any beneficial effect of operative treatment. If cervical fusion is being considered, it is recommended that the injured worker refrain from smoking for at least six weeks prior to surgery and during the time of healing.

General Indications for Surgery — Operative intervention should be considered and a consultation obtained when improvement of symptoms has plateaued and the residual symptoms of pain and functional disability are unacceptable at the end of six weeks of treatment, or at the end of longer duration of nonoperative intervention for debilitated patients with complex problems. Choice of hardware instrumentation is based on anatomy, the patient's pathology, and surgeons experience and preference.

General indications include:

1. For patients with myelopathy, immediate surgical evaluation and treatment is indicated.

2. For patients with cervical radiculopathy, specific indications include:

a. Persistence or recurrent arm pain with functional limitations, unresponsive to conservative treatment after six weeks; or

b. Progressive functional neurological deficit; or

c. Static neurological deficit associated with significant radicular pain; and

d. Confirmatory imaging studies consistent with clinical findings.

3. For patients with persistent non-radicular cervical pain in the absence of a radiculopathy, it is recommended that a decisive commitment to surgical or nonsurgical interventions be made within 4 to 5 months following injury. The effectiveness of three-level cervical fusion for non-radicular pain has not been established. In patients with non-radicular cervical pain for whom fusion is being considered, required pre-operative indications include all of the following:

a. All pain generators are identified and treated; and

b. All physical medicine and manual therapy interventions are completed; and

c. X-ray, MRI, or CT/discography demonstrating disc pathology or spinal instability; and

d. Spine pathology limited to two levels; and

e. Psychosocial evaluation for confounding issues addressed.

f. For any potential surgery, it is recommended that the injured worker refrain from smoking for at least six weeks prior to surgery and during the period of healing. a. Cervical Discectomy with or without Fusion

1) Description — Procedure to relieve pressure on one or more nerve roots or spinal cord.

2) Complications — May include strut graft dislodgment (multi-level decompression), infection, hemorrhage, CSF leak, hematoma, catastrophic spinal cord injury causing varying degrees of paralysis, pseudoarthosis, in-hospital mortality, non-union of fusion, donor site pain (autograft only). Anterior approach: permanent or transient dysphonia, permanent or transitory dysphagia, denervation, esophageal perforation, and airway obstruction.

3) Surgical Indications — Radiculopathy from ruptured disc or spondylosis, spinal instability, or patients with non-radicular neck pain meeting fusion criteria. There is no evidence that discectomy with fusion versus discectomy without fusion has superior long-term results. Discectomy alone is generally considered in patients with pure radicular symptoms from their herniated disc and who have sufficiently large foramen that disc space collapse is unlikely to further compromise the nerve root. Failure rates increase with disease at more than two levels.

4) Operative Treatment — Allografts may be used for single bone graft fusion; however autografts are generally preferable for multi-level fusions unless a large strut graft is required. Cervical plating may be used to prevent graft dislodgment especially for multi-level disease.

5) Post-Operative Therapy — Long-term neck bracing (6 to 12 weeks) with fusion. Active and/or passive therapy. Initial home rehabilitation programs should include instruction in ADL's, posture, and contain a daily walking program. Referral to a formal rehabilitation program may be appropriate for most patents at 8 to 16 weeks post-operatively and should be strongly considered in patients not making expected functional progress in the immediate postoperative period. b. Cervical Corpectomy

1) Description — Removal of a portion or the entire vertebral body from the front of the spine. May also include removal of the adjacent discs. Usually involves fusion.

3) Surgical Indications — Single or two-level spinal stenosis, spondylothesis, or severe kyphosis with cord compression.

4) Operative Treatment — Neural decompression, fusion with instrumentation, or halo vest placement to maintain cervical position. Hemicorpectomy may be done when only a portion of the vertebral body needs to be resected. Allografts may be used for single bone graft fusion; however autografts are generally preferable for multilevel fusions unless a large strut graft is required.

5) Post-Operative Therapy — Dependent upon number of vertebral bodies involved, healing time longer than discectomy. Active and/or passive therapy, halo vest care. Initial home rehabilitation programs should include instruction in ADL's, posture, and contain a daily walking program. Referral to a formal rehabilitation program may be appropriate for most patents at 8 to 16 weeks post-operatively and should be strongly considered in patients not making expected functional progress in the immediate post-operative period. c. Cervical Laminectomy with or without Foraminotomy or Fusion

1) Description — Surgical removal of the posterior portion of a vertebrae in order to gain access to the spinal cord or nerve roots.

2) Complications — May include perineural fibrosis, kyphosis in fractures without fusion or with failed fusion, nerve injury, post surgical instability (with foraminotomies), CSF leak, infection, inhospital mortality, non-union of fusion, donor site pain (autograft only).

3) Surgical Indications — Neural decompression. 4) Operative Treatment — Laminotomy, partial discectomy, and nerve root decompression.

5) Post-Operative Therapy — Neck bracing, active and/or passive therapy. Initial home rehabilitation programs should include instruction in ADL's, posture, and contain a daily walking program. Referral to a formal rehabilitation program may be appropriate for most patents at 8 to 16 weeks post-operatively and should be strongly considered in patients not making expected functional progress in the immediate post-operative period. d. Cervical Laminoplasty

1) Description — Technique that increases anterior or posterior dimensions of the spinal canal while leaving posterior elements partially intact.

2) Complications — Loss of cervical motion, especially extension.

3) Surgical Indications — Multi-level disease: cervical spinal stenosis or spondylitic myelopathy. Not indicated in cervical kyphosis.

4) Operative Treatment — Posterior approach, with or without instrumentation.

5) Post-Operative Therapy — Active and/or passive therapy. May include 4 to 12 weeks of bracing. Initial home rehabilitation programs should include instruction in ADL's, posture, and contain a daily walking program. Referral to a structured rehabilitation program may be appropriate for most patents at 8 to 16 weeks post-operatively and should be strongly considered in patients not making expected functional progress in the immediate post-operative period.

RULE XVII, EXHIBIT F Chronic Pain Disorder Medical Treatment Guidelines July 30, 2003

(Previously Adopted March 15, 1998)

Presented By:

State of Colorado Department of Labor and Employment DIVISION OF WORKERS' COMPENSATION

TABLE OF CONTENTS

A. INTRODUCTION

B. GENERAL GUIDELINE PRINCIPLES

1. APPLICATION OF GUIDELINES

2. EDUCATION

3. TREATMENT PARAMETER DURATION

4. ACTIVE INTERVENTIONS

5. ACTIVE THERAPEUTIC EXERCISE PROGRAM

6. POSITIVE PATIENT RESPONSE

7. RE-EVALUATION TREATMENT EVERY 3 TO 4 WEEKS 8. SURGICAL INTERVENTIONS

9. SIX-MONTH TIME FRAME

10. RETURN-TO-WORK

11. DELAYED RECOVERY

12. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE

13. TREATMENT OF PREEXISTING CONDITIONS

C. INTRODUCTION TO CHRONIC PAIN

D. DEFINITIONS

E. INITIAL EVALUATION & DIAGNOSTIC PROCEDURES

1. HISTORY AND PHYSICAL EXAMINATION (HX & PE)

2. PERSONALITY/PSYCHOSOCIAL/PSYCHOLOGICAL EVALUATION

3. DIAGNOSTIC STUDIES

4. LABORATORY TESTING

5. INJECTIONS – DIAGNOSTIC

6. SPECIAL TESTS

a. Computer-Enhanced Evaluations

b. Functional Capacity Evaluation (FCE)

c. Job Site Evaluation

d. Vocational Assessment

e. Work Tolerance Screening

F. THERAPEUTIC PROCEDURES — NON-OPERATIVE

1. ACUPUNCTURE

a. Acupuncture

b. Acupuncture with Electrical Stimulation

c. Other Acupuncture Modalities

2. BIOFEEDBACK

3. COMPLEMENTARY ALTERNATIVE MEDICINE (CAM)

4. SLEEP DISTURBANCES 5. INJECTIONS — THERAPEUTIC

a. Epidural Steroid Spinal Injections

b. Zygoapophyseal (Facet) Injection

c. Selective Nerve Root Blocks

d. Trigger point Injections

e. Botulinum Toxin (Botox) Injection

f. Sacroiliac Joint Injection

g. Sympathetic Injections

h. Peripheral Nerve Blocks

6. INTERDISCIPLINARY REHABILITATION PROGRAMS

a. Formal Rehabilitation Programs

b. Informal Rehabilitation Program

7. MEDICATIONS

a. Alpha-Acting Agents

b. Anticonvulsants

c. Antidepressants

d. Hypnotics and Sedatives

e. Skeletal Muscle Relaxants

f. Opioids

g. Non-Steroidal Anti-Inflammatory Drugs

h. Topical Drug Delivery

i. Herbal/Dietary Supplements

j. Other Agents

8. ORTHOTICS/PROSTHETICS/EQUIPMENT

9. PATIENT EDUCATION

10. PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION

11. RESTRICTION OF ACTIVITIES

12. RETURN-TO-WORK 13. THERAPY — ACTIVE

a. Activities of Daily Living (ADL)

b. Aquatic Therapy

c. Functional Activities

d. Functional Electrical Stimulation

e. Lumbar Stabilization

f. Neuromuscular Re-Education

g. Therapeutic Exercise

h. Work Conditioning

i. Work Simulation

14. THERAPY — PASSIVE

a. Electrical Stimulation (Unattended)

b. Infrared Therapy

c. Iontophoresis

d. Manipulation

e. Massage — Manual or Mechanical

f. Mobilization (Joint)

g. Mobilization (Soft Tissue)

h. Superficial Heat and Cold Therapy

i. Traction — Manual

j. Traction — Mechanical

k. Transcutaneous Electrical Nerve Stimulation (TENS)

l. Ultrasound

G. THERAPEUTIC PROCEDURES — OPERATIVE

1. NEUROSTIMULATION

2. INTRATHECAL DRUG DELIVERY

3. NEUROABLATION WITH RHIZOTOMY AS THE EXCEPTION

4. FACET RHIZOTOMY H. MAINTENANCE MANAGEMENT

1. HOME EXERCISE PROGRAMS AND EXERCISE EQUIPMENT

2. EXERCISE PROGRAMS REQUIRING SPECIAL FACILITIES

3. PATIENT EDUCATION MANAGEMENT

4. PSYCHOLOGICAL MANAGEMENT

5. NON-NARCOTIC MEDICATION MANAGEMENT

6. NARCOTIC MEDICATION MANAGEMENT

7. THERAPY MANAGEMENT

8. INJECTION THERAPY

9. PURCHASE OR RENTAL OF DURABLE MEDICAL EQUIPMENT

A. INTRODUCTION

To properly utilize this document, the reader should not skip nor overlook any sections.

B. GENERAL GUIDELINE PRINCIPLES

1. Application of Guidelines

2. Education

Education of the patient and family, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of chronic pain and disability. Currently, practitioners often think of education last, after medications, manual therapy and surgery. Practitioners must develop and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers and the community as a whole. An education-based paradigm should always start with inexpensive communication providing reassuring information to the patient. More in-depth education currently exists within a treatment regime employing functional restorative and innovative programs of prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of facilitating self-management of symptoms and prevention.

3. Treatment Parameter Duration

Timeframes for specific interventions commence once treatments have been initiated, not on the date of injury. Obviously, duration will be impacted by patient compliance, as well as availability of services. Clinical judgment may substantiate the need to accelerate or decelerate the timeframes discussed in this document.

4. Active Interventions

5. Active Therapeutic Exercise Program

Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and education. This includes functional application in vocational or community settings.

6. Positive Patient Response

7. Re-Evaluation Treatment Every 3 to 4 Weeks

8. Surgical Interventions

9. Six-Month Time Frame

The prognosis drops precipitously for returning an injured worker to work once he/she has been temporarily totally disabled for more than six months. The emphasis within these guidelines is to move patients along a continuum of care and return-to-work within a six-month timeframe, whenever possible. It is important to note that timeframes may not be pertinent to injuries that do not involve work-time loss or are not occupationally related. 10. Return-to-Work

11. Delayed Recovery

12. Guideline Recommendations and Inclusion of Medical Evidence

“Some” means the recommendation considered at least one adequate scientific study, which reported that a treatment was effective.

13. Treatment of Preexisting Conditions

C. INTRODUCTION TO CHRONIC PAIN

The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience with actual or potential tissue damage.” Pain is a complex experience embracing physical, mental, social and behavioral processes that often compromises the quality of life of many individuals. Pain is an unpleasant subjective perception usually in the context of tissue damage.

Pain is subjective and cannot be measured or indicated objectively. Pain evokes negative emotional reactions such as fear, anxiety, anger, and depression. People usually regard pain as an indicator of physical harm, despite the fact that pain can exist without tissue damage and tissue damage can exist without pain. Many people report pain in the absence of tissue damage or any likely pathophysiologic cause. There is no way to distinguish their experience from that due to actual tissue damage. If they regard their experience as pain and they report it the same way as pain caused by tissue damage, it should be accepted as pain.

Pain can generally be classified as:

a. Nociceptive, which includes pain from visceral origins or damage to other tissues. Myofascial pain is a nociceptive type of pain characterized by myofascial trigger points limited to a specific muscle or muscles.

b. Neuropathic, including that originating from brain, peripheral nerves or both; and

c. Psychogenic, that originates in mood, characterological, social, or psychophysiological processes.

Recent advances in the neurosciences reveal additional mechanisms involved in chronic pain. In the past, pain was seen as a sensation arising from the stimulation of pain receptors by damaged tissue, initiating a sequence of nerve signals ending in the brain and there recognized as pain. A consequence of this model was that ongoing pain following resolution of tissue damage was seen as less physiological and more psychological than acute pain with identifiable tissue injury. Current research indicates that chronic pain involves additional mechanisms that cause: 1) neural remodeling at the level of the spinal cord and higher levels of the central nervous system; 2) changes in membrane responsiveness and connectivity leading to activation of larger pain pathways; and 3) recruitment of distinct neurotransmitters.

Changes in gene function and expression may occur, with lasting functional consequences. These physiologic functional changes cause chronic pain to be experienced in body regions beyond the original injury and to be exacerbated by little or no stimulation. The chronic pain experience clearly represents both psychologic and complex physiologic mechanisms, many of which are just beginning to be understood.

Chronic Pain is defined as “pain that persists for at least 30 days beyond the usual course of an acute disease or a reasonable time for an injury to heal or that is associated with a chronic pathological process that causes continuous pain (e.g., reflex sympathetic dystrophy).” The very definition of chronic pain describes a delay or outright failure to relieve pain associated with some specific illness or accident. Delayed recovery should prompt a clinical review of the case and a psychological evaluation by the health care provider. Referral to a recognized pain specialist for further evaluation is recommended. Consideration may be given to new diagnostic testing or a change in treatment plan.

Use of the term “chronic pain syndrome” has been used and defined in a variety of ways that generally indicate a belief on the part of the health care provider that the patient's pain is inappropriate or out of proportion to existing problems or illness. Use of the term “chronic pain syndrome” should be discontinued because the term ceases to have meaning due to the many different physical and psychosocial issues associated with it. Instead, practitioners should use the nationally accepted terminology indicated in the definition section and/or the psychiatric diagnosis of “Pain Disorder” and the subtypes according to established standards of the American Psychiatric Association.

The IASP offers taxonomy of pain, which underscores the wide variety of pathological conditions associated with chronic pain. This classification system may not address the psychological and psychosocial issues that occur in the perception of pain, suffering and disability and may require referral to psychiatric or psychological clinicians. These issues should be documented with preference to the diagnostic categories of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association, including the subcategories of pain disorder and any other applicable diagnostic categories (i.e., depressive, anxiety, and adjustment disorders).

Chronic pain is a phenomenon not specifically relegated to anatomical or physiologic parameters. The prevailing biomedical model (which focuses on identified disease pathology as the sole cause of pain) cannot capture all of the important variables in pain behavior. While diagnostic labels may pinpoint contributory physical and/or psychological factors and lead to specific treatment interventions that are helpful, a large number of patients defy precise taxonomic classification. Furthermore, such diagnostic labeling often overlooks important social contributions to the chronic pain experience. Failure to address these operational parameters of the chronic pain experience may lead to incomplete or faulty treatment plans. The term “pain disorder” is perhaps the most useful term in the medical literature today, in that it captures the multifactorial nature of the chronic pain experience.

It is recognized that some health care practitioners, by virtue of their experience, additional training and/or accreditation by pain specialty organizations, have much greater expertise in the area of chronic pain evaluation and treatment than others. Referrals for the treatment of chronic pain should be to such recognized specialists. Chronic pain treatment plans should be monitored and coordinated by pain medicine physicians with such specialty training, in conjunction with other health care specialists.

Most acute and some chronic pain problems are adequately addressed in other Division treatment guidelines, and are generally beyond the scope of these guidelines. However, because chronic pain is more often than not multifactorial, involving more than one pathophysiologic or mental disorder, some overlap with other guidelines is inevitable. These guidelines are meant to apply to any patient who fits the operational definition of chronic pain discussed at the beginning of this section.

D. DEFINITIONS a. After Sensation – Refers to the abnormal persistence of a sensory perception, provoked by a stimulus even though the stimulus has ceased. b. Allodynia – Pain due to a non-noxious stimulus that does not normally provoke pain.

Mechanical Allodynia – Refers to the abnormal perception of pain from usually non-painful mechanical stimulation.

Static Mechanical Allodynia – Refers to pain obtained by applying a single stimulus such as light pressure to a defined area.

Dynamic Mechanical Allodynia – Obtained by moving the stimulus such as a brush or cotton tip across the abnormal hypersensitive area.

Thermal Allodynia – Refers to the abnormal sensation of pain from usually non-painful thermal stimulation such as cold or warmth. c. Analgesia – Absence of pain in response to stimulation that would normally be painful. d. Biopsychosocial – A term that reflects the multiple facets of any clinical situation; namely, the biological, psychological, and social situation of the patient. e. Central Pain – Pain initiated or caused by a primary lesion or dysfunction in the central nervous system. f. Central Sensitization – The experience of pain evoked by the excitation of non-nociceptive neurons or of nerve fibers that normally relay non-painful sensations to the spinal cord. This results when non-nociceptive afferent neurons act on a sensitized CNS. g. Dysesthesia – An abnormal sensation described by the patient as unpleasant. As with paresthesia, dysesthesia may be spontaneous or evoked by maneuvers on physical examination. h. Hyperalgesia – Refers to an exaggerated pain response from a usually painful stimulation. i. Hyperesthesia (Positive Sensory Phenomena) – Includes allodynia, hyperalgesia, and hyperpathia. Elicited by light touch, pin prick, cold, warm, vibration, joint position sensation or two point discrimination, which is perceived as increased or more. j. Hyperpathia – Refers to an abnormally painful and exaggerated reaction to stimulus, especially to a repetitive stimulus. k. Hypoalgesia – Diminished pain perception in response to a normally painful stimulus. l. Hypoesthesia (Negative Sensory Phenomena) – Refers to a stimulus such as light touch, pin prick, cold, point position sensation, two-point discrimination or sensory neglect which is perceived as decreased. m. Malingering – Intentional feigning of illness or disability in order to escape work or gain compensation. n. Myofascial Pain – A regional pain characterized by tender points in taut bands of muscle that produce pain in a characteristic reference zone. o. Myofascial Trigger Point – A physical sign in a muscle which includes a) exquisite tenderness in a taut muscle band; and b) referred pain elicited by mechanical stimulation of the trigger point. The following findings may be associated with myofascial trigger points: 1) Local twitch or contraction of the taut band when the trigger point is mechanically stimulated; 2) Reproduction of the patient's spontaneous pain pattern when the trigger point is mechanically stimulated; 3) Weakness without muscle atrophy; 4) Restricted range of motion of the affected muscle; and 5) Autonomic dysfunction associated with the trigger point such as changes in skin or limb temperature. p. Neuralgia – Pain in the distribution of a nerve or nerves. q. Neuritis – Inflammation of a nerve or nerves. r. Neurogenic Pain – Pain initiated or caused by a primary lesion, dysfunction, or transitory perturbation in the peripheral or central nervous system. s. Neuropathic Pain – Pain due to an injured or dysfunctional central or peripheral nervous system. t. Neuropathy – A disturbance of function or pathological change in a nerve: in one nerve, mononeuropathy; in several nerves, mononeuropathy multiplex; if diffuse and bilateral, polyneuropathy. u. Nociceptor – A receptor preferentially sensitive to a noxious stimulus or to a stimulus which would become noxious if prolonged. v. Pain Behavior – The non-verbal actions (such as grimacing, groaning, limping, using visible pain relieving or support devices and requisition of pain medications, among others) that are outward manifestations of pain, and through which a person may communicate that pain is being experienced. w. Pain Threshold – The smallest stimulus perceived by a subject as painful. x. Paresthesia – An abnormal sensation that is not described as pain. It can be either a spontaneous sensation (such as pins and needles) or a sensation evoked from non-painful or painful stimulation, such as light touch, thermal, or pinprick stimulus on physical examination. y. Peripheral Neurogenic Pain – Pain initiated or caused by a primary lesion or dysfunction or transitory perturbation in the peripheral nervous system. z. Peripheral Neuropathic Pain – Pain initiated or caused by a primary lesion or dysfunction in the peripheral nervous system. aa. Summation – Refers to abnormally painful sensation to a repeated stimulus although the actual stimulus remains constant. The patient describes the pain as growing and growing as the same intensity stimulus continues. bb. Sympathetically Maintained Pain – A pain that is maintained by sympathetic efferent innervations or by circulating catecholamines. cc. Tender Points – Tenderness on palpation at a tendon insertion, muscle belly or over bone. Palpation should be done with the thumb or forefinger, applying pressure approximately equal to a force of 4 kilograms (blanching of the entire nail bed).

E. INITIAL EVALUATION & DIAGNOSTIC PROCEDURES

The Division recommends the following diagnostic procedures be considered, at least initially, the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Standard procedures that should be utilized when initially diagnosing a work- related chronic pain complaint are listed below.

1. History and Physical Examination (Hx & PE) a. Medical History

As in other fields of medicine, a thorough patient history is an important part of the evaluation of chronic pain. In taking such a history, factors influencing a patient's current status can be made clear and taken into account when planning diagnostic evaluation and treatment. One efficient manner in which to obtain historical information is by using a questionnaire. The questionnaire may be sent to the patient prior to the initial visit or administered at the time of the office visit. The following item are considered essential history:

1) General Information – General items requested are name, sex, age, birth date, etc.

2) Level of Education – The level of patients' education may influence response to treatment.

3) Work History/Occupation – To include both impact of injury on job duties and impact on ability to perform job duties, work history, job description, mechanical requirements of the job, duration of employment, and job satisfaction. 4) Current Employment Status

5) Marital Status

6) Family Environment – Is the patient living in a nuclear family or with friends? Is there or were there, any family members with chronic illness or pain problems? Responses to such questions reveal the nature of the support system or the possibility of conditioning toward chronicity.

7) Ethnic Origin – Ethnicity of the patient, including any existing language barriers, may influence the patient's perception of and response to pain. There is evidence that providers may under-treat patients of certain ethnic backgrounds due to underestimation of their pain.

8) Belief System – The patient may refuse various treatments or may have an altered perception of his pain due to his particular beliefs.

9) Activities of Daily Living – Pain has a multidimensional effect on the patient that is reflected in changes in usual daily vocational, social, recreational, and sexual activities.

10) Past And Present Psychological Problems

11) History of Abuse – Physical, emotional, sexual.

12) History of Disability in the Family

13) Sleep Disturbances b. Pain History

Characterization of the patient's pain and of the patient's response to pain is one of the key elements in treatment.

1) Site of Pain – localization and distribution of the pain help determine the type of pain the patient has (i.e., central versus peripheral).

2) Pain Drawing/Visual Analog Scale (VAS)

3) Duration

4) Place of onset

5) Pain Characteristics – time of pain occurrence as well as intensity, quality and radiation give clues to the diagnosis and potential treatment.

6) Response of Pain to Activity

1) Prior Treatment – What has been tried and which treatments have helped?

2) Prior Surgery – If the patient has had prior surgery specifically for the pain, he/she is less likely to have a positive outcome.

3) Medications – History of and current use of medications, including over the counter and herbal/dietary supplements to determine drug usage (or abuse) interactions and efficacy of treatment.

4) Review of Systems Check List – Determine if there is any interplay between the pain complaint and other medical conditions.

5) Psychosocial Functioning – Determine if the following are present: current symptoms of depression or anxiety, evidence of stressors in the workplace or at home, and past history of psychological problems. It is recommended that patients diagnosed with Chronic Pain be referred for a psychosocial evaluation.

6) Diagnostic Tests – All previous radiological and laboratory investigations should be reviewed.

7) Preexisting Conditions – Treatment of these conditions is appropriate when the preexisting condition affects recovery from chronic pain. d. Substance Use/Abuse

1) Alcohol use

2) Smoking History

3) History of drug use and abuse.

4) Caffeine or caffeine-containing beverages. e. Other Factors Affecting Treatment Outcome

1) Compensation/Disability/Litigation

2) Treatment Expectations – What does the patient expect from treatment: complete relief of pain or reduction to a more tolerable level? f. Physical Examination

1) Neurologic Evaluation – Cranial nerves, muscle tone and strength, atrophy, upper motor neuron signs, motor evaluation reflexes, and provocative neurological maneuvers.

2) Sensory Evaluation – A detailed sensory examination is crucial in evaluating a patient with chronic pain complaints. Quantitative sensory testing, such as Semmes-Weinstein, may be useful tools in determining sensory abnormalities. The examination should determine if the following sensory signs are present:

a) Hyperalgesia

b) Hyperpathia

c) Paresthesia

d) Dysesthesia

e) Mechanical Allodynia – static versus dynamic f) Thermal Allodynia

g) Hypoesthesia

h) Hyperesthesia

i) Summation

3) Musculoskeletal Evaluation – Range of motion, segmental mobility, musculoskeletal provocative maneuvers, palpation, observation, and functional activities. All joints, muscles, ligaments and tendons should be examined for swelling, laxity and tenderness. A portion of the musculoskeletal evaluation is the myofascial examination. The myofascial examination includes palpating soft tissues for evidence of tightness and trigger points.

4) Evaluation of Nonphysiologic Findings

a) Waddell's nonorganic findings including: a) superficial or nonorganic tenderness; b) pseudo maneuvers; c) discrepant straight leg raise; d) nonanatomic sensory and/or motor examination; and e) overreaction: collapsing, tremor, pain behavior, muscle tension.

b) Variabilities on formal exam including variable sensory exam, inconsistent tenderness, and or swelling secondary to extrinsic sources.

c) Inconsistencies between formal exam and observed abilities of range-of-motion, motor strength, gait and cognitive/emotional state.

d) Observation of consistencies between pain behavior, affect and verbal pain rating, and affect and physical re-examination.

2. Personality/Psychosocial/Psychological Evaluation

Psychosocial Evaluations are generally accepted, well-established diagnostic procedures not only with selected use in acute pain problems, but also with more widespread use in subacute and chronic pain populations. Diagnostic evaluations should distinguish between conditions that are preexisting, aggravated by the current injury or work related.

Psychosocial evaluations should determine if further psychosocial interventions are indicated for patients diagnosed with chronic pain. The interpretations of the evaluation should provide clinicians with a better understanding of the patient in their social environment, thus allowing for more effective rehabilitation. Psychosocial assessment requires consideration of variations in pain experience and expression because of factors such as gender, age, race, ethnicity, national origin, religion, sexual orientation, disability, language or socioeconomic status.

Psychometric Testing is a valuable component of a consultation to assist the physician in making a more effective treatment plan. There is strong evidence that psychometric testing provides unique and useful information, and that the validity of such tests is comparable to the validity of medical tests.

All patients who are diagnosed as having chronic pain should be referred for a Psychosocial Evaluation as well as concomitant interdisciplinary rehabilitation treatment whenever appropriate. a. Qualifications

1) A psychologist with a PhD, PsyD, EdD credentials, or a physician with Psychiatric MD/DO credentials may perform the initial comprehensive evaluations. It is preferable that these professionals have experience in diagnosing and treating chronic pain disorders in injured workers.

2) Psychometric tests may be administered by psychologists with a PhD, PsyD, or EdD, or by physicians with appropriate training. b. Clinical Evaluation – All chronic pain patients should have a clinical evaluation that addresses the following areas:

1) History of Injury – The history of the injury should be reported in the patient's words or using similar terminology. Caution must be exercised when using translators.

a) Nature of injury

b) Psychosocial circumstances of the injury

c) Current symptomatic complaints

d) Extent of medical corroboration

e) Treatment received and results

f) Compliance with treatment

g) Coping strategies used, including perceived locus of control

h) Perception of medical system and employer

i) History of response to prescription medications

2) Health History

a) Nature of injury

b) Medical history

c) Psychiatric history

d) History of alcohol or substance abuse

e) Activities of daily living

f) Mental status exam

g) Previous injuries, including disability, impairment, and compensation

3) Psychosocial history

a) Childhood history, including abuse

b) Educational history

c) Family history, including disability

d) Marital history and other significant adulthood activities and events e) Legal history, including criminal and civil litigation

f) Employment and military history

g) Signs of pre-injury psychological dysfunction

h) Current interpersonal relations, support, living situation

i) Financial history

4) Psychological test results, if performed

5) Danger to self or others.

6) Current psychiatric diagnosis consistent with the standards of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).

7) Preexisting psychiatric conditions. Treatment of these conditions is appropriate when the preexisting condition affects recovery from chronic pain.

8) Causality (to address medically probable cause and effect, distinguishing pre-existing psychological symptoms, traits and vulnerabilities from current symptoms).

9) Treatment recommendations with respect to specific goals, frequency, timeframes, and expected outcomes. c. Tests of Psychological Functioning

1) Comprehensive Inventories for Medical Patients

a) Battery for Health Improvement, 2nd Edition (BHI-2)

What it measures – Depression, anxiety and hostility; violent and suicidal ideation; borderline, dependency, chronic maladjustment, substance abuse, conflicts with work, family and physician, pain preoccupation, somatization, perception of functioning and others.

Benefits – When used as a part of a comprehensive evaluation, can contribute substantially to the understanding of psychosocial factors underlying pain reports, perceived disability, somatic preoccupation, and help to design interventions. Serial administrations can track changes in a broad range of variables during the course of treatment, and assess outcome.

b) Millon Behavioral Medical Diagnostic (MBMD) What it Measures – Updated version of the Millon Behavioral Health Inventory (MBHI). Provides information on Coping Styles (introversive, inhibited, dejected, cooperative, sociable, etc), Health Habits (smoking, drinking, eating, etc.), Psychiatric Indications (anxiety, depression, etc), stress moderators (Illness Apprehension vs. Illness Tolerance, etc), treatment prognostics (Interventional Fragility vs. Interventional Resilience, Medication Abuse vs. Medication Competence, etc) and other factors.

Benefits – When used as a part of a comprehensive evaluation, can contribute substantially to the understanding of psychosocial factors affecting medical patients. Understanding risk factors and patient personality type can help to optimize treatment protocols for a particular patient.

c) Pain Assessment Battery (PAB)

What it measures – Collection of four separate measures that are administered together. Emphasis on the assessment of pain, coping strategies, degree and frequency of distress, health-related behaviors, coping success, beliefs about pain, quality of pain experience, stress symptoms analysis, and others.

Benefits – When used as a part of a comprehensive evaluation, can contribute substantially to the understanding of patient stress, pain reports and pain coping strategies, and help to design interventions. Serial administrations can track changes in measured variables during the course of treatment, and assess outcome.

2) Comprehensive Psychological Inventories.

These tests are designed for detecting various psychiatric syndromes, but in general are more prone to false positive findings when administered to medical patients.

a) Millon Clinical Multiaxial Inventory, 3rd Edition (MCMI-III)

What it measures – Has scales based on DSM diagnostic criteria for affective, personality, and psychotic disorders and somatization.

Benefits – When used as a part of a part of a comprehensive evaluation, can screen for a broad range of DSM diagnoses.

b) Minnesota Multiphasic Personality Inventory, 2nd Edition (MMPI 2)

What it measures – Original scale constructs, such as hysteria and psychesthenia are archaic but continue to be useful. Newer content scales include depression, anxiety, health concerns, bizarre mentation, social discomfort, low self-esteem and almost 100 others.

Benefits – When used as a part of a part of a comprehensive evaluation, measure a number of factors that have been associated with poor treatment outcome.

c) Personality Assessment Inventory (PAI)

What it measures – A good measure of general psychopathology. Measures depression, anxiety, somatic complaints, stress, alcohol and drug use reports, mania, paranoia, schizophrenia, borderline, antisocial and suicidal ideation and more than 30 others.

Benefits – When used as a part of a comprehensive evaluation, can contribute substantially to the identification of a wide variety of risk factors that could potentially affect the medical patient.

3) Brief Multidimensional Screens for Medical Patients.

Treating providers, to assess a variety of psychological and medical conditions, including depression, pain, disability and others, may use brief instruments. These instruments may also be employed as repeated measures to track progress in treatment, or as one test in a more comprehensive evaluation. Brief instruments are valuable in that the test may be administered in the office setting and hand scored by the physician. Results of these tests should help providers distinguish which patients should be referred for a specific type of comprehensive evaluation.

a) Brief Battery for Health Improvement, 2nd Edition (BBHI-2)

What it measures – Depression, anxiety, somatization, pain, function, and defensiveness.

Benefits – Can identify patients needing treatment for depression and anxiety, and identify patients prone to somatization, pain magnification and self- perception of disability. Can compare the level of factors above to other pain patients and community members. Serial administrations can track changes in measured variables during the course of treatment, and assess outcome.

b) Multidimensional Pain Inventory (MPI)

What it measures – Interference, support, pain severity, life-control, affective distress, response of significant other to pain, and self-perception of disability at home and work, and in social and other activities of daily living (ADL).

Benefits – Can identify patients with high levels of disability perceptions, affective distress, or those prone to pain magnification. Serial administrations can track changes in measured variables during the course of treatment, and assess outcome.

c) Pain Patient Profile (P3)

What it measures – Assesses depression, anxiety, and somatization.

Benefits – Can identify patients needing treatment for depression and anxiety, as well as identify patients prone to somatization. Can compare the level of depression, anxiety and somatization to other pain patients and community members. Serial administrations can track changes in measured variables during the course of treatment, and assess outcome.

d) SF-36®;

What it measures – A survey of general health well-being and functional states.

Benefits – Assesses a broad spectrum of patient disability reports. Serial administrations could be used to track patient perceived functional changes during the course of treatment, and assess outcome. e) Sickness Impact Profile (SIP)

What it measures – Perceived disability in the areas of sleep, eating, home management, recreation, mobility, body care, social interaction, emotional behavior and communication.

f) McGill Pain Questionnaire (MPQ)

What it measures – Cognitive, emotional and sensory aspects of pain.

Benefits – Can identify patients prone to pain magnification. Repeated administrations can track progress in treatment for pain.

g) McGill Pain Questionnaire – Short Form (MPQ-SF)

What it measures – Emotional and sensory aspects of pain.

Benefits – Can identify patients prone to pain magnification. Repeated administrations can track progress in treatment for pain.

h) Oswestry Disability Questionnaire

What it measures – Disability secondary to low back pain.

Benefits – Can measure patients' self-perceptions of disability. Serial administrations could be used to track changes in self-perceptions of functional ability during the course of treatment, and assess outcome.

i) Visual Analog Scales (VAS)

What it measures – Graphical measure of patient's pain report.

Benefits – Quantifies the patients' pain report. Serial administrations could be used to track changes in pain reports during the course of treatment and assess outcome.

4) Brief Multidimensional Screens for Psychiatric Patients.

These tests are designed for detecting various psychiatric syndromes, but in general are more prone to false positive findings when administered to medical patients.

a) Brief Symptom Inventory

What it measures: Somatization, obsessive-compulsive, depression, anxiety, phobic anxiety, hostility, paranoia, psychoticism, and interpersonal sensitivity.

Benefits: Can identify patients needing treatment for depression and anxiety, as well as identify patients prone to somatization. Can compare the level of depression, anxiety and somatization to community members. Serial administrations could be used to track changes in measured variables during the course of treatment, and assess outcome. b) Brief Symptom Inventory – 18 (BSI-18)

What it Measures: Depression, anxiety, somatization.

Benefits: Can identify patients needing treatment for depression and anxiety, as well as identify patients prone to somatization. Can compare the level of depression, anxiety and somatization to community members. Serial administrations could be used to track patient perceived functional changes during the course of treatment, and assess outcome.

c) Symptom Check List 90 (SCL 90)

What it measures: Somatization, obsessive-compulsive, depression, anxiety, phobic anxiety, hostility, paranoia, psychoticism, and interpersonal sensitivity.

5) Brief Specialized Psychiatric Screening Measures

a) Beck Depression Inventory (BDI)

What it measures: Depression

Benefits: Can identify patients needing referral for further assessment and treatment for depression and anxiety, as well as identify patients prone to somatization. Repeated administrations can track progress in treatment for depression, anxiety and somatic preoccupation.

b) Post Traumatic Stress Diagnostic Scale (PDS)

What it Measures: PTSD

Benefits: Helps confirm suspected PTSD diagnosis. Repeated administrations can track treatment progress of PTSD patients.

c) Center of Epidemiologic Studies – Depression Questionnaire

What it measures: Depression

Benefits: Brief self-administered screening test. Requires professional evaluation to verify diagnosis.

d) Brief Patient Health Questionnaire from PRIME – MD

What it measures: Depression, panic disorder

Benefits: Brief self-administered screening test. Requires professional evaluation to verify diagnosis.

e) Zung Questionnaire What it measures: Depression

Benefits: Brief self-administered screening test. Requires professional evaluation to verify diagnosis.

3. Diagnostic Studies

Imaging of the spine and/or extremities is a generally accepted, well established and widely used diagnostic procedure when specific indications, based on history and physical examination, are present. Physicians should refer to individual Division guidelines for specific information about specific testing procedures.

a. Radiographic Imaging, MRI, CT, bone scan, radiography, and other special imaging studies may provide useful information for many musculoskeletal disorders causing chronic pain.

b. Electrodiagnostic studies may be useful in the evaluation of patients with suspected myopathic or neuropathic disease and may include Nerve Conduction Studies (NCS), Standard Needle Electromyography, or Somatosensory Evoked Potential (SSEP). The evaluation of electrical studies is difficult and should be relegated to specialists who are well trained in the use of this diagnostic procedure.

c. Special Testing Procedures may be considered when attempting to comfirm the current diagnosis or reveal alternative diagnosis. In doing so, other special tests may be performed at the discretion of the physician.

d. Testing for complex regional pain syndrome (CRPS-I) or sympathetically maintained pain (SMP) is described in Division Rule XVII, Exhibit D, Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome Medical Treatment Guideline.

4. Laboratory Testing

Laboratory tests are generally accepted well established and widely used procedures and can provide useful diagnostic and monitoring information. They may be used when there is suspicion of systemic illness, infection, neoplasia, or underlying rheumatologic disorder, connective tissue disorder, or based on history and/or physical examination. Tests include, but are not limited to:

a. CBC with differential can detect infection, blood dyscrasias, and medication side effects;

b. Erythrocyte sedimentation rate, rheumatoid factor, ANA, HLA, and C-reactive protein can be used to detect evidence of a rheumatologic, infection, or connective tissue disorder;

c. Thyroid, glucose and other tests to detect endocrine disorders;

d. Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease;

e. Urinalysis to detect bacteria (usually with culture and sensitivity), calcium, phosphorus, hydroxyproline, or hematuria;

f. Liver and kidney function may be performed for baseline testing and monitoring of medications; and

g. Toxicology Screen and or Blood Alcohol Level if suspected drug or alcohol abuse.

5. Injections – Diagnostic Diagnostic injections are frequently employed in assessing the type of pain a patient may be having. They also aid in ascertaining possible mechanisms and origins of the pain as well as the site of the pain source. Some diagnostic injections have therapeutic properties that may be used to both diagnose and treat chronic pain. In those cases, refer to Non-Operative Treatment – Therapeutic Injections for specific information regarding these injections.

Description — generally accepted, well-established procedures. These injections may be useful for localizing the source of pain, and may have added therapeutic value when combined with injection of therapeutic medication(s). Each diagnostic injection has inherent risks, and risk versus benefit should always be evaluated when considering injection therapy. Since these procedures are invasive, less invasive or non-invasive procedures should be considered first. Selection of patients, choice of procedure, and localization of the level for injection should be determined by clinical information indicating strong suspicion for pathologic condition(s) and the source of pain symptoms.

The interpretation of the test result is primarily based upon pain response; the diagnostic significance of the test result should be evaluated in conjunction with clinical information and the results of other diagnostic procedures. Injections with local anesthetics of differing duration are required to confirm a diagnosis. In some cases, injections at multiple levels may be required to accurately diagnose pain. Refer to “Injections – Therapeutic” for information on specific injections.

Special Requirements for Diagnostic Injections — Since fluoroscopic, arthrographic and/or CT guidance during procedures is required to document technique and needle placement, an experienced physician should perform the procedure. The subspecialty disciplines of the physicians may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry. The practitioner should have experience in ongoing injection training workshops provided by organizations such as the International Spinal Injection Society (ISIS) and be knowledgeable in radiation safety. In addition, practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments of Radiology, as applicable.

Complications — General complications of diagnostic injections may include transient neurapraxia, nerve injury, infection, headache, vasovagal effects, as well as epidural hematoma, permanent neurologic damage, dural perforation and CSF leakage, and spinal meningeal abscess. Severe complications of cervical injections are remote but can include spinal cord damage, quadriplegia, and/or death.

Contraindications — Absolute contraindications of diagnostic injections include: (a) bacterial infection – systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d) possible pregnancy. Relative contraindications of diagnostic injections may include: (a) allergy to contrast or shellfish, (b) poorly controlled Diabetes Mellitus or hypertension, and (c) ASA/NSAIDs/antiplatelet therapy (drug may be held for 3 days or more, depending on the medication, prior to injection).

Specific Diagnostic Injections — In general, relief should last for at least the duration of the local anesthetic used and give significant relief of pain. Refer to “Injections – Therapeutic” for information on other specific therapeutic injections. The following injections are used primarily for diagnosis:

a. Medial Branch Blocks are primarily diagnostic, used to confirm the diagnosis of cervical facet pain. When used for diagnosis, two injections at different times with different duration of local anesthetic are recommended.

b. Intra-Articular Facet injections are principally diagnostic yet some patients may obtain therapeutic response. If the patient demonstrates definite shortterm but not long-term response, confirmatory medial branch blocks and possible medial branch neurotomy should be considered.

c. Atlanto-Axial and Atlanto-Occipital injections are for diagnosis and treatment but do not lend themselves to denervation techniques owing to variable neuroanatomy. Injection of this articulation is complicated by the proximity of the vertebral artery. The vertebral artery may be tortuous at the level of the C0-C1 joint. Inadvertent injection of the vertebral artery may cause respiratory arrest, seizure, stroke, or permanent neurological sequelae. Only practitioners skilled in these injections should perform them.

d. Sympathetic Injections are diagnostic injections that may be used in suspected cases of CRPS-I. Refer to Division Rule XVII, Exhibit D, Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome Medical Treatment Guideline for specific information regarding the use of these injections.

e. Peripheral Nerve Blocks are diagnostic injections that may be used in for specific nerve injury or entrapment syndromes. Refer to Injections – Therapeutic for detailed information about their use.

6. Special Tests

Special tests are generally well-accepted tests and are performed as part of a skilled assessment of the patients' capacity to return to work, his/her strength capacities, and or physical work demand classifications and tolerance. a. Computer-Enhanced Evaluations

(1) Frequency: One time for evaluation. Can monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations. b. Functional Capacity Evaluation (FCE)

Functional capacity evaluation is a comprehensive or modified evaluation of the various aspects of function as they relate to the worker's ability to return to work. This test may also be known as Physical Capacity Evaluation, Functional Capacity Assessment, and Work Capacity Evaluation. Areas such as endurance, lifting (dynamic and static), postural tolerance, specific range of motion, coordination and strength, worker habits, employability and financial status, as well as psychosocial aspects of competitive employment may be evaluated. Components of this evaluation may include: (a) musculoskeletal screen; (b) cardiovascular profile/aerobic capacity; (c) coordination; (d) lift/carrying analysis; (e) job-specific activity tolerance; (f) maximum voluntary effort; (g) pain assessment/psychological screening; (h) non- material and material handling activities; and (i) validity of effort and reproducibility. Standardized national guidelines (such as NIOSH) should be used as the basis for FCE recommendations.

Job Site evaluation is a comprehensive analysis of the physical, mental and sensory components of a specific job. The goal of the Job Site evaluation is to identify any job modification needed to ensure the safety of the employee upon return to work. These components may include, but are not limited to: (a) postural tolerance (static and dynamic); (b) aerobic requirements; (c) range of motion; (d) torque/force; (e) lifting/carrying; (f) cognitive demands; (g) social interactions; (h) visual perceptual; (i) environmental requirements of a job; (j) repetitiveness; and (k) essential functions of a job; and (1) ergonomic set up. Job descriptions provided by the employer are helpful but should not be used as a substitute for direct observation.

(1) Frequency: One time with additional visits as needed for follow-up per Job Site. d. Vocational Assessment

(1) Frequency: One time with additional visits as needed for follow-up e. Work Tolerance Screening

(1) Frequency: One time for evaluation. May monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations.

F. THERAPEUTIC PROCEDURES – NON-OPERATIVE

Non-operative therapeutic rehabilitation is applied to patients with chronic and complex problems of deconditioning and functional disability. Treatment modalities may be utilized sequentially or concomitantly depending on chronicity and complexity of the problem, and treatment plans should always be based on a diagnosis utilizing appropriate diagnostic procedures.

1) Return to work or maintaining work status

2) Fewer restrictions at work or performing activities of daily living (ADL).

3) Decrease in usage of medications

The following procedures are listed in alphabetical order.

1. Acupuncture

Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain.

(1) Time to produce effect: 3 to 6 treatments

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 1 to 2 months

(4) Maximum duration: 14 treatments b. Acupuncture with Electrical Stimulation

It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.

(1) Time to produce effect: 3 to 6 treatments

(2) Frequency: 1 to 3 times per week (3) Optimum duration: 1 to 2 months

(4) Maximum duration: 14 treatments c. Other Acupuncture Modalities

(1) Time to produce effect: 3 to 6 treatments

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 1 to 2 months

(4) Maximum duration: 14 treatments

2. Biofeedback

Biofeedback is a generally well-accepted form of behavioral medicine that helps patients learn self- awareness and self-regulation skills for the purpose of gaining greater control of their physiology. Stress- related psychophysiological reactions may arise as a reaction to organic pain, and in some cases may cause pain. Electronic instrumentation is used to monitor the targeted physiology and then displayed or fed back to the patient visually, auditorially, or tactilely, with coaching by a biofeedback specialist.

Indications for biofeedback include individuals who are suffering from musculoskeletal injury where muscle dysfunction or other physiological indicators of excessive or prolonged stress response affects and/or delays recovery. Other applications include training to improve self-management of pain, anxiety, panic, anger or emotional distress, narcotic withdrawal, insomnia/sleep disturbance, and other central and autonomic nervous system imbalances. Biofeedback is often utilized for relaxation training. Mental health professionals may also utilize it as a component of psychotherapy, where biofeedback and other behavioral techniques are integrated with psychotherapeutic interventions. Biofeedback is often used in conjunction with physical therapy or medical treatment.

Recognized types of biofeedback include the following: a. sEMG/Electromyogram (EMG) – Used for self-management of pain and stress reactions involving muscle tension. b. Skin Temperature – Used for self-management of pain and stress reactions, especially vascular headaches. c. Respiration Feedback (RFB) – Used for self-management of pain and stress reactions via breathing control. d. Respiratory Sinus Arrhythmia (RSA) – Used for self-management of pain and stress reactions via synchronous control of heart rate and respiration. Respiratory sinus arrhythmia is a benign phenomena, which consists of a small rise in heart rate during inhalation, and a corresponding decrease during exhalation. This phenomenon has been observed in meditators and athletes, and is thought to be a psychophysiological indicator of health. e. Heart Rate Variability (HRV) – Used for self-management of stress via managing cardiac reactivity. f. Electrodermal Response (EDR, EDG) – Used for self-management of stress involving palmar sweating or galvanic skin response. g. Electroencephalograph (EEG, QEEG) – Used for self-management of various psychological states by controlling brainwaves.

The goal in biofeedback treatment is normalizing the physiology to the pre-injury status to the extent possible and involves transfer of learned skills to the workplace and daily life. Candidates for biofeedback therapy or training must be motivated to learn and practice biofeedback and self-regulation techniques. In the course of biofeedback treatment, patient stressors are discussed and self-management strategies are devised. If the patient has not been previously evaluated, a psychological evaluation should be performed prior to beginning biofeedback treatment for chronic pain. The psychological evaluation may reveal cognitive difficulties, belief system conflicts, somatic delusions, secondary gain issues, hypochondriasis, and possible biases in patient self-reports, which can affect biofeedback. Home practice of skills is often helpful for mastery and may be facilitated by the use of home training tapes.

Psychologists or psychiatrists who provide psychophysiological therapy which integrates biofeedback with psychotherapy, should be either Biofeedback Certification Institute of America (BCIA) certified or practicing within the scope of their training. All other providers of Biofeedback for chronic pain patients must be BCIA certified and shall have their biofeedback treatment plan approved by the authorized treating psychologist or psychiatrist. Biofeedback treatment must be done in conjunction with the patient's psychosocial intervention. Biofeedback may also be provided by unlicensed health care providers, who follow a set treatment and educational protocol. Such treatment may utilize standardized material or relaxation tapes.

(1) Time to produce effect: 3 to 4 sessions

(2) Frequency: 1 to 2 times per week

(3) Optimum duration: 6 to 8 sessions

(4) Maximum duration: 10 to 12 sessions. Treatment beyond 12 sessions must be documented with respect to need, expectation, and ability to facilitate positive symptomatic or functional gains.

3. Complementary Alternative Medicine (CAM)

Although CAM practices are diverse and too numerous to list, they can be generally classified into five domains: a. Alternative Medical Systems – These are defined as medical practices that have developed their own systems of theory, diagnosis and treatment and have evolved independent of and usually prior to conventional Western Medicine. Some examples are Traditional Chinese Medicine, Ayurvedic Medicine, Homeopathy, and Naturopathy. b. Mind-Body Interventions – These include practices such as hypnosis, meditation, bioenergetics, and prayer. c. Biological-based Practices – These include herbal and dietary therapy as well as the use of nutritional supplements. To avoid potential drug interactions, supplements should be used in consultation with the authorized treating physician. d. Body-Based Therapy – Included in this category are the practices of Yoga and Rolfing bodywork. e. Energy-Based Practices – Energy-based practices include a wide range of modalities that support physical as well as spiritual and/or emotional healing. Some of the more well known energy practices include Qi Gong, Tai Chi, Healing Touch and Reiki. Practices such as Qi Gong and Tai Chi are taught to the patient and are based on exercises the patient can practice independently at home. Other energy-based practices such as Healing Touch and Reiki involve a practitioner/patient relationship.

Methods used to evaluate chronic pain patients for participation in CAM will differ with various approaches and with the training and experience of individual practitioners. A patient may be referred for CAM therapy when the patient's cultural background, religious beliefs or personal concepts of health suggest that an unconventional medical approach might assist in the patient's recovery or when the physician's experience and clinical judgment support a CAM approach. The patient must demonstrate a high degree of motivation to return to work and improve their functional activity level while participating in therapy. Other more traditional conservative treatments should generally be attempted before referral to CAM. Treatment with CAM requires prior authorization.

(1) Frequency: Per CAM therapy selected

(2) Optimum duration: Should be based upon the physician's clinical judgment and demonstration by the patient of positive symptomatic and functional gains. Practitioner provided CAM therapy is generally not recommended on a maintenance basis.

4. Sleep Disturbances

Disturbances of sleep are common in chronic pain. Although primary insomnia may accompany pain as an independent co-morbid condition, it more commonly occurs secondary to the pain condition itself. Exacerbations of pain often are accompanied by exacerbations of insomnia; the reverse can also occur. Sleep laboratory studies have shown disturbances of sleep architecture in pain patients. Loss of deep slow-wave sleep and increase in light sleep occur and sleep efficiency, the proportion of time in bed spent asleep, is decreased. These changes are associated with patient reports of non-restorative sleep.

Many chronic pain patients develop behavioral habits that exacerbate and maintain sleep disturbances. Excessive time in bed, irregular sleep routine, napping, low activity and worrying in bed are all maladaptive responses that can arise in the absence of any psychopathology. There is some evidence that behavioral modification, such as patient education and group or individual counseling, can be effective in reversing the effects of insomnia. Behavioral modifications are easily implemented and can include: a. Maintaining a regular sleep schedule, retiring and rising at approximately the same time on weekdays and weekends. b. Avoiding daytime napping. c. Avoiding caffeinated beverages after lunchtime d. Making the bedroom quiet and comfortable, eliminating disruptive lights, sounds, television sets, and keeping a bedroom temperature of about 65°;F. e. Avoiding alcohol or nicotine within two hours of bedtime. f. Avoiding large meals within two hours of bedtime. g. Exercising vigorously during the day, but not within two hours of bedtime, since this may raise core temperature and activate the nervous system. h. Associating the bed with sleep and sexual activity only, using other parts of the home for television, reading and talking on the telephone. i. Leaving the bedroom when unable to sleep for more than 20 minutes, retuning to the bedroom when ready to sleep again.

These modifications should be undertaken before sleeping medication is prescribed for long term use.

5. Injections — Therapeutic

Injections may be diagnostic, prognostic, or therapeutic. Diagnostic injections are frequently employed in assessing the type of pain a patient may be having. It also aids in ascertaining possible mechanisms and origins of the pain as well as the site of the pain source. Prognostic injection may be done, before administration of a neurolytic agent or subjecting such patient to a neurosurgical procedure, to ensure that benefits achieved with the prognostic nerve block or injection may exhibit a similar sensation that the patient may experience with a more permanent procedure. Therapeutic injections are employed after diagnostic blocks or injections have determined the nature and location of a pain syndrome.

When considering the use of injections in chronic pain management, the treating physician must carefully consider the inherent risks and benefits. First, it is understood that these injections are seldom meant to be “curative” but may have diagnostic or prognostic qualities and when used for therapeutic purposes they are employed in conjunction with other treatment modalities for maximum benefit.

Second, education of the patient should include the proposed goals of the injections, expected gains, risks or complications, and alternative treatment.

Lastly, reassessment of the patient's status in terms of functional improvement should be documented after each injection and/or series of injections. Any continued use of injections should be monitored using objective measures such as:

(1) Return to work or maintaining work status.

(2) Fewer restrictions at work or performing activities of daily living (ADL)

(3) Decrease in usage of medications

(4) Measurable functional gains, such as increased range of motion or documented increase in strength.

Visual analog scales (VAS) provide important subjective data but are not an appropriate measure of function.

The physician must be aware of the possible placebo effect as well as the longterm effects of injections related to the patient's physical and mental status. Strict adherence to contraindications, both absolute and relative, may prevent potential complications. Subjecting the patient to potential risks, i.e., needle trauma, infection, nerve injury, or systemic effects of local anesthetics and corticosteroids, must be considered before the patient consents to such procedures.

General Description – Therapeutic injections are generally accepted, well-established procedures. They may be used after initial conservative treatment, such as physical and occupational therapy, medication, manual therapy, exercise, acupuncture etc., has been undertaken. Therapeutic injections should be used only after pathology has been demonstrated. Injections are invasive procedures that can cause serious complications; thus clinical indications and contraindications should be closely adhered to. Cervical Injections are invasive procedures that can cause catastrophic complications. Refer to the Cervical Spine Injury guideline for more specific contraindications. It is recommended that all patients participate in an appropriate exercise program that may include a functionally directed rehabilitation program.

Special Considerations – For all injections (excluding trigger point, botox and occipital or peripheral nerve blocks) fluoroscopic, arthrographic and/or CT guidance during procedures is required to document technique and needle placement, and should be performed by a physician experienced in the procedure. The subspecialty disciplines of the physicians may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry. The practitioner should participate in ongoing injection training workshops such as those sponsored by International Society for Injection Studies (ISIS) and be knowledgeable in radiation safety. In addition, practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments of Radiology, as applicable.

Complications – General complications of these spinal injections may include (a) transient neurapraxia, local pain, nerve injury, infection, headache, urinary retention and vasovagal effects; (b) epidural hematoma, permanent neurologic damage, dural perforation and cerebral spinal fluid (CSF) leakage, spinal meningeal abscess; and or (c) suppression of the hypothalamic pituitary adrenal axis, which may be steroid dose dependent. Permanent paresis, anaphylaxis and arachnoiditis have been rarely reported with the use of epidural steroids. For cervical injections, severe complications are remote but can include spinal cord damage, quadriplegia, and/or death.

Contraindications – Absolute contraindications of therapeutic injections include: (a) bacterial infection – systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d) possible pregnancy. Relative contraindications of diagnostic injections may include: (a) allergy to contrast or shellfish, (b) poorly controlled Diabetes Mellitus or hypertension, and (c) ASA/NSAIDs/antiplatelet therapy (drug may be held for 3 days or more, depending on the medication, prior to injection).

Specific Therapeutic Injections – The following injections are considered to be reasonable treatment for patients with chronic pain. Other injections not listed may be beneficial. Please refer to specific treatment guidelines for indications, complications, and contraindications of each. a. Epidural Steroid Spinal Injections

Description – Epidural steroid injections (ESI) deliver corticosteroid into the epidural space. The purpose of ESI is to reduce pain and inflammation, restoring range of motion and thereby facilitating progress in more active treatment programs. ESI use three approaches: transforaminal, translaminar (midline), and caudal. There is good evidence to support a preference for a transforaminal approach. The evidence also suggests that the transforaminal approach can deliver medication to the target tissue with few complications and is therefore used to identify the specific site of pathology. This is also the preferred approach for post-surgical patients.

Needle Placement – Spinal imaging is required for all transforaminal epidural steroid injections. Since injections performed without radiographic guidance result in an increased risk of incorrect needle placement, spinal imaging is recommended for caudal and translaminar injections if available within 30 miles of the patient's home. Contrast epidurograms allow one to verify the flow of medication into the epidural space. Indications – There is some evidence that epidural steroid injections are effective for patients with radicular pain or radiculopathy (sensory or motor loss in a specific dermatome or myotome). Although there is no evidence regarding the effectiveness of ESI for non-radicular pain, it is a generally accepted intervention. Selected cases of vertebral compression fracture may be helped by ESI.

(1) Time to produce effect: Local anesthetic, approximately 30 minutes; corticosteroid, 48 to 72 hours for 80% of patients and 2 weeks for 20%.

(3) Optimum: Usually 1 up to 3 injection(s) in a series, depending upon each patient's response and functional gain. These should be performed in a 3 to 9 week period of time.

(4) Maximum: Up to 3 to 4 series of injections may be done based upon the patient's response to pain and function. Patients should be reassessed for measurable functional improvement after each injection session. The time between series should not be less than 4 to 6 months. b. Zygoapophyseal (Facet) Injection

Description – Intra-articular or pericapsular injection of local anesthetic and corticosteroid. Medial branch nerve blocks may be diagnostic only. There is conflicting evidence to support a long-term therapeutic effect using facet injections.

Indications – Facet injections may be considered in those patients whose history and examination are suggestive of a facet pain generator. Lumbar facet injections are primarily of diagnostic value. The therapeutic value of facet injections provides short-term pain relief for patients to progress through a functionally directed rehabilitation program. These injections are useful when used in conjunction with Manipulation Under Joint Anesthesia (MUJA). Facet injections determine level(s) of lumbar facet involvement and the degree of pain coming from the posterior elements. Facet injections may help determine the best therapeutic exercise approach (i.e., lumbar stabilization vs. sacroiliac stabilization).

(1) Time to produce effect: Approximately 30 minutes for local anesthetic; 48 to 72 hours for corticosteroid.

(2) Optimum: Usually 1 up to 3 injection(s) in a series, depending upon each patient's response and functional gain. These should be performed in a 3 to 9 week period of time.

(3) Maximum: Up to 3 to 4 series of injections may be done based upon the patient's response to pain and function. Patients should be reassessed for measurable functional improvement after each injection session. The time between series should not be less than 4 to 6 months. c. Selective Nerve Root Blocks

Description – Diagnostic and therapeutic blocks for radiculopathy. Therapeutic SNRB's serve as selective epidural with contrast flowing proximally into the epidural space. These are frequently useful in postoperative patients. The volume of medication used may be higher than with the diagnostic SNRB.

Indications – When used for diagnosis, small amounts of local anesthetic (with or without steroid) up to a total volume of 1.0 to 1.5 cc should be used to determine the level of nerve root irritation. The relief should last for at least the duration of the local anesthetic used and give significant relief of pain. Needle Placement – Selective placement for the needle is documented by neurogram under fluoroscopic or CT imaging. The transforaminal approach is useful and safer in patients with spinal stenosis in the cervical or thoracic areas where an interlaminar ESI may be contraindicated.

(1) Time to produce effect: 30 minutes for local anesthetic; 48 to 72 hours for 80% of patients and 2 weeks for 20% of patient when cortisone is used.

(2) Optimum: Usually 1 up to 3 injection(s) in a series, depending upon each patient's response and functional gain. These should be performed in a 3 to 9 week period of time.

Description – Trigger point injection consists of dry needling or injection of local anesthetic with or without corticosteroid into highly localized, extremely sensitive bands of skeletal muscle fibers that produce local and referred pain when activated. Medication is injected in the area of maximum tenderness. Injection efficacy can be enhanced if injections are immediately followed by myofascial therapeutic interventions, such as vapo-coolant spray and stretch, ischemic pressure massage (myotherapy), specific soft tissue mobilization and physical modalities. The effectiveness of trigger point injection is uncertain, in part due to the difficulty of demonstrating advantages of active medication over injection of saline. Needling alone may be responsible for some of the therapeutic response.

Indications – Trigger point injections may be used to relieve myofascial pain and facilitate active therapy and stretching of the affected areas. They are to be used as an adjunctive treatment in combination with other active treatment modalities. Trigger point injections should be utilized primarily for the purpose of facilitating functional progress. Patients should continue in an aggressive aerobic and stretching therapeutic exercise program as tolerated throughout the time period they are undergoing intensive myofascial interventions. Trigger point injections are indicated in those patients where well circumscribed trigger points have been consistently observed, demonstrating a local twitch response characteristic radiation of pain pattern and local autonomic reaction, such as persistent hyperemia following palpation. Generally, these injections are not necessary unless consistently observed trigger points are not responding to specific, noninvasive, myofascial interventions within approximately a 4 -week timeframe.

Complications – Potential but rare complications of trigger point injections include infection, pneumothorax, anaphylaxis, penetration of viscera, neurapraxia and neuropathy. If corticosteroids are injected in addition to local anesthetic, there is a risk of local myopathy developing. Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be immediately repositioned.

(1) Time to produce effect: Local anesthetic 30 minutes; 24 to 48 hours for no anesthesia.

(2) Frequency: Weekly. Suggest no more than 4 injection sites per session per week to avoid significant post-injection soreness.

(3) Optimum duration: 4 sessions.

(4) Maximum duration: 8 weeks. Some patients may require 2 to 4 repetitions of trigger point injection series over a 1 to 2 year period. e. Botulinum Toxin (Botox) Injection

Description – Used to temporarily weaken or paralyze muscles. May reduce muscle pain in conditions associated with spasticity, dystonia, or other types of painful muscle spasm. Neutralizing antibodies develop in at least 4% of patients treated with botulinum toxin type A, rendering it ineffective. Several antigenic types of botulinum toxin have been described. Botulinum toxin type B, first approved by the FDA in 2001, is similar pharmacologically to botulinum toxin type A, and there is good evidence of its efficacy in improving function in cervical dystonia (torticollis). It appears to be effective in patients who have become resistant to the type A toxin. The immune responses to botulinum toxins type A and B are not cross-reactive, allowing type B toxin to be used when type A action is blocked by antibody. Experimental work with healthy human volunteers suggests that muscle paralysis from type B toxin is not as complete or as long lasting as that resulting from type A. The duration of treatment effect of botulinum toxin type B for cervical dystonia has been estimated to be 12 to 16 weeks. EMG needle guidance may permit more precise delivery of botulinum toxin to the target area.

Indications – To improve range of motion and reduce painful muscle spasm. May be useful in musculoskeletal conditions associated with muscle spasm,, or headaches. There should be evidence of limited range of motion prior to the injection. May be useful in central neurologic conditions that produce spasticity or dystonia (e.g., brain injury, spinal cord injury, or stroke).

Complications – Over-weakening of injected muscles, allergic reaction to medications. Rare systemic effects include flu-like syndrome, weakening of distant muscle. There is an increased risk of systemic effects in patients with motor neuropathy or disorders of the neuromuscular junction.

(1) Time to produce effect: 24 to 72 hours post injection with peak effect by 4 to 6 weeks.

(2) Frequency: No less than 3 months between readministration.

(3) Optimum duration: 3 to 4 months.

(4) Maximum duration: Currently unknown. Repeat injections should be based upon functional improvement and therefore used sparingly in order to avoid development of antibodies that might render future injections ineffective. f. Sacroiliac Joint Injection

Description – Injection of local anesthetic under radiographic guidance, which may include corticosteroids in an intra-articular fashion into the sacroiliac joint. Long-term therapeutic effect has not yet been established.

Indications – Primarily diagnostic to rule out sacroiliac joint dysfunction vs. other pain generators. Intra- articular injection can be of value in diagnosing the pain generator. There should be documented relief from previously painful maneuvers (e.g., Patrick's test) on post-injection physical exam. Once diagnosis has been documented by intrajoint injection, posterior ligament block may be as effective as intra-joint injection for therapeutic value unless the primary pain is coming from an anterior capsular pain generator. Therapeutic responses to these injections vary but sacroiliac joint blocks may facilitate functionally directed rehabilitation programs.

(1) Time to produce effect: Approximately 30 minutes for local anesthetic; 48 to 72 hours for corticosteroid.

(2) Optimum: Usually 1 to 3 injection(s) in a series, depending upon each patient's response and functional gain. These should be performed in a 3-9 week period of time.

Refer to Division Rule XVII, Exhibit D, Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome Medical Treatment Guideline for specific information regarding the use of these injections. h. Peripheral Nerve Blocks

Description – These injections are principally diagnostic for specific nerve injury or entrapment syndromes, yet some patients may obtain therapeutic response. Injections may include local anesthetic or corticosteroid.

Indications – Painful neuropathy occurring in a peripheral nerve distribution and documented by clinical correlation or specific testing (i.e., EMG).

Needle Placement – The nerve is located by anatomy. If during insertion, the patient encounters pain, the needle must be repositioned. This procedure should be performed by those trained in regional anesthesia techniques. Knowledge of anatomy and use of local anesthetic must be adhered to in order to prevent severe complications.

(1) Time to produce effect: 30 minutes for local anesthetic; 48 to 72 hours for 80% of patients and 2 weeks for 20% of patient when cortisone is used.

(2) Frequency: Usually 1 to 3 injection(s) in a series, depending upon each patient's response and the nerve involved.

(3) Optimum/Maximum: Repeat injections should only be considered based on functional improvement.

6. Interdisciplinary Rehabilitation Programs

Interdisciplinary Rehabilitation Programs are the gold standard of treatment for individuals with chronic pain who have not responded to less intensive modes of treatment. In addition, there are current studies to support the use of pain programs. There is strong evidence that interdisciplinary programs improve function in chronic pain and moderate evidence that these programs decrease pain in these patients.

These programs should assess the impact of pain and suffering on the patient's medical, physical, psychological, social and/or vocational functioning. In general, interdisciplinary programs deal with irreversible, painful musculoskeletal, neurological, and other chronic painful disorders and psychological issues, including drug dependence, high levels of stress and anxiety, failed surgery and preexisting or latent psychopathology. The number of professions involved in the team in a chronic pain program may vary due to the complexity of the needs of the person served. The Division recommends consideration of referral to an interdisciplinary program within 6 months post-injury in patients with delayed recovery unless surgical interventions or other medical complications intervene.

Chronic pain patients need to be treated as outpatients within a continuum of treatment intensity. Outpatient chronic pain programs are available with services provided by a coordinated interdisciplinary team within the same facility (formal) or as coordinated by the authorized treating physician (informal). Formal programs are able to provide coordinated, high intensity level of services and are recommended for most chronic pain patients who have received multiple therapies during acute management. Informal programs offer a lesser intensity of service and may be considered for patients who are currently employed, those who cannot attend all day programs, those with language barriers, or those living in areas not offering formal programs. Before treatment has been initiated, the patient, physician, and insurer should agree on treatment approach, methods and goals. Generally the type of outpatient program needed will depend on the degree of impact the pain has had on the patient's medical, physical, psychological, social and/or vocational functioning. When referring a patient for formal outpatient interdisciplinary pain rehabilitation or Work Hardening programs, the Division recommends the programs be Commission on Accreditation of Rehabilitation Facilities (CARF) eligible and/or certified. CARF eligibility or certification ensures that programs meet specific care standards of design and efficacy.

Inpatient Pain Rehabilitation Programs are rarely needed but may be necessary for patients with any of the following conditions: (a) High risk for medical instability; (b) Moderate to severe impairment of physical/functional status; (c) Moderate to severe pain behaviors; (d) Moderate impairment of cognitive and/or emotional status; (e) Dependence on medications from which he or she needs to be withdrawn; and (f) The need for 24-hour supervised nursing.

Interdisciplinary programs are characterized by a variety of disciplines that participate in the assessment, planning, and/or implementation of the treatment program. These programs are for patients with greater levels of perceived disability, dysfunction, deconditioning and psychological involvement. The following programs are listed in order of decreasing intensity. a. Formal Rehabilitation Programs

1) Interdisciplinary Pain Rehabilitation

An Interdisciplinary Pain Rehabilitation Program provides outcomes-focused, coordinated, goal- oriented interdisciplinary team services to measure and improve the functioning of persons with pain and encourage their appropriate use of health care system and services. The program can benefit persons who have limitations that interfere with their physical, psychological, social, and/or vocational functioning. The program shares information about the scope of the services and the outcomes achieved with patients, authorized providers, and insurers.

The interdisciplinary team maintains consistent integration and communication to ensure that all interdisciplinary team members are aware of the plan of care for the patient, are exchanging information, and implement the plan of care. The team members make interdisciplinary team decisions with the patient and then ensure that decisions are communicated to the entire care team.

The medical director of the pain program should be board certified in his or her specialty area, have at least two years full-time experience in an interdisciplinary pain rehabilitation program, and ideally be board certified in pain management. Individuals who assist in the accomplishment of functional, physical, psychological, social and vocational goal must include, at the least, a medical director, pain physician(s), psychologist, Biofeedback Therapist, Occupational Therapist, Physical Therapist, and Registered Nurse. Other disciplines on the team may include, but are not limited to, case manager, exercise physiologist, psychiatrist, and/or nutritionist.

(1) Time to produce effect: 3 to 4 weeks

(2) Frequency: No less than 5 hours/day, 5 days/week

(3) Optimum duration: 3 to 4 weeks 5 times a week, followed by 6 to 9 weeks of follow-up 1 to 3 times a week.

(4) Maximum duration: 4 months, including follow-up. Periodic review and monitoring thereafter on an as needed basis, is founded upon the documented maintenance of functional gains.

2) Work Hardening

Work Hardening is an interdisciplinary program addressing a patient's employability and return to work. It includes a progressive increase in the number of hours per day that a patient completes work simulation tasks until the patient can tolerate a full workday. A full workday is case specific and is defined by the previous employment of the patient. This is accomplished by addressing the medical, psychological, behavioral, physical, functional, and vocational components of employability and return-to-work. The interdisciplinary team should, at a minimum, be comprised of a qualified medical director who is board certified with documented training in occupational rehabilitation, team physicians having experience in occupational rehabilitation, occupational therapy, physical therapy, case manager, and psychologist. As appropriate, the team may also include: chiropractor, RN, or vocational specialist.

(1) Time to produce effect: 2 weeks

(2) Frequency: 2 to 5 visits per week, up to 8 hours/day.

(3) Optimum duration: 2 to 4 weeks

A Coordinated Interdisciplinary Pain Rehabilitation Program is one in which the authorized treating physician coordinates all aspects of care. This type of program is similar to the formal programs in that it is goal oriented and provides interdisciplinary rehabilitation services to manage the needs of the patient in the following areas: (a) functional, (b) medical, (c) physical, (d) psychological, (e) social, and (f) vocational.

This program is different from a formal program in that it involves lesser frequency and intensity of services/treatment. Informal rehabilitation is geared toward those patients who do not need the intensity of service offered in a formal program or who cannot attend an all-day program due to employment, daycare, language or other barriers.

Patients should be referred to professionals experienced in outpatient treatment of chronic pain. The Division recommends the authorized treating physician consult with physicians experienced in the treatment of chronic pain to develop the plan of care.

(1) Time to produce effect: 3 to 8 weeks

(2) Frequency: 2 to 6 hours per day, 2 to 5 days each week.

(3) Optimum duration: 6 to 12 weeks, including follow-up.

(4) Maximum duration: 4 months, including follow-up. Periodic review and monitoring thereafter on an as needed basis, is founded upon the documented maintenance of functional gains.

7. Medications

There is no single formula for pharmacological treatment of patients with chronic nonmalignant pain. A thorough medication history, including use of alternative and over the counter medications, should be performed at the time of the initial visit and updated periodically. Appropriate application of pharmacological agents depends on the patient's age, past history (including history of substance abuse), drug allergies and the nature of all medical problems. It is incumbent upon the physician to thoroughly understand pharmacological principles when dealing with the different drug families and their respective side effects, bioavailability profiles, and primary reason for each medication's usage.

Control of chronic non-malignant pain is expected to involve the use of medication. Strategies for pharmacological control of pain cannot be precisely specified in advance. Rather, drug treatment requires close monitoring of the patient's response to therapy, flexibility on the part of the prescriber, and a willingness to change treatment when circumstances change. Many of the drugs discussed in the medication section were licensed for indications other than analgesia, but are effective in the control of many types of chronic pain. Consensus regarding the use of opioids has generally been reached in the field of cancer pain, where nociceptive mechanisms are generally identifiable, expected survival may be short, and symptomatic relief is emphasized more than functional outcomes. In injured workers, by contrast, central and neuropathic mechanisms frequently overshadow nociceptive processes, expected survival is relatively long, and return to a high level of function is a major goal of treatment. Approaches to pain, which were developed in the context of malignant pain, therefore may not be transferable to chronic non-malignant pain.

The preceding principles do no apply to chronic headache patients. These patients should be referred to a physician specializing in the diagnosis and treatment of headache and facial pain.

For the clinician to interpret the following material, it should be noted that: (1) drug profiles listed are not complete; (2) dosing of drugs will depend upon the specific drug, especially for off-label use; and (3) not all drugs within each class are listed, and other drugs within the class may be appropriate. Clinicians should refer to informational texts or consult a pharmacist before prescribing unfamiliar medications or when there is a concern for drug interactions.

The following drug classes are listed in alphabetical order, not in order of suggested use. a. Alpha-Acting Agents

Noradrenergic pain-modulating systems are present in the central nervous system, and the alpha-2 adrenergic receptor may be involved in the functioning of these pathways. Alpha-2 agonists may act by stimulating receptors in the substantia gelatinosa of the dorsal horn of the spinal cord, inhibiting the transmission of nociceptive signals. Spasticity may be reduced by presynaptic inhibition of motor neurons. Given limited experience with their use, they cannot be considered first-line analgesics, but a trial of their use may be warranted in many cases of refractory pain.

1) Clonidine (Catapres)

a) Description – Central alpha 2 agonist.

b) Indications – Sympathetically mediated pain, treatment of withdrawal from opioids.

c) Major Contraindications – Severe coronary insufficiency, renal impairment.

d) Dosing and Time to Therapeutic Effect – Increase dosage weekly to therapeutic effect.

e) Major Side Effects – Sedation, orthostatic hypotension, sexual dysfunction, thrombocytopenia, weight gain, agitation, rebound hypertension with cessation.

f) Drug Interactions – Beta adrenergics, tricyclic antidepressants.

g) Recommended Laboratory Monitoring – Renal function. 2) Tizanidine (Zanaflex)

a) Description – Alpha 2 adrenergic agonist.

b) Indications – Spasticity, musculoskeletal disorders.

c) Major Contraindications – Hepatic disease.

d) Dosing and Time to Therapeutic Effect – As needed (PRN) or titrate to effective dose.

e) Major Side Effects – Hypotension, sedation, hepatotoxicity, hallucinations and psychosis, dry mouth.

f) Drug Interactions – Alcohol, oral contraceptives, acetaminophen. Use with caution with other alpha agonists.

g) Recommended Laboratory Monitoring – Hepatic and renal function. b. Anticonvulsants

1) Gabapentin (Neurontin)

a) Description – Structurally related to GABA but does not interact with GABA receptors.

b) Indications – Neuropathic pain.

c) Relative Contraindications – Renal insufficiency.

d) Dosing and Time to Therapeutic Effect – Dosage may be increased over several days.

e) Major Side Effects – Confusion, sedation.

f) Drug Interactions – Oral contraceptives, cimetidine, antacids.

g) Recommended Laboratory Monitoring – Renal function.

2) Oxcarbazepine (Trileptal)

a) Description – The mechanism of action resembles that of carbamazepine, but has an advantage in being a less potent inducer of hepatic enzymes. Controlled trials of its effectiveness in chronic pain are lacking.

b) Indications – Neuropathic pain. c) Major Contraindications – Hypersensitivity to carbamazepine.

d) Dosing and Time to Therapeutic Effect – Dosage may be increased weekly.

e) Major Side Effects – Sedation, visual disturbances.

f) Drug Interactions – Oral contraceptives, valproic acid, carbamazepine.

g) Recommended Laboratory Monitoring – Drug levels, renal and hepatic function.

3) Carbamazepine (Tegretol)

a) Description – Anticonvulsant structurally related to tricyclic antidepressants.

b) Indications – Trigeminal neuralgia and other neuropathic pain.

c) Major Contraindications – Bone marrow depression, hypersensitivity to tricyclic antidepressants.

d) Dosing and Time to Therapeutic Effect – Dosage levels typically exceed those utilized for seizure prophylaxis. Titrate to desired effect.

e) Major Side Effects – Aplastic anemia, agranulocytosis, nausea, diplopia, pulmonary sensitivity, inappropriate antidiuretic hormone, dysphoria, disequilibrium.

f) Drug Interactions – Many interactions have been reported including, but not limited to, macrolide antibiotics, valproic acid, SSRI's, propoxyphene, doxycycline, bupropion, anticoagulants, and acetaminophen.

g) Recommended Laboratory Monitoring – Drug levels, renal and hepatic function, complete blood count. c. Antidepressants

1) Tricyclics (e.g., amitriptyline [Elavil], nortriptyline [Pamelor, Aventyl], doxepin [Sinequan, Adapin])

a) Description – Serotonergics, typically tricyclic antidepressants (TCAs), are utilized for their serotonergic properties as increasing CNS serotonergic tone can help decrease pain perception in non-antidepressant dosages. Amitriptyline is known for its ability to repair Stage 4 sleep architecture, a frequent problem found in chronic pain patients and to treat depression, frequently associated with chronic pain. b) Indications – Chronic musculoskeletal and/or neuropathic pain, insomnia. Second line drug treatment for depression.

c) Major Contraindications – Cardiac disease or dysrhythmia, glaucoma, prostatic hypertrophy, seizures, suicide risk.

d) Dosing and Time to Therapeutic Effect – Varies by specific tricyclic. Low dosages are commonly used for chronic pain and/or insomnia.

e) Major Side Effects – Anticholinergic side effects including, but not limited to, dry mouth, sedation, orthostatic hypotension, cardiac arrhythmia, weight gain.

f) Drug Interactions – Tramadol (may cause seizures), Clonidine, cimetidine, sympathomimetics, valproic acid, warfarin, carbamazepine, bupropion, anticholinergics, quinolones.

g) Recommended Laboratory Monitoring – Renal and hepatic function. EKG for those on high dosages or with cardiac risk.

2) SSRIs (e.g., citalopram [Celexa], fluoxetine [Prozac], paroxetine [Paxil], sertraline [Zoloft]).

a) Description – SSRIs are characterized by the predominance of inhibition of serotonin reuptake at the pre-synaptic nerve terminal.

b) Indications – Depression, chronic pain with depression and/or anxiety. Less effective than tricyclic antidepressants for neuropathic pain.

c) Major Contraindications – Allergy to SSRIs.

d) Time to Produce Therapeutic Effect – 3 to 4 weeks.

e) Major Side Effects – Insomnia, GI distress, sexual dysfunction.

f) Drug Interactions – Multiple drug interactions have been reported, including non-sedating antihistamine. May be used in combination with TCAs but therapeutic TCA levels (as used for depression) are known to increase when used in combination with SSRIs and may persist for at lease 5 weeks after discontinuance. Tramadol should not be used with SSRIs due to potential for seizures.

g) Recommended Laboratory Monitoring – Renal and hepatic function.

3) Atypical Antidepressants/Other Agents

a) Description – Venlafaxine, (Effexor), nefazadone (Serzone), trazodone (Deseryl), and mirtazapine (Remeron) share adjuvant analgesic effects with tricyclic antidepressants. They differ in their side effect and drug interaction profiles.

b) Indications – Venlafaxine is approved for generalized anxiety disorder, bupropion for smoking cessation.

c) Major Contraindications – Seizures, eating disorders.

d) Major Side Effects – Depends on the drug, but commonly include GI distress, drowsiness, sexual dysfunction less than other classes except trazadone, which may cause priapism. Hypertension (venlafaxine). e) Drug Interactions – Drug specific. Prolongation of QT interval with rare arrhythmias associated with nefazadone and non-sedating antihistamines.

f) Recommended Laboratory Monitoring – Drug specific. d. Hypnotics and Sedatives

Most insomnia in chronic pain patients should be managed primarily though behavioral interventions with medications as secondary measures (refer to “Disturbances of Sleep” section).

1) Zaleplon (Sonata)

a) Description – A nonbenzodiazepine hypnotic.

b) Indications – Insomnia.

c) Dosing and Time to Therapeutic Effect – Time of onset is 30 to 60 minutes. Due to rapid elimination, may be taken as little as 4 hours before awakening.

d) Major Side Effects – Dizziness, dose-related amnesia.

e) Drug Interactions – Increases sedative effect of other CNS depressant drugs. Use low dose if on cimetidine.

f) Recommended Laboratory Monitoring – Hepatic function.

2) Zolpidem (Ambien)

a) Description – A nonbenzodiazepine hypnotic, which does not appear to cause rebound insomnia. It has little respiratory depression and insignificant anxiolytic or muscle relaxant activity.

b) Indications – Short-term use for insomnia

c) Time to Therapeutic Effect – Onset of action is 30 to 60 minutes

d) Major Side Effects – Dizziness, dose-related amnesia.

e) Drug Interactions – Increases sedative effect of other CNS depressant drugs.

f) Recommended Laboratory Monitoring – Hepatic function. e. Skeletal Muscle Relaxants

Skeletal muscle relaxants are most useful for acute musculoskeletal injury or exacerbation of injury. Chronic use of benzodiazepines is discouraged due to their habit-forming potential and due to seizure risk following abrupt withdrawal.

1) Cyclobenzaprine (Flexeril) a) Description – Structurally related to tricyclics.

b) Indications – Chronic pain associated with muscle spasm.

c) Major Contraindications – Cardiac dysrhythmias.

d) Dosing and Time to Therapeutic Effect – Variable, onset of action is 1 hour.

e) Major Side Effects – Sedation, anticholinergic, blurred vision.

f) Drug Interactions – Consider interactions similar to tricyclic antidepressants as listed under antidepressant class.

g) Recommended Laboratory Monitoring – Hepatic and renal function.

2) Carisopordol (Soma)

a) Description – Mode of action may be central; meprobamate is an active metabolite.

b) Indications – Chronic pain associated with muscle spasm.

c) Major Contraindications – Sensitivity to meprobamate, renal or hepatic disease.

d) Major Side Effects – Sedation, withdrawal symptoms, abuse potential.

e) Recommended Laboratory Monitoring – Renal and hepatic function.

3) Metazalone (Skelaxin)

a) Description – Central acting muscle relaxant.

b) Indications – Muscle spasm.

c) Major Contraindications – Hepatic disease, pregnancy, and disposition to drug induced hemolytic anemia.

d) Dosing and Time to Therapeutic Effect – Onset of action 1 hour.

f) Recommended Laboratory Monitoring – Hepatic function. f. Opioids

Opioids include some of the oldest and most effective drugs used in the control of severe pain. The discovery of opioid receptors and their endogenous peptide ligands has led to an understanding of effects at the binding sites of these naturally occurring substances. Most of their analgesic effects have been attributed to their modification of activity in pain pathways within the central nervous system; however, it has become evident that they also are active in the peripheral nervous system. Activation of receptors on the peripheral terminals of primary afferent nerves can mediate antinociceptive effects, including inhibition of neuronal excitability and release of inflammatory peptides. Some of their undesirable effects on inhibiting gastrointestinal motility are peripherally mediated by receptors in the bowel wall. The central nervous system actions of these drugs account for much of their analgesic effect and for many of their other actions, such as respiratory depression, drowsiness, mental clouding, reward effects, and habit formation. With respect to the latter, it is crucial to distinguish between three distinct phenomena: tolerance, dependence, and addiction.

Tolerance refers to a state of adaptation in which exposure to a drug over time causes higher doses of that drug to be required in order to produce the same physiologic effect.

Tolerance and dependence are physiological phenomena, are expected with the continued administration of opioids, and should not deter physicians from their appropriate use. Before increasing the narcotic dose due to a presumption of physiologic tolerance, the physician should review other possible causes for the decline in analgesic effect.

Consideration should be given to possible new psychologic stressors or an increase in the activity of the nociceptive pathways.

1) General Indications – There must be a clear understanding that opioids are to be used for a limited term in the first instance (see trial indications below), that their use is contingent upon certain obligations or goals being met by the patient, e.g., return to work, and the patient understands that there may be drug screening to ensure compliance.

2) Therapeutic Trial Indications – A therapeutic trial of opioids should not be employed unless the patient has begun or completed a full rehabilitation program. Once this criterion has been met, opioids would be indicated when a patient meets the following:

a) The failure of pain management alternatives, including active therapies, cognitive behavioral therapy, pain self-management techniques, and other appropriate medical techniques. b) Physical and psychosocial assessment, performed by two specialists including the authorized treating physician and a specialist with expertise in chronic pain.

c) Informed, written, witnessed consent by the patient.

3) On-Going, Long-Term Management – Actions should include:

a) Prescriptions from a single practitioner,

b) Ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects,

c) Ongoing effort to gain improvement of social and physical function as a result of pain relief,

d) Contract detailing reasons for termination of supply, with appropriate tapering of dose,

e) Use of random drug screening as deemed appropriate by the prescribing physician,

f) Use of more than two opioids: a long acting opioid for maintenance of pain relief and a short acting opioid for limited rescue use when pain exceeds the routine level. If more than two opioids are prescribed for long-term use, a second opinion from specialist who is Board Certified in Neurology, Physical Medicine and Rehabilitation, or Anesthesiology with recognized training and/or certification in pharmacological pain management is strongly recommended.

g) Use of acetaminophen-containing medications in patients with liver disease should be limited; and

h) Continuing review of overall situation with regard to nonopioid means of pain control.

i) Inpatient treatment in complex cases. Refer to Interdisciplinary Rehabilitation Programs for detailed information on in-patient criteria.

4) Relative Contraindications – Extreme caution should be used in prescribing controlled substances for workers with one or more “relative contraindications”:

a) History of alcohol or other substance abuse, or a history of chronic, high-dose benzodiazepine use;

b) Off work for more than six months;

c) Severe personality disorder

5) General Contraindications –

a) Active alcohol or other substance abuse.

b) Untreated mood or psychotic disorders (e.g., depression).

c) Decreased physical or mental function with continued opioid use. d) Addictive behaviors. Warning signs include:

(1) Preoccupation with drugs;

(2) Refusal to participate in medication taper;

(3) Reporting that nothing but a specific opioid works;

(4) Strong preference for short-acting over long-acting opioids;

(5) Use of multiple prescribers and pharmacies;

(6) Use of street drugs or other patients drugs;

(7) Not taking medications as prescribed;

(8) Loss of medications more than once; and/or

(9) Criminal behaviors to obtain drugs, i.e., forged prescriptions.

6) Dosing and Time to Therapeutic Effect – Oral route is the preferred route of analgesic administration because it is the most convenient and cost-effective method of administration. When patients cannot take medications orally, rectal and transdermal routes should be considered because they are also relatively noninvasive.

7) Major Side Effects – There is great individual variation in susceptibility to opioid-induced side effects and clinicians should monitor for these potential side effects. Common initial side effects include nausea, vomiting, drowsiness, unsteadiness, and confusion. Occasional side effects include dry mouth, sweating, pruritus, hallucinations, and myoclonus. Rare side effects include respiratory depression and psychological dependence. Constipation and nausea/vomiting are common problems associated with long-term opioid administration and should be anticipated, treated prophylactically, and monitored constantly.

8) Drug Interactions – Patients receiving opioid agonists should not be given a mixed agonist-antagonist (pentazocine [Talwin], butorphanol [Stadol]) because doing so may precipitate a withdrawal syndrome and increase pain.

9) Recommended Laboratory Monitoring – Primary laboratory monitoring is recommended for acetaminophen/ASA/NSAIDs combinations (renal and liver function, blood dyscrasias). May perform urine and or blood drug screen if suspect use of other narcotics or lack of compliance with full medication regimen.

10) Patient Physician Contracts – All patients on chronic opioids should have an informed, written, witnessed consent. The contract should discuss side effects of opioids, results of use in pregnancy, inability to refill lost or missing medication, withdrawal symptoms, requirement for drug testing, and necessity of tapering.

11) Potentiating Agents – Some medications appear to potentiate the analgesic effects of opioids. Dextromethorphan is available as a nonopioid non-prescription antitussive agent in numerous cough and cold remedies. It antagonizes N-methyl-D-aspartate receptors involved in central sensitization of pain pathways. It may exert some morphine sparing effects in patients taking morphine, but its activity as an analgesic in neuropathic pain is likely to be weak. It is well tolerated in most patients. Because the patient profiles that might predict response to dextromethorphan are undefined, its use in chronic pain must be empirically tried on an individual basis. Diphenhydramine and hydroxyzine (Atarax, Vistaril) are antihistamines, which act at H1 receptors to alleviate allergic symptoms and produce somnolence. Diphenhydramine is a component of some non-prescription sleeping preparations. Their use in potentiating the effects of analgesic drugs is not clearly defined, but it may be used empirically for this purpose. g. Non-Steroidal Anti-Inflammatory Drugs

There are several classes of NSAIDs and the response of the individual injured worker to a specific medication is unpredictable. For this reason a range of NSAIDs may be tried in each case with the most effective preparation being continued. COX-2 inhibitors differ in adverse side effect profiles from the traditional NSAIDs. The major advantage of COX-2 inhibitors over traditional NSAIDs is that they have less gastrointestinal toxicity and do not inhibit platelet aggregation.

1) Non-Selective NSAIDs

a) Description – Inhibit cyclooxygenase (COX) enzymes, which are involved in several inflammatory processes.

b) Indications – Pain and inflammation.

c) Major Contraindications – Renal and liver failure.

d) Major Side Effects – Serious GI toxicity, such as bleeding, perforation, and ulceration can occur at any time, with or without warning symptoms. Renal insufficiency. Anaphylactic reactions, interference with platelet function, fluid retention and edema has been observed in some patients. Exacerbation of hypertension.

e) Drug Interactions – Varies with medication. Should not be used in aspirin-sensitive patients.

f) Recommended Laboratory Monitoring – Renal function.

2) Selective Cyclooxygenase-2 (COX-2) Inhibitors

a) Description – Inhibit the COX-2 enzyme, allowing the COX-1 enzyme to continue its protective effects on the gastric mucosa. Differ in adverse side effect profiles from non-selective NSAIDs in that they have less GI toxicity and no platelet effect.

b) Indications – Recommended in select patients whom traditional NSAIDS are not tolerated or in patients at high risk of peptic ulcer. Celecoxib is FDA approved for osteoarthritis and rheumatoid arthritis. Rofecoxib is FDA approved for acute pain and osteoarthritis.

c) Major Contraindications – Celecoxib is contraindicated in sulfonamide allergic patients.

d) Major Side Effects – COX-2 inhibitors can worsen renal function in patients with renal insufficiency.

e) Drug Interactions – Varies with medication.

f) Recommended Laboratory Monitoring – Renal function h. Topical Drug Delivery a) Description – Topical medications may be an alternative treatment for localized musculoskeletal disorders and is an acceptable form of treatment in selected patients although there is no scientific evidence to support its use in chronic pain. b) Indications – Generalized musculoskeletal or joint pain. Patient selection must be rigorous to select those patients with the highest probability of compliance. c) Dosing and Time to Therapeutic Effect – It is necessary that all topical agents be used with strict instructions for application as well as maximum number of applications per day to obtain the desired benefit and avoid potential toxicity. d) Side Effects – Localized skin reactions may occur, depending on drug. i. Herbal/Dietary Supplements

Botanical preparations have been used for centuries to remedy human illnesses, but only recently have been subjected to systematic study. Many medications currently manufactured by pharmaceutical firms are derivatives of compounds originally isolated from plants.

Clinical trials of folk remedies have been few in number, and often flawed by methodological problems. The lack of reliable data on the clinical and biological effects of herbal remedies often leads to inappropriate use. Patients commonly use non-standard remedies without discussing them with their physicians; when pharmacological interactions exist between herbs and prescription drugs, adverse effects may follow. Quality control varies between manufacturers, and because herbs are classified as dietary supplements, they are exempt from regulations governing standardization of ingredients. Physicians should ask all patients about their use of herbal medications and dietary supplements.

1) Description – The following herbs may be appropriate for patients who prefer herbs as an alterative to prescription analgesics or NSAIDs:

a) White Willow Bark – There is some evidence of the effectiveness of Salix (willow) bark extract in chronic low back pain. A principal ingredient is salicin, with salicylic acid as the principal metabolite. In doses of 240 mg of salicin daily, willow bark extract is more effective than placebo in alleviating pain and improving scores of physical impairment. This dose is approximately equivalent to 50 mg of acetylsalicylate, which cannot alone account for its analgesic effect. It is well tolerated, with gastrointestinal complaints occurring no more frequently than with placebo. In patients at risk for GI problems from NSAID drugs, willow bark may be an appropriate option.

b) Devil's Claw Root – Extract of Hapagophytum procumbens, with the common name of devil's claw root, have been used in parts of Europe for conditions of the musculoskeletal system, including osteoarthritis and low back pain. There is some evidence that it may relieve back pain more effectively than placebo, but functional improvement has not yet been shown. The doses used in clinical trials have consisted of 50 to 100 mg of harpagoside daily. Mild gastrointestinal upset has been reported at higher doses.

c) Phytodolor – A standardized extract of Populus tremula (aspen), Fraxinus excelsior (European ash), and Solidago virgaurea (goldenrod), Phytodolor may have anti-inflammatory properties through inhibition of cyclooxygenase pathways. In doses of up to 180 drops per day in 3 divided doses, it has shown superiority to placebo in osteoarthritis and epicondylitis when pain and grip strength were evaluated. Adverse effects were not reported to exceed those of placebo.

d) St. John's Wort – An herbal extract of the flowering plant Hypericum perforatum commonly used in the treatment of mild to moderate depression, St. John's Wort has been tested for effectiveness in neuropathic pain. There is some evidence that it lacks effectiveness on pain in polyneuropathy. The Division does not recommend its use as an alternative analgesic in chronic pain conditions. There is also some evidence that it is no more effective than placebo in the treatment of major depression. It should not be considered an antidepressant agent in patients requiring medical treatment of depression.

2) Specific Drug Interactions – Current regulations prohibit herb manufacturers from claiming that their products treat or prevent disease, but allow them to make claims about the product's effect on body function. Because herbal products are biologically active, they may interact with prescription drugs and with one another. Much of what is known concerning drug interactions is based on case reports or case series, which commonly lack crucial documentation of concomitant medication use or positive identification of herbs involved.

a) Physicians should be aware that patients on warfarin should have INR measured a week after starting to take any herbal preparation.

b) Ginkgo, ginseng, and garlic are commonly used for reasons unrelated to relief of pain; they interfere with platelet function, and patients who take them should have bleeding times monitored.

c) St. John's Wort should not be combined with an SSRI, since a serotonin syndrome may result. St. John's Wort induces the CYP3A4 hepatic enzyme, lowering levels of drugs metabolized by this system; these drugs include anticonvulsants, oral contraceptives, antiretroviral, and calcium channel blockers.

d) Kava, often used to alleviate anxiety, may potentiate benzodiazepine anxiolytics and produce excess sedation.

e) Herbal preparation usage during the perioperative period should be discouraged. j. Other Agents

1) Tramadol (Ultram)

a) Description – An opioid partial agonist that is generally well tolerated, does not cause GI ulceration, or exacerbate hypertension or congestive heart failure.

b) Indications – Mild to moderate pain relief. This drug has been shown to provide pain relief equivalent to that of commonly prescribed NSAIDs.

c) Contraindications – Use cautiously in patients who have a history of seizures or who are taking medication that may lower the seizure threshold, such as MAO inhibitors, SSRIs, and TCAs. Not recommended in those with prior opioid addiction.

d) Side Effects – May cause impaired alertness or nausea. This medication has physically addictive properties and withdrawal may follow abrupt discontinuation.

e) Drug Interactions – Narcotics, sedating medications.

f) Recommended Laboratory Monitoring – Renal and hepatic function.

2) Baclofen (Lioresal)

a) Description – May be effective due to stimulation of GABA receptors.

b) Indications – Pain from muscle rigidity.

c) Side Effects – Development of ovarian cysts, exacerbation of psychotic disorders, may precipitate seizures in epileptics, dry mouth, sexual dysfunction. d) Recommended Laboratory Monitoring – Renal function.

3) Mexilitene (Mexitil)

a) Description – An antiarrhythmic drug, which, like some anticonvulsive agents, may act on ion channels in neuronal tissue and reduce its pathological activity to a more stable level. Low concentrations may suffice to abolish impulses in damaged nerves, and mexilitene has been used successfully to treat neuropathic pain.

b) Indications – Neuropathic pain.

c) Major Contraindications – Heart disease (may depress ventricular function).

d) Dosing and Time to Therapeutic Effect – Titrate to therapeutic effect.

e) Major Side Effects – Tremor, light-headedness, coordination difficulties, and nausea are common dose-related adverse effects that may be reduced by taking with food.

f) Drug Interactions – Lidocaine.

g) Recommended Laboratory Monitoring – Hepatic function, CBC. Plasma levels may also be necessary.

8. Orthotics/Prosthetics/Equipment

Devices and adaptive equipment may be necessary in order to reduce impairment and disability, to facilitate medical recovery, to avoid re-aggravation of the injury, and to maintain maximum medical improvement. Indications would be to provide relief of the industrial injury or prevent further injury and include the need to control neurological and orthopedic injuries for reduced stress during functional activities. In addition, they may be used to modify tasks through instruction in the use of a device or physical modification of a device. Equipment needs may need to be reassessed periodically. Refer to Return To Work section for more detailed information.

Equipment may include high and low technology assistive devices, computer interface or seating, crutch or walker training, and self-care aids. It should improve safety and reduce risk of re-injury. Standard equipment to alleviate the effects of the injury on the performance of activities of daily living may vary from simple to complex adaptive devices to enhance independence and safety. Certain equipment related to cognitive impairments may also be required.

Ergonomic modifications may be necessary to facilitate medical recovery, to avoid re-aggravation of the injury, and to maintain maximum medical improvement. Ergonomic evaluations with subsequent recommendations may assist with the patients return to work. (Refer to Job Site Evaluation for further information.)

For chronic pain disorders, equipment such as foot orthoses or lumbar support devices may be helpful. The injured worker should be educated as to the potential harm from using a lumbar support for a period of time greater than which is prescribed. Harmful effects include deconditioning of the trunk musculature, skin irritation and general discomfort. Use of cervical collars is not recommended for chronic cervical myofascial pain. Special cervical orthosis and or equipment may have a role in the rehabilitation of a cervical injury such as those injuries to a cervical nerve root resulting in upper extremity weakness or a spinal cord injury with some degree of paraparesis or tetraparesis. Use of such devices would be in a structured rehabilitation setting as part of a comprehensive rehabilitation program.

Fabrication/modification of orthotics, including splints, would be used when there is need to normalize weight-bearing, facilitate better motion response, stabilize a joint with insufficient muscle or proprioceptive/reflex competencies, to protect subacute conditions as needed during movement, and correct biomechanical problems. Orthotic/prosthetic training is the skilled instruction (preferably by qualified providers) in the proper use of orthotic devices and/or prosthetic limbs.

For information regarding specific types of orthotics/prosthetics/equipment, refer to individual medical treatment guidelines.

9. Patient Education

a. The treatment plan;

b. Indications for and potential side effects of medications;

c. Their home exercise program;

d. Expected results of treatment;

e. Tests to be performed, the reasons for them and their results;

f. Activity restrictions and return-to-work status;

g. Home management for exacerbations of pain;

h. Procedures for seeking care for exacerbations after office hours;

i. Home self-maintenance program;

j. Patient responsibility to communicate with all medical providers and the employer; and

k. Patient responsibility to keep appointments.

Educational efforts should also target family and other support persons, the case manager, the insurer and the employer as indicated to optimize the understanding of the patient and the outcome. Professional translators should be provided for non-English speaking patients to assure optimum communication. All education, teaching, and instruction given to the patient should be documented in the medical record.

(2) Frequency: At each visit

10. Personality/Psychological/Psychosocial Intervention

Psychosocial treatment is a generally accepted, well-established therapeutic and diagnostic procedure with selected use in acute pain problems, but with more widespread use in sub-acute and chronic pain populations. Psychosocial treatment is recommended as an important component in the total management of a patient with chronic pain and should be implemented as soon as the problem is identified.

Once a diagnosis consistent with the standards of the American Psychiatric Association (DSM) has been determined, the patient should be evaluated for the potential need for psychiatric medications. Use of any medication to treat a diagnosed condition may be ordered by the authorized treating physician or by the consulting psychiatrist. Visits for management of psychiatric medications are medical in nature and are not a component of psychosocial treatment. Therefore, separate visits for medication management may be necessary, depending upon the patient and medications selected.

A psychologist with a PhD, PsyD, EdD credentials, or a Psychiatric MD/DO may perform psychosocial treatments. Other licensed mental health providers working in consultation with a PhD, PsyD, EdD, or Psychiatric MD/DO, and with experience in treating chronic pain disorders in injured workers may also perform treatment.

A status report must be provided to the authorized treating physician within two weeks of each visit to facilitate the patient's care. The report should provide documentation of progress towards functional recovery and discussion of the psychosocial issues affecting the patient's ability to participate in treatment. The report should also address pertinent issues as preexisting, aggravated, and or causative, as well as project realistic functional prognosis.

(1) Time to produce effect: 2 to 4 weeks

(2) Frequency: 1 to 5 times weekly for the first 4 weeks (excluding hospitalization, if required), decreasing to 1 to 2 times per week for the second month. Thereafter, 2 to 4 times monthly with the exception of exacerbations which may require increased frequency of visits. Not to include visits for medication management.

(3) Optimum duration: 2 to 6 months

(4) Maximum duration: 6 to 12 months, not to include visits for medication management. For select patients, longer supervised treatment may be required and, if further counseling beyond 6 months is indicated, functional progress must be documented.

11. Restriction of Activities

Continuation of normal daily activities is the recommendation for chronic pain patients since immobility will negatively affect rehabilitation. Prolonged immobility results in a wide range of deleterious effects, such as a reduction in aerobic capacity and conditioning, loss of muscle strength and flexibility, increased segmental stiffness, promotion of bone demineralization, impaired disc nutrition, and the facilitation of the illness role. Immobility may range from bed rest to the continued use of othoses, such as cervical collars and lumbar support braces. While these interventions may have been ordered in the acute phase, the provider should be aware of their impact on the patient's ability to adequately comply with and successfully complete rehabilitation.

12. Return-to-Work

The following should be considered when attempting to return an injured worker with chronic pain to work. a. Job History Interview

A formal job description for the injured/ill employee who is employed is necessary to identify physical demands at work and assist in the creation of modified duty. A Job Site Evaluation may be utilized to identify tasks such as pushing, pulling, lifting, reaching above shoulder level, grasping, pinching, sitting, standing, posture, ambulatory distance and terrain, and if applicable, environment for temperature, air flow, noise and the number of hours that may be worked per day. Work restriction assigned by the authorized treating physician may be temporary or permanent. The case manager should continue to seek out modified work until restrictions become less cumbersome or as the worker's condition improves or deteriorates. f. Rehabilitation and Return to Work

Formal vocational rehabilitation is a generally accepted intervention and can assist disabled persons to return to viable employment. Assisting patients to identify vocational goals will facilitate medical recovery and aid in the maintenance of MMI by 1) increasing motivation towards treatment and 2) alleviating the patient's emotional distress. Chronic pain patients will benefit most if vocational assistance is provided during the interdisciplinary rehabilitation phase of treatment. To assess the patient's vocational capacity, a vocational assessment may be utilized to identify rehabilitation program goals, as well as optimize both patient motivation and utilization of rehabilitation resources.

Recommendations to Employers and Employees of Small Businesses – Employees of small businesses who are diagnosed with chronic pain may not be able to perform any jobs for which openings exist. Temporary employees may fill those slots while the employee functionally improves. Some small businesses hire other workers and if the injured employee returns to the job, the supervisor/owner may have an extra employee. To avoid this, it is suggested that case managers be accessed through their insurer or third party insurers. Case managers may assist with resolution of these problems, as well as assist in finding modified job tasks, or find jobs with reduced hours, etc., depending upon company philosophy and employee needs.

Recommendations to Employers and Employees of Mid-Sized and Large Businesses – Employers are encouraged by the Division to identify modified work within the company that may be available to injured workers with chronic pain who are returning to work with temporary or permanent restrictions. To assist with temporary or permanent placement of the injured worker, it is suggested that a program be implemented that allows the case manager to access descriptions of all jobs within the organization.

13. Therapy — Active

The following active therapies have some evidence to support their use and are widely used and accepted methods of care for a variety of work-related injuries. Active therapy is based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion, and can alleviate discomfort.

The following active therapies are listed in alphabetical order: a. Activities of Daily Living (ADL)

(1) Time to produce effect: 4 to 5 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks b. Aquatic Therapy

Aquatic therapy is the implementation of active therapeutic procedures in a swimming or therapeutic pool. The water provides a buoyancy force that lessens the amount of force of gravity applied to the body, and the pool should be large enough to allow full extremity range of motion and full erect posture. The decreased gravity effect allows the patient to have a mechanical advantage and more likely have a successful trial of therapeutic exercise. Indications are for individuals who may not tolerate active land- based or full weight bearing therapeutic procedures or who require augmentation of other therapy. Aquatic vests, belts and other devices can be used to provide stability, balance, buoyancy, and resistance.

(1) Time to produce effect: 4 to 5 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks c. Functional Activities

Functional activities are the use of therapeutic activity to enhance mobility, body mechanics, employability, coordination, and sensory motor integration.

(1) Time to produce effect: 4 to 5 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 6 weeks (4) Maximum duration: 6 weeks d. Functional Electrical Stimulation

Functional electrical stimulation is the application of electrical current to elicit involuntary or assisted contractions of atrophied and/or impaired muscles. Indications include muscle atrophy, weakness, and sluggish muscle contraction secondary to pain, injury, neuromuscular dysfunction, peripheral nerve lesion, or radicular symptoms. This modality may be prescribed for use at home when patients have demonstrated knowledge of how to self-administer and are in an independent exercise program.

(1) Time to produce effect: 2 to 6 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 8 weeks

(4) Maximum Duration: 8 weeks. If beneficial, provide with home unit. e. Lumbar Stabilization

Lumbar stabilization is a therapeutic program whose goal is to strengthen the spine in its neutral and anatomic position. The stabilization is dynamic which allows whole body movements while maintaining a stabilized spine. It is the ability to move and function normally through postures and activities without creating undue vertebral stress. Lumbar stabilization programs can be performed with or without increase in spinal axial loading, on land or in a pool. Indications include lumbar instability, lumbar mechanical pain, lumbar segmental hypermobility, spondylolisthesis, discogenic injury or pain, facet joint injury, or pain after lumbar surgery.

(1) Time to produce effect: 4 to 8 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 8 weeks

(4) Maximum Duration: 8 weeks. f. Neuromuscular Re-Education

(1) Time to produce effect: 2 to 6 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 4 to 8 weeks

(4) Maximum Duration: 8 weeks g. Therapeutic Exercise Therapeutic exercise, with or without mechanical assistance or resistance, may include isoinertial, isotonic, isometric and isokinetic types of exercises. Indications include the need for cardiovascular fitness, reduced edema, improved muscle strength, improved connective tissue strength and integrity, increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle recruitment, increased range-of-motion and are used to promote normal movement patterns. Can also include alternative/complementary exercise movement therapy. Therapeutic exercise programs should be tissue specific to the injury and address general functional deficits as identified in the diagnosis and clinical assessment. Patients should be instructed in and receive a home exercise program that is progressed as their functional status improves. Upon discharge, the patient would be independent in the performance of the home exercise program and would have been educated in the importance of continuing such a program. Educational goals would be to maintain or further improve function and to minimize the risk for aggravation of symptoms in the future.

(1) Time to produce effect: 2 to 6 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 4 to 8 weeks and concurrent with an active daily home exercise program.

(4) Maximum Duration: 8 to 12 weeks of therapist oversight. Home exercise should continue indefinitely. h. Work Conditioning

These programs are work-related, outcome-focused, individualized treatment programs. Objectives of the program includes, but are not limited to, improvement of cardiopulmonary and neuromusculoskeletal functions (strength, endurance, movement, flexibility, stability, and motor control functions), patient education, and symptom relief. The goal is for patients to gain full or optimal function and return to work. The service may include the time-limited use of modalities, both active and passive, in conjunction with therapeutic exercise, functional activities, general conditioning, body mechanics and lifting techniques retraining.

(1) Length of visit: 1 to 2 hours per day

(2) Frequency: 2 to 5 visits per week

(3) Optimum duration: 2 to 4 weeks

(1) Length of visit: 2 to 6 hours per day (2) Frequency: 2 to 5 visits per week

(3) Optimum duration: 2 to 4 weeks

(4) Maximum duration: 6 weeks. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.

14. Therapy — Passive

The following passive therapies are listed in alphabetical order: a. Electrical Stimulation (Unattended)

(1) Time to produce effect: 2 to 4 treatments

(2) Frequency: Varies, depending upon indication, between 2 to 3 times per day to 1 time week.

(3) Optimum duration: 1 to 3 months

(4) Maximum duration: 3 months. Provide home unit if intended for frequent use. b. Infrared Therapy

Infrared therapy is a radiant form of heat application. Indications include the need to elevate the pain threshold before exercise and to alleviate muscle spasm to promote increased movement.

(1) Time to produce effect: 2 to 4 treatments

(2) Frequency: 3 to 5 times per week

(3) Optimum duration: 3 weeks as primary, or intermittently as an adjunct to other therapeutic procedures up to 2 months

(4) Maximum duration: 2 months c. Iontophoresis Iontophoresis is the transfer of medication, including, but not limited to, steroidal anti-inflammatories and anesthetics, through the use of electrical stimulation. Indications include pain (Lidocaine), inflammation (hydrocortisone, salicylate), edema (mecholyl, hyaluronidase, salicylate), ischemia (magnesium, mecholyl, iodine), muscle spasm (magnesium, calcium), calcific deposits (acetate), scars and keloids (chlorine, iodine, acetate).

(1) Time to produce effect: 2 to 6 treatments

(2) Frequency: 3 times per week with at least 48 hours between treatments

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks d. Manipulation

Manipulation is a generally accepted, well-established and widely used therapeutic intervention for pain. Manipulation may include, but is not limited to, high velocity, low amplitude technique (adjustment, grade V mobilization, mobilization with impulse), chiropractic manipulation, osteopathic manipulation, muscle energy techniques and non-force techniques. It is performed by taking a joint to its end range of motion and moving the articulation into the zone of accessory joint movement, well within the limits of anatomical integrity.

The purpose of manipulation in the treatment of chronic pain is to assess the structure and function of the patient and to identify areas of musculoskeletal dysfunction that may be causing, or contributing to, the patient's symptoms.

Evaluations for manipulation in the chronic pain patient should be comprehensive, taking into consideration the entire musculoskeletal system and identifying both local and remote factors in the generation of pain and dysfunction. The evaluation should be designed to isolate the presence of dysfunctional entities that will be responsive to manual medicine interventions. Results of the evaluation should assist in the differentiation of biomechanical dysfunction from anatomic pathology, as well as the clinical significance of both as possible pain generators. It is important to consider visceral causes of somatic pain and to rule out organic disease.

The physical evaluation involves a direct palpatory examination to assess asymmetries of form and function; alterations in range-of-motion, including hypermobility and hypomobility; tissue-texture abnormalities, particularly muscular, fascial, and ligamentous structures. Special attention should be given to the presence of restrictions within the expected range-of-motion (hypomobility) in vertebral segments and the muscular responses to these restrictions. Extremities should also be considered in the physical evaluation. The evaluation may include use of other assessment tools such as Surface EMG, postural analysis, radiographic imaging, and imaging studies.

Manipulation may be indicated in patients who have not had an evaluation for manual medicine, or have not progressed adequately in an exercise program. Manipulation should be considered when there is evidence of suspicion of scoliosis, apparent leg length inequality, pelvic imbalance, facet restriction, sacroiliac dysfunction, myofascial dysfunction, gait disturbances, or postural dysfunction.

Indications for manipulation include joint pain, decreased joint motion and joint adhesions. Contraindications may include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthridites, aortic aneurysm, and signs of new or progressive neurologic deficits.

Response to treatment will depend on the appropriate application of procedures used for the clinical condition, the number of body regions involved, the chronicity of the condition, the age and general health of the patient, invasiveness of previous therapeutic interventions, and psychological factors. For chronic pain patients who have not had manipulation previously, providers should refer to the current medical treatment guidelines of the original injury for treatment and timeframe parameters. Daily treatment is usually not indicated unless they have not had any prior manipulation or they have had a recent exacerbation.

(1) Time to produce effect: 4 to 6 treatments.

(2) Frequency: 1 to 2 times per week for the first 2 weeks as indicated by the severity of the condition. Treatment may continue at 1 treatment per week for the next 6 weeks.

(3) Optimum duration: 8 weeks.

(4) Maximum duration: 8 weeks. At week 8, patients should be reevaluated. Care beyond 8 weeks may be indicated for certain chronic pain patients in whom manipulation is helpful in improving function, decreasing pain and improving quality of life. In these cases, treatment may be continued at 1 treatment every other week until the patient has reached MMI and maintenance treatments have been determined. Extended durations of care beyond what is considered “maximum” may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with comorbidities. Such care should be re-evaluated and documented on a monthly basis. e. Massage — Manual or Mechanical

(1) Time to produce effect: Immediate

(2) Frequency: 1 to 2 times per week

(3) Optimum duration: 6 weeks

(4) Maximum duration: 2 months f. Mobilization (Joint)

Mobilization is passive movement involving oscillatory motions to the vertebral segment(s). The passive mobility is performed in a graded manner (I, II, III, IV, or V), which depicts the speed of the maneuver. It may include skilled manual joint tissue stretching. Indications include the need to improve joint play, segmental alignment, improve intracapsular arthrokinematics, or reduce pain associated with tissue impingement. Contraindications include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthritidies, aortic aneurysm, and signs of progressive neurologic deficits.

(1) Time to produce effect: 6 to 9 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks g. Mobilization (Soft Tissue)

Mobilization of soft tissue is the skilled application of manual techniques designed to normalize movement patterns through the reduction of soft tissue pain and restrictions. Indications include muscle spasm, voluntary or involuntary muscle guarding, adaptive shortening, trigger points, adhesions and neural compression.

(1) Time to produce effect: 2 to 3 weeks

(2) Frequency: 2 to 3 times per week

(3) Optimum duration: 4 to 6 weeks

(4) Maximum duration: 6 weeks h. Superficial Heat and Cold Therapy

(1) Time to produce effect: Immediate

(2) Frequency: 2 to 5 times per week

(3) Optimum duration: 3 weeks as primary or intermittently as an adjunct to other therapeutic procedures up to 2 months

(4) Maximum duration: 2 months i. Traction — Manual

(1) Time to produce effect: 1 to 3 sessions

(2) Frequency: 2 to 3 times per week

(3) Optimum duration: 4 weeks

(4) Maximum duration: 1 month j. Traction — Mechanical

Mechanical traction is indicated for decreased joint space, muscle spasm around joints, and the need for increased synovial nutrition and response. Traction modalities are contraindicated in patients with tumor, infections, fracture or fracture dislocation. Nonoscillating inversion traction methods are contraindicated in patients with glaucoma or hypertension. (1) Time to produce effect: 1 to 3 sessions up to 30 minutes. If response is negative after 3 treatments, discontinue this modality.

(2) Frequency: 2 to 3 times per week

(3) Optimum duration: 4 weeks

(4) Maximum duration: 1 month k. Transcutaneous Electrical Nerve Stimulation (TENS)

(1) Time to produce effect: Immediate

(2) Frequency: Variable

(3) Optimum duration: 3 sessions. If beneficial, provide with home unit.

(4) Maximum duration: 3 sessions. Purchase if effective. l. Ultrasound

Ultrasound uses sonic generators to deliver acoustic energy for therapeutic thermal and/or nonthermal soft tissue effects. Indications include scar tissue, adhesions, collagen fiber and muscle spasm, and the need to extend muscle tissue or accelerate the soft tissue healing. Ultrasound with electrical stimulation is concurrent delivery of electrical energy that involves dispersive electrode placement. Indications include muscle spasm, scar tissue, pain modulation and muscle facilitation. Phonophoresis is the transfer of medication through the use of sonic generators to the target tissue to control inflammation and pain. These topical medications include, but are not limited to, steroidal anti-inflammatory and anesthetics.

(1) Time to produce effect: 6 to 15 treatments

(2) Frequency: 3 times per week

(3) Optimum duration: 4 to 8 weeks

(4) Maximum duration: 2 months

G. THERAPEUTIC PROCEDURES — OPERATIVE

a. Return to work or maintaining work status b. Fewer restrictions at work or performing activities of daily living (ADL).

c. Decrease in usage of medications.

d. Measurable functional gains, such as increased range of motion or documented increase in strength.

e. Education of the patient should include the proposed goals of the surgery, expected gains, risks or complications, and alternative treatment.

1. Neurostimulation a. Description — Neurostimulation is the delivery of low-voltage electrical stimulation to the spinal cord or peripheral nerves to inhibit or block the sensation of pain. This is a generally accepted procedure that has limited use. May be most effective in patients with chronic, intractable limb pain who have not achieved relief with oral medications, rehabilitation therapy, or therapeutic nerve blocks, and in whom the pain has persisted for longer than 6 months.

Particular technical expertise is required to perform this procedure and is available in some neurosurgical, rehabilitation, and anesthesiology training programs and fellowships. Physicians performing this procedure must be trained in neurostimulation implantation and participate in ongoing injection training workshops, such as those sponsored by the Internal Society for Injection Studies or as sponsored by implant manufacturers. b. Complications — May include paraplegia, epidural hematoma, epidural hemorrhage, undesirable change in stimulation, seroma, CSF leakage, infection, erosion, allergic response, hardware malfunction or equipment migration, pain at implantation site, loss of pain relief, chest wall stimulation, and other surgical risks. c. Surgical Indications — Failure of conservative therapy including active and/or passive therapy, medication management, or therapeutic injections. Preauthorization is required. Habituation to narcotic analgesics in the absence of a history of addictive behavior does not preclude the use of neurostimulation. Only patients who meet the following criteria should be considered candidates for neurostimulation:

1) A diagnosis of a specific physical condition known to be chronically painful has been made on the basis of objective findings; and

2) All reasonable surgical and non-surgical treatment has been exhausted; and

3) Pre-surgical psychiatric or psychological evaluation has been performed and has demonstrated motivation and long-term commitment without issues of secondary gain; and

4) There is no evidence of addictive behavior. (Tolerance and dependence to narcotic analgesics are not addictive behaviors and do not preclude implantation.); and

5) The topography of pain and its underlying pathophysiology are amenable to stimulation coverage (the entire painful area has been covered); and

6) A successful neurostimulation screening test of 2-3 days. A screening test is considered successful if the patient (a) experiences a 50% decrease in pain, which may be confirmed by VAS, and (b) demonstrates objective functional gains or decreased utilization of pain medications. Functional gains may be evaluated by an occupational therapist and/or physical therapist prior to and before discontinuation of the trial. 7) For spinal cord stimulation, a temporary lead is implanted at the level of pain and attached to an external source to validate therapy effectiveness. (For peripheral nerve screening, a nerve block is performed to define the specific nerve branch but if multiple branches are involved, a screening test for spinal cord stimulation may be indicated.) Long-term functional improvement is anticipated when objective functional improvement has been observed during time of neurostimulation screen exam. d. Contraindications — Unsuccessful neurostimulation test – either inability to obtain functional improvement or reduction of pain, those with cardiac pacemakers, patient unable to properly operate the system. It should not be used if future MRI is planned. e. Operative Treatment — Implantation of stimulating leads connected by extensions to either an implanted neurostimulator or an implanted receiver powered by an external transmitter. The procedure may be performed either as an open or a percutaneous procedure, depending on the presence of epidural fibrosis and the anatomical placement required for optimal efficacy. f. Post-Operative Considerations — MRI is contraindicated after placement of neurostimulators. g. Post-Operative Therapy – Active and/or passive therapy should be employed to improve function. Implantable stimulators will require frequent monitoring such as adjustment of the unit and replacement of batteries.

2. Intrathecal Drug Delivery a. Description – This mode of therapy delivers small doses of medications directly into the cerebrospinal fluid. Clinical studies are conflicting regarding long-term, effective pain relief in patients with non- malignant pain. As with other routes of drug administration, escalation of dose may be required. Typically, pump refills are needed every 2-3 months. b. Complications – Intrathecal delivery is associated with significant complications, such as infection, catheter disconnects, CSF leak, arachnoiditis, pump failure, nerve injury, and paralysis. c. General Indications – The Division does not routinely recommend the use of Intrathecal Drug Delivery systems in injured workers with chronic pain. It may be considered only in rare cases where all other commonly used methods to control pain have failed and must be based on preauthorization and the recommendation of at least one physician experienced in chronic pain management in consultation with the primary treating physician. Patients should only be selected for intrathecal drug delivery if they have opioidresponsive pain but cannot tolerate the effects of systemic administration. The patient must have good to excellent pain relief with a test dose using a temporary catheter prior to pump implantation. The patient must be motivated for the procedure, and must understand the potential for complications and requirements of treatment maintenance. d. Surgical Indications – Failure of conservative therapy including active and/or passive therapy, medication management, or therapeutic injections. Only patients who meet the following criteria should be considered candidates for intraspinal analgesic infusions:

1) A diagnosis of a specific physical condition known to be chronically painful has been made on the basis of objective findings; and

2) All reasonable surgical and non-surgical treatment has been exhausted; and

3) Pre-surgical psychiatric or psychological evaluation has been performed and has demonstrated motivation and long-term commitment without issues of secondary gain;

4) There is no evidence of addictive behavior. (Tolerance and dependence to narcotic analgesics are not addictive behaviors and do not preclude implantation.); and

5) A successful trial of continuous infusion by a percutaneous spinal infusion pump for a minimum of 24 hours. A screening test is considered successful if the patient (a) experiences a 50% decrease in pain, which may be confirmed by VAS, and (b) demonstrates objective functional gains or decreased utilization of pain medications. Functional gains may be evaluated by an occupational therapist and/or physical therapist prior to and before discontinuation of the trial. e. Contraindications – Infection, body size insufficient to support the size and weight of the implanted device. Patients with other implanted programmable devices should not be given these pumps, since interference between devices may cause unintended changes in infusion rates.

3. Neuroablation with Rhizotomy as the Exception

Neuroablation or neurodestructive procedures are not commonly used in the management of non- malignant pain. These techniques require specific expertise to perform, have erratic results, and high rates of complication. Therefore, the Division does not recommend the use of neuroablative procedures, excepting rhizotomy, in injured workers with chronic pain.

4. Facet Rhizotomy a. Description – A procedure designed to denervate the facet joint by ablating the periarticular facet nerve branches. There is good evidence to support this procedure for the cervical spine and some evidence in lumbar spine but benefits beyond one year are not yet established. Therefore, the patient should be committed to active therapy during the first post-surgical year. b. Complications – Bleeding, infection, neural injury. There is a risk of developing a deafferentation centralized pain syndrome as a complication of this and other neuroablative procedures. c. Surgical Indications – Pain of well-documented facet origin, unresponsive to active and/or passive therapy, unresponsive to manual therapy, and in whom a psychosocial evaluation has been performed. This procedure is commonly used to provide a window of pain relief allowing for participation in active therapy. All patients must have a successful response to diagnostic medial nerve branch blocks. A successful response is considered to be a 70 percent or greater relief of pain for the length of time appropriate to the local anesthetic used (i.e., bupivacaine greater than lidocaine). d. Contraindications – Failure to obtain 70 percent or greater relief of pain with diagnostic medial branch block as well as bacterial infection – systemic or localized to region of implantation, bleeding diatheses, hematological conditions, and possible pregnancy. e. Operative Treatment – Percutaneous radio-frequency rhizotomy is the procedure of choice over alcohol, phenol, or cryoablation. Position of the probe using fluoroscopic guidance is recommended since the maximum effective radius of the device is 2 millimeters. f. Post-Operative Therapy – Active and/or passive therapy, implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-procedure week, barring complications. Instruction and participation in a long-term home-based program of ROM, strengthening, endurance and stability exercises should be done 1 to 2 weeks post procedure.

H. MAINTENANCE MANAGEMENT

Maintenance care in CRPS and SMP requires a close working relationship between the carrier, the providers and the patient. Providers and patients have an obligation to design a cost effective, medically appropriate program that is predictable and allows the carrier to set aside appropriate reserves. Carriers and adjusters have an obligation to assure that medical providers can design medically appropriate programs. A designated primary physician for maintenance team management is recommended.

Maintenance Care will be based on principles of patient self-management. When developing a maintenance plan of care, the patient, physician and insurer should attempt to meet the following goals:

a. Maximal independence will be achieved through the use of home exercise programs or exercise programs requiring special facilities (e.g., pool, health club) and educational programs;

b. Modalities will emphasize self-management and self-applied treatment;

c. Management of pain or injury exacerbations will emphasize initiation of active therapy techniques and may occasionally require anesthetic injection blocks.

d. Dependence on treatment provided by practitioners other than the authorized treating physician will be minimized;

e. Periodic reassessment of the patient's condition will occur as appropriate.

f. Patients will understand that failure to comply with the elements of the self-management program or therapeutic plan of care may affect consideration of other interventions.

The following are Specific Maintenance Interventions and Parameters:

1. Home Exercise Programs and Exercise Equipment

2. Exercise Programs Requiring Special Facilities

(1) Frequency: 2 to 3 times per week.

(2) Optimal Duration: 1 to 3 months.

3. Patient Education Management

Educational classes, sessions, or programs may be necessary to reinforce self-management techniques. This may be performed as formal or informal programs, either group or individual.

(1) Maintenance duration: 2 to 6 educational sessions during one 12-month period.

4. Psychological Management

An ideal maintenance program will emphasize management options implemented in the following order: (a) individual self-management (pain control, relaxation and stress management, etc.), (b) group counseling, (c) individual counseling by a psychologist or psychiatrist, and (d) in-patient treatment. Aggravation of the injury may require psychological treatment to restore the patient to baseline. In those cases, use treatments and timeframe parameters listed in the Biofeedback and Psychological Evaluation or Intervention sections.

(1) Maintenance duration: 6 to 10 visits during one 12-month period.

5. Non-Narcotic Medication Management

(1) Maintenance duration: Usually, four medication reviews within a 12-month period. Frequency depends on the medications prescribed. Laboratory and other monitoring as appropriate.

6. Narcotic Medication Management

a. The medications should be clearly linked to improvement of function, not just pain control. All follow up visits should document the patient's ability to perform routine functions satisfactorily. Examples include the abilities to: perform work tasks, drive safely, pay bills or perform basic math operations, remain alert for 10 hours, or participate in normal family and social activities. If the patient is not maintaining reasonable levels of activity the patient should usually be tapered from the narcotic and tried on a different long acting opioid.

b. A low dose narcotic medication regimen should be defined, which may minimally increase or decrease over time. Dosages will need to be adjusted based on side effects of the medication and objective function of the patient. A patient may frequently be maintained on additional non-narcotic medications to control side effects, treat mood disorders, or control neuropathic pain; however, only one long-acting narcotic and one short acting narcotic for rescue use should be prescribed in most cases.

c. All patients on chronic narcotic medication dosages need to sign an appropriate narcotic contract with their physician for prescribing the narcotics.

d. The patient must understand that continuation of the medication is contingent on their cooperation with the maintenance program. Use of non-prescribed drugs may result in tapering of the medication. The clinician may order random drug testing when deemed appropriate to monitor medication compliance.

e. Patients on chronic narcotic medication dosages must receive them through one prescribing physician.

(1) Maintenance duration: Up to 12 visits within a 12-month period to review the narcotic plan. Laboratory and other monitoring as appropriate.

7. Therapy Management

(1) Active Therapy, Acupuncture, and Manipulation maintenance duration: 10 visits in a 12-month period.

8. Injection Therapy a. Sympathetic Blocks

These injections may occasionally be necessary to maintain function in those with myofascial problems.

(1) Maintenance duration: Not more than 4 injections per session not to exceed 3 to 6 sessions per 12-month period. c. Epidural and Selective Nerve Root Injections

Patients who have experienced functional benefits from these injections in the past may require injection for exacerbations of the condition.

(1) Maintenance duration: 2 to 4 injections per 12-month period.

9. Purchase or Rental of Durable Medical Equipment

(1) Maintenance duration: Not to exceed 3 months for rental equipment. Purchase if effective.

RULE XVII, EXHIBIT G Traumatic Brain Injury Medical Treatment Guidelines March 15, 1998

presented by:

State of Colorado Department of Labor and Employment DIVISION OF WORKERS' COMPENSATION

TABLE OF CONTENTS SECTION DESCRIPTION

INTRODUCTION I GENERAL GUIDELINE PRINCIPLES A. Application of Guidelines B. Education C. Treatment Parameter Duration D. Active Intervention E. Active Therapeutic Exercise Program F. Positive Patient Response G. Re-Evaluate Treatment Every 3-4 Weeks H. Surgical Interventions I. Six-Month Time Frame J. Return-to-Work K. Delayed Recovery II SYSTEMS OF CARE, DEFINITION OF INTERDISCI-PLINARY TEAM AND THERAPEUTIC DISCIPLINES A. Introduction 1. Intervention 2. Education 3. Return-to-Work 4. Disability 5. Course of Recovery 6. Guardianship and Conservatorship B. Systems of Care 1. Acute Care 2. Acute Rehabilitation 3. Post-Acute Rehabilitation 4. Subacute Rehabilitation Programs 5. Outpatient Rehabilitation Services 6. Home & Community- Based Rehabilitation 7. Behavioral Programs 8. Extended Nursing Facility Care 9. Supported Living Programs (SLP) C. Interdisciplinary Treatment Team D. Therapeutic Disciplines 1. Behavioral Psychologist 2. Clinical Psychologist 3. Neurologist 4. Neurophthalmologist 5. Neuropsychologist 6. Neurosurgeon 7. Nurse 8. Occupational Therapist 9. Optometrist 10. Ophthalmologist 11. Physical Therapist 12. Physiatrist 13. Psychiatrist 14. Rehabilitation Counselor 15. Social Work 16. Speech/Language Pathologist 17. Therapeutic Recreation Specialist E. TBI Case Management III INITIAL DIAGNOSTIC PROCEDURES A. Taking a History of Injury 1. Identification Data 2. Precipitating Event 3. Neurological History 4. Review of Medical Records B. Past Medical/Health History 1. Family History 2. Patient Social History 3. Occupational History 4. Nonoccupational History 5. Substance Abuse History C. Review of Systems D. Physical Examination E. Neurological Examination F. Initial Neuropsychological Assessment 1. Initial Neuropsychological Assessment MTBI 2. Initial Neuropsychological Assessment Moderate- Severe TBI G. Initial Diagnostic Recommendations H. Other Initial Diagnostic Procedures 1. Skull X-Rays 2. Computerized Axial Tomography (CT) 3. Magnetic Resonance Imaging (MRI) 4. Electroencephalography (EEG) 5. Qualified Electroenciphalography/ QEEG 6. Single Photon Emission Computerized Tomography (SPECT) 7. Position Emission Testing (PET) 8. Vascular Imaging Tests 9. Lumbar Puncture 10. Electrodiagnostic Studies 11. Diagnostic Nerve Blocks 12. Audiometry and Otology 13. Vestibular Function Tests 14. Vision Evaluation 15. Swallowing Evaluations IV FOLLOW-UP DIAGNOSTIC PROCEDURES A. Computerized Tomography (CT) B. Magnetic Resonance Imaging (MRI) C. Electroencephalography (EEG) D. Single Photon Emission Computerized Tomography (SPECT) E. Position Emission Testing (PET) F. Neuropsychological Assessment 1. Mild TBI 2. Moderate-Severe TBI G. Audiometry H. Vision Evaluation 1. Visual Perceptual Testing 2. Low Vision Evaluation 3. Electrodiagnostic Studies I. Return-to-Work Evaluation 1. Functional Capacity Evaluation (FCE) 2. Job Site Analysis V THERAPEUTIC MEDICAL PROCEDURES – OPERATIVE A. Diagnostic Procedures and Invasive Monitoring 1. Intracranial 2. Extracranial B. Therapeutic Procedures – Acute & Subacute 1. Extracranial Soft Tissue 2. Maxillofacial 3. Skull 4. Brain 5. Ophthalmologic 6. Otologic 7. Other Oranial Nerve Repair or Decompression 8. Vascular Injury 9. Cerebral Spinal Fluid 10. Peripheral Nerve Injury 11. Fracture Management C. Operative Therapeutic Procedures – Delayed or Chronic 1. Reconstruction 2. Ophthalmologic 3. Otologic 4. Orthopedic 5. Spasticity 6. Cerebral Spinal Fluid VI THERAPEUTIC MEDICAL PROCEDURES – NONOPERATIVE A. Acute Medical Care 1. Resuscitation 2. Intracranial Pressure (ICP) an Cerebral Perfusion Pressure (CPP) 3. Hyperventilation 4. Nutrition 5. Anticonvulsants 6. Hyperthermia B. Treatment of Neuromedical Conditions Following MTBI 1. Headaches 2. Neurotological Disorders 3. Neurologic Sequelae 4. Other Symptoms C. Treatment of Neuromedical Conditions – Moderate- Severe Brain Injury 1. Neurological Complications 2. Cardiopulmonary Complications 3. Musculoskeletal Complications 4. Gastrointestinal Complications 5. Genitourinary Complications 6. Neuroendocrine Complications 7. Fluid and Electrolyte Complications 8. Immobilization and Disuse Complications 9. Vascular Complications D. Medications E. Nursing Interventions VII THERAPEUTIC REHABILITATION PROCEDURES A. Treatment of Cognitive Impairments B. Treatment of Communication Impairments 1. Motor Speech Disorders 2. Aphasia 3. Cognitive/Communicativ e Language Disorders C. Swallowing Impairments (Dysphagia) D. Neuromuscular Management 1. Motor Control 2. Tone and Joint Restrictions Management 3. Treatment of Coordination Impairments E. Sensory Systems 1. Treatment of Hearing Impairments 2. Treatment of Visual Impairments F. Balance and Vestibular Impairments G. Mobility H. Activities of Daily Living (ADLs) 1. Basic ADLs 2. Higher Level ADLs I. Psychological Interventions – MTBI 1. Acute Psychological Interventions in MTBI 2. Problem-Specific Referrals During the First Three Months Following MTBI 3. Referrals of Patients Who Are Three or More Months Post-MTBI J. Psychological Interventions – Moderate-Severe Injury 1. During Post-Traumatic Amnesia 2. Promote Insight and Support Coping 3. Support Transition to the Community and Functioning in the Community 4. Consultation in Regard to Use of Medications K. Behavioral Treatment L. Patient/Family Education M. Driving N. Return-to-Work 1. Return-to-work MTBI 2. Return-to-work Moderate-Severe TBI O. Complimentary Medicine P. Long-Term Maintenance Plans

INTRODUCTION

This document has been prepared by the Colorado Department of Labor and Employment, Division of Workers' Compensation (Division) and should be interpreted within the context of guidelines for physicians/providers treating individuals qualifying under Colorado Workers' Compensation Act as injured workers with traumatic brain injury (TBI). Although the primary purposes of this document for practitioners are advisory and educational, these guidelines are enforceable under the Workers' Compensation Rules of Procedure, 7 CCR 1101-3. The Division recognizes that acceptable medical practice may include deviations from these guidelines, as individual cases dictate. Therefore these guidelines are not relevant as evidence of a provider's legal standard of professional care.

To properly utilize this document, the reader should not skip nor overlook any sections.

I. GENERAL GUIDELINE PRINCIPLES

The principles summarized in this section are key to the intended implementation of these guidelines and critical to the reader's application of the guidelines in this document.

A. APPLICATION OF GUIDELINES:

The Division provides procedures to implement medical treatment guidelines and to foster communication to resolve disputes among the provider, payer and patient through the Workers' Compensation Rules of Procedure, Rule XVII and Rule VIII. In lieu of more costly litigation, parties may wish to seek administrative dispute resolution services through the Division.

B. EDUCATION:

Education of the patient and family, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of TBI and disability. Currently, practitioners often think of education last, after medications, manual therapy and surgery. Practitioners must develop and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers and the community as a whole. An educationbased paradigm should always start with inexpensive communication providing reassuring information to the patient. More in-depth education currently exists within a treatment regime employing functional restorative and innovative programs of prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of facilitating self-management of symptoms and prevention.

C. TREATMENT PARAMETER DURATION:

Time frames for specific interventions commence once treatments have been initiated, not on the date of injury. Obviously, duration will be impacted by patient compliance, as well as availability of services. Clinical judgement may substantiate the need to accelerate or decelerate the time frames discussed in this document.

D. ACTIVE INTERVENTIONS:

Interventions emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment, are generally emphasized over passive modalities, especially as treatment progresses. Generally, passive and palliative interventions are viewed as a means to facilitate progress in an active rehabilitation program with concomitant attainment of objective functional gains.

E. ACTIVE THERAPEUTIC EXERCISE PROGRAM:

Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and education. This includes functional application in vocational or community settings.

F. POSITIVE PATIENT RESPONSE:

G. RE-EVALUATE TREATMENT EVERY 3-4 WEEKS:

H. SURGICAL INTERVENTIONS:

I. SIX-MONTH TIME FRAME:

Since the prognosis drops precipitously for returning an injured worker to work once he/she has been temporarily totally disabled for more than six months, the emphasis within these guidelines is to return patients to work along a continuum of care within a six-month time frame, whenever possible. Recovery following TBI is generally longer. It is important to note that time frames may not be pertinent to injuries which do not involve work-time loss or are not occupationally related.

J. RETURN-TO-WORK:

Return-to-work following TBI involves a skillful match between the patient's physical, cognitive, emotional, behavioral abilities, and the work requirements. Even if there is residual chronic pain, return-to-work is not necessarily contraindicated. Return-to-work may be therapeutic, assuming the work is not likely to aggravate the basic problem or increase long-term pain.

The practitioner must write detailed restrictions when returning a patient to limited duty. The following functions should be considered and modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, bending at the waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and other repetitive motion tasks, cognitive and behavioral requirements, sustained grip, tool usage and vibration factors. In the case of TBI or chronic pain disorder, the provider should additionally consider cognitive and behavioral workplace demands in the preparation of a return-to-work plan. The patient should never be released to “sedentary or light duty” without specific physical or cognitive limitations. The practitioner must understand all of the physical, cognitive and behavioral demands of the patient's job position before returning the patient to full duty and should request clarification of the patient's job duties. Clarification should be obtained from the employer or, if necessary, including, but not limited to, an occupational health nurse, occupational therapist, vocational rehabilitation specialist, or an industrial hygienist.

K. DELAYED RECOVERY:

All patients with moderate or severe TBI will require an integrated system of care. For mild TBI patients strongly consider a psychological evaluation, if not previously provided, as well as initiating interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to make expected progress 6-12 weeks after an injury. The Division recognizes that 3-10% of all industrially injured patients will not recover within the timelines outlined in this document despite optimal care. Such individuals may require treatment beyond the limits discussed within this document, but such treatment will require clear documentation by the authorized treating practitioner focusing on objective functional gains afforded by further treatment and impact upon prognosis.

The remainder of this document should be interpreted within the parameters of these guideline principles which will hopefully lead to more optimal medical and functional outcomes for injured workers.

II. SYSTEMS OF CARE, DEFINITIONS OF INTER-DISCIPLINARY TEAM AND THERAPEUTIC DISCIPLINES

A. INTRODUCTION:

1. Intervention:

Early identification and early intervention by experienced providers are critical in the treatment and management of brain injury. Brain injury treatment may also require immediate interdisciplinary evaluation and treatment. The treatment and ultimate functional outcome of persons with TBI depends upon a complex interactional set of pre-injury, injury, and post-injury factors. Treatment programs should be specialized, based upon a comprehensive data set, functional and goal and outcome-oriented, and delivered in least restrictive settings. Treatment settings should include home and community settings, and should be time-limited, based upon progress.

Early identification of patients with brain injury by insurance carriers within the first 24 hours is well accepted and widely used. In addition, the provision of on-site case management by certified insurance case managers experienced in brain injury rehabilitation is well accepted for all Moderate-Severe TBI cases of brain injury, and for select mild traumatic brain injury (MTBI) cases, based upon complexity and need.

2. Education:

Outcome following TBI is often dependent on the health, education, and resources of the patient's family. Therefore, education of the patient and family, insurer, case manager and employer should be a primary emphasis in the treatment and management of persons with TBI. Providers should develop and implement effective strategies and forums to include family members with the interdisciplinary treatment team. Patient and family education should include, but is not limited to: communication of basic information about the brain and the effects of brain injury on behavior, cognition, function, and outcome. Insurance carriers, case managers, and treatment providers are highly encouraged to provide education and support services to families in order to maximize treatment outcomes and the durability of those outcomes. Further in-depth education may be required to maximize patient's potential for functional living. Treatment plans should include individual and group education as a means of facilitating self-awareness, self-management, and prevention of secondary disability.

3. Return-to-Work following brain injury involves a skillful match between the patient's physical, cognitive, emotional, behavioral abilities, and the physical, cognitive, emotional, and behavioral requirements of the work. Successful return-to-work activities should usually include vocational evaluation, job analysis, supervisor and co-worker education, on-the-job-trials, monitored and skillful increased titration of job duties and demands, job coaching, and follow-up maintenance support services.

4. Disability:

The World Health Organization (WHO) and the specialty field of brain injury rehabilitation utilizes different definitions for the terms impairment, disability, and handicap. The WHO defines “impairment” as an organic deficit, “disability” as how the impairment alters function in the body, and “handicap” as how the disability affects function in the person's real world environment. Because of the nature of TBI and the nature of learning and memory, functional skills often cannot be generalized across environments. Therefore the evaluation, treatment, and assessment of disability must not only consider the injured worker, but also include evaluations of the patient's real world environment, conducted by qualified practitioners. Therefore, under WHO definitions, the focus of rehabilitation is reducing handicap, not merely reducing impairments or disability.

5. Course of Recovery:

In patients with MTBI, neurological recovery is generally achieved at one year post-injury, but functional improvements can be made beyond one year. Neurological recovery following moderate-severe brain injury is greatest in the first 12 months post-injury, but can occur for up-to-2 years post-injury, with further functional improvements beyond two years.

Due to the uncertain evolving nature of disability secondary to TBI, patients may either improve or deteriorate over time. In most cases of moderate-severe brain injury, and in some cases of MTBI, impairment will be lifelong, and will require a lifelong maintenance plan of services. Complications may warrant periods of active treatment in addition to the maintenance plan.

In at least 40% of cases, TBI is accompanied by other substantial trauma (e.g. internal, orthopedic injuries), which can involve dysfunction in other bodily systems. Users of these are encouraged to use appropriate guidelines for other disorders and dysfunction as the need arises.

6. Guardianship and Conservatorship:

Persons with brain injury may clinically be determined to be unable to make competent and informed decisions concerning their medical care, housing, and/or finances. Health care providers, insurance carriers, and case managers should become familiar with Colorado laws regarding guardianship, conservatorship, medical power of attorney, advanced directives, living wills, etc, and provide family members with appropriate education and/or resources concerning these issues when clinically indicated.

B. SYSTEMS OF CARE:

Integrated systems of care have been established in Colorado with the goal of assisting patients with TBI in progressing along a continuum of care toward achieving optimal clinical outcomes as efficiently and as cost-effectively as possible. Long-term outcome and “value” are recognized as superior to short-term price-driven management, both in terms of clinical outcomes and cost savings.

Individuals with brain injury respond to medical and therapeutic interventions at different rates and achieve different outcomes. Each patient's treatment plan must be based upon the identification of patient-focused problems, and goals that are patient specific, and are re-evaluated on a regular basis. The type, amount, frequency and duration of rehabilitation services are determined by the degree of functional improvement within specific time frames as well as the patient's potential to achieve additional functional improvements with continued provision of services.

1. Acute Care:

Established EMS triage guidelines and organized pre-hospital trauma systems improve the delivery of trauma care and should be utilized. Trauma systems with identified regionally designated neurotrauma centers should be utilized to treat neurotrauma cases effectively. Neurotrauma centers should have a multidisciplinary trauma team, an in-house trauma surgeon, promptly available neurosurgeon, a continuously staffed Operating Room, Intensive Care Unit, lab, etc. and a CT immediately available at all times. Other team members should include orthopedists, radiologists, anesthesiologists, and neuronursing. Insurance carriers should develop early identification programs in order that patients with TBI are identified quickly, and nurse case managers to be dispatched to provide on-site case management. This includes on-site interaction with treatment providers and support for patients and families.

2. Acute Rehabilitation:

Patients with moderate-severe brain injury should be transferred from acute hospital care to a designated inpatient brain injury rehabilitation whenever feasible. Patients must be able to tolerate a minimum of 3 hours of therapeutic intervention per day, 5 days per week.

Interdisciplinary inpatient brain injury rehabilitation is a generally accepted and widely used practice. Inpatient brain injury rehabilitation programs should have designated staff for TBI, designated TBI patient rooms, designated TBI treatment facilities and programs, and serve at least 25-30 TBI patients per year. Inpatient programs should be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and by the Commission on the Accreditation of Rehabilitation Facilities (CARF) and preferably have a CARF Specialty TBI Accreditation.

The length of initial inpatient rehabilitation treatment depends on the severity of deficits, complications, and progress etc. Continued lengths of stay should be based upon documented functional progress, and can typically range from 30-90 days for moderate-severe injury with every 30 day re-evaluations. On-site insurance case managers are encouraged to be a part of the treatment team, attend team conferences and assist the patient, family, and hospital discharge planners in short and long-term disease management.

3. Post-Acute Rehabilitation is also called residential or transitional living. Post-acute rehabilitation is clinically appropriate for patients who have completed initial inpatient rehabilitation, but who continue to have significant deficits, who are deemed to be unsafe to be discharged home, who require continued behavioral treatment, or who are deemed to be more effectively treated in a residential setting.

Post-acute residential rehabilitation is generally accepted, typically for a period of 30-90 days, depending on the patient's condition and discharge needs, with every 30 day re-evaluations. Post-acute rehabilitation typically includes treatment and management by an interdisciplinary treatment team, with an emphasis on functional community re-integration. JCAHO and CARF eligibility and/or accreditation are recommended for post-acute programs.

4. Subacute Rehabilitation Programs are located on separate and specially licensed units of hospitals or nursing homes. Subacute programs are designed for patients who are not clinically ready to participate in full rehabilitation programs. Patients appropriate for subacute care typically are medically stable, require skilled nursing care, and require and can tolerate a minimum of 1 hour, but less than 3 hours of therapeutic intervention per day, 5 days per week.

Subacute rehabilitation is generally accepted, but should not be used in lieu of categorical inpatient rehabilitation. When patients are able to tolerate 3 hours per day of therapeutic intervention, 5 days per week, they should be transferred to acute brain injury rehabilitation programs. Subacute programs should be required to be accredited by JCAHO and in addition are encouraged to be accredited by CARF.

5. Outpatient Rehabilitation Services are a generally accepted and widely used practice. It can include single disciplines or interdisciplinary treatment. Therapeutic interventions are delivered in a hospital, free-standing outpatient facility, or community-based facility with focused goals for home and community functioning. Intensity can vary from 1 hour per day to 4-6 hours per day (sometimes called “day treatment”). Frequency can vary from daily to less than one day per week. Immediately following inpatient rehabilitation, outpatient is usually intensive, followed by a systematic and gradual reduction in therapy as appropriate. Typically outpatient treatments include physical therapy, occupational therapy, speech/language, mental health counseling, therapeutic recreation, family counseling, and vocational rehabilitation. Outpatient rehabilitation should be functionallyoriented, goal specific, time-limited, and case managed.

6. Home and Community-Based Rehabilitation are rehabilitation services provided in a patient's home and community settings, as opposed to a treatment facility. These services are generally accepted and widely used for patients with TBI who have completed inpatient or postacute rehabilitation. Home and community-based services may be delivered alone, or in conjunction with outpatient treatment.

Home and community-based services are designed to maximize the transition and generalization of skills in patients with moderate-severe injuries from institutional settings to application in the community. In MTBI, community-based services may be the primary type of appropriate intervention.

One or more therapeutic disciplines are appropriate to deliver home and community based services including certified clinicians from physical therapy, occupational therapy, speech therapy, medicine, mental health, therapeutic recreation, family counseling, nursing services, and vocational rehabilitation. There are no accreditations for home and community based providers, but providers should be experienced in brain injury rehabilitation.

a. Frequency: 1-3 hours per discipline per day, 1-3 times per week

b. Optimum duration: up-to-24 months or beyond, with monthly re-evaluations

7. Behavioral Programs are specialized TBI inpatient or residential rehabilitation programs designed for patients with brain injury who have persistent and significant maladaptive behaviors. While all brain injury rehabilitation programs treat behavior, behavioral programs are usually required for patients who are unsafe, or who have suicidal, homicidal, or violent behavior and patients who cannot be treated in less restrictive environments.

Behavioral programs can be physically located in secured hospital units, or community-based programs.

Behavioral programs generally use an interdisciplinary approach that may include behavior modification, medications, socialization skills training, substance abuse treatment, family therapy, and physical management programs, as well as traditional interdisciplinary treatment. Length of stay can greatly vary depending on etiology and severity of the behavioral disorders, and can typically range from 1-6 months. Discharge from behavioral programs is either back to inpatient acute rehabilitation, post-acute residential programs, outpatient programs, supported living programs, or home and community-based programs. Use of psychiatric hospitals that are not experienced in brain injury rehabilitation is not recommended. Behavioral programs are also appropriate for severe behavioral problems due to other concomitant diagnoses, such as alcohol or substance abuse. Categorical adolescent inpatient hospital and residential programs may be appropriate for adolescent behavioral disorders due to TBI.

8. Extended Nursing Facility Care is generally provided in specialty licensed units of nursing homes. Extended nursing facility care is generally accepted and widely used. Patients appropriate for extended care are not able to be cared for in private home, group home, or community settings, do not generally require skilled nursing care, but require on-going care that is supervised by RNs. Rehabilitation therapies may be necessary to supplement nursing care. Patient rehabilitation programs are established by appropriately licensed or certified therapists, but may be delivered by paraprofessionals. The goal of care is to maintain function, and improve function if possible, which usually occurs at a slower rate over an extended period of time. Accreditation by JCAHO is recommended.

9. Supported Living Programs (SLP) include licensed personal care boarding homes (group homes) or supported apartment programs, designed for long-term living at the completion of rehabilitation. SLPs are designed for patients who due to their brain injury are not able to safely and independently care for themselves in the community, and for whom home placement is unavailable or inappropriate. Such programs are appropriate for patients who are at risk for medical, physical, and psychological complications, but who do not require a secured setting. Housing, food, supervision, activity programs, sheltered employment, transportation, and case management are typical components of supported living programs. These programs are becoming more available and are generally accepted services for patients with chronic brain injury who are moderately and severely disabled, and who require long-term living programs and support services.

C. INTERDISCIPLINARY TREATMENT TEAM, also called multidisciplinary or transdisciplinary, is a team of professionals from different therapeutic disciplines (field of study). This team participates in establishing treatment priorities, goals, planning, and providing treatment. Team members contribute their respective skills, competencies, insights, and perspectives in the rehabilitation process. This also includes mutual education, communication, and alignment of expectations for the benefit of maximizing patient outcomes. Patient, family, insurance carrier, and case management involvement with the interdisciplinary treatment team is highly recommended.

D. THERAPEUTIC DISCIPLINES most involved in the medical and rehabilitation treatment of TBI include, but are not limited to:

1. Behavioral Psychologist: psychologist with special training, credentials, and licensing, who specializes in the area of behavior analysis and treatment.

2. Clinical Psychologist: psychologist with special training, credentials, and licensing, who specializes in the assessment and treatment of personality and personality disorders, education and adjustment counseling, psychotherapy, and management of behavior.

3. Neurologist: physician with special training and credentials in the area of the nervous system, who has successfully completed an approved residency in neurology.

4. Neurophthalmologist: ophthalmologist with special training and credentials in the areas of brain-related vision and visual disorders, who has successfully completed an approved residency in ophthalmology.

5. Neuropsychologist: licensed psychologist with special training in and knowledge of brain-behavior relationships including causality of neurobehavioral changes and treatment, and management of neurobehavior disorders. 6. Neurosurgeon (Neurological Surgeon): physician who has special training and credentialing in the surgery of nervous system disorders, who has successfully completed an approved residency in neurosurgical medicine.

7. Nurse:

LPN or RN with specialty training, credentialing, and licensing, who specializes in the collection and assessment of health data, health teaching, and providing therapy and treatment that is supportive and restorative to life and well-being.

8. Occupational Therapist (OT): therapist who specializes in the assessment and treatment of physical, perceptual, and cognitive skills needed to perform self-care, home maintenance, and community skills. The term occupation, as used in occupational therapy, refers to any activity used for evaluating, specifying, and treating problems interfering with functional performance.

9. Optometrist: specialist with training, credentials, and licensing, who specializes in the examination, assessment, diagnosis, treatment, and management of diseases and disorders of the visual system, the eye, and associated structures, as well as diagnoses related systemic conditions.

10. Ophthalmologist: physician with special training, credentials, and licensing in the field of vision and visual disorders who has successfully completed an approved residency in ophthalmology.

11. Physical Therapist (PT): licensed therapist who specializes in the assessment and treatment of patients in the areas of strength, tone, posture, coordination, endurance, stamina, general mobility, and increasing functional independence.

12. Physiatrist: physician with special training, credentials, and licensing, in the field of physical medicine and rehabilitation, who has successfully completed an approved residency in physiatry.

13. Psychiatrist: physician with special training, credentials, and licensing, who specializes in the field of mental health and mental disorders, who has successfully completed an approved residency in psychiatry.

14. Rehabilitation Counselor: bachelor's or master's prepared counselor, who specializes in assisting patients in the process of independent living, productive activity and employment. This includes assistance with financial resources, housing, community resources, social skills, vocational evaluation and treatment, and patient and family counseling.

15. Social Worker: licensed bachelor's or master's prepared social workers who specializes in patient and family relationships, as well as housing, financial resources, and society re-integration.

16. Speech/Language Pathologist (Speech Therapist): therapist who specializes in the assessment and treatment of patients in the areas of communication, speech and language, hearing, voice, cognition, education, reading, and writing.

17. Therapeutic Recreation Specialist (Recreational Therapist): bachelor's or master's prepared therapist who specializes in the assessment and treatment of patients in the areas of planning and management of leisure activities, time management, mental health through recreation, and community access.

E. TBI CASE MANAGEMENT is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual's health needs, using communication and available resources to promote quality, cost-effective outcomes. TBI case management operates with an underlying premise that when individuals reach their optimum level of wellness and functional capability, everyone benefits: the individuals being served, their support systems, the health care delivery system, and the insurance carriers.

The primary functions of TBI case management are:

1. To maximize patient and family understanding, compliance, and treatment outcomes through education and support

2. To advocate for patient wellness and autonomy through advocacy, communication, and identification of service resources.

3. To optimize patient access to appropriate health care services

4. To integrate and coordinate service delivery by multiple providers and to prevent fragmentation of services

5. To predict and avoid potential complications

III. INITIAL DIAGNOSTIC PROCEDURES

The purpose of these procedures is to establish the type and severity of TBI as a diagnosis, and to establish initial treatment goals and plans.

A diagnosis of TBI should be determined by criteria listed below. Severity of initial impairment following brain injury is subdivided into two major categories, Mild (MTBI) and Moderate-Severe TBI. These definitions apply to the initial severity of impairment, and do not necessarily define or describe the degree of subsequent impairment, disability, or handicap. Further, they do not necessarily define or describe the need for the subsequent type, intensity, or frequency of treatment.

Mild TBI (MTBI) is defined as a patient who has had a traumatically induced physiological disruption of brain function, as manifested by at least one of the following:

1. any period of loss of consciousness up-to-30 minutes;

2. any loss of memory for events immediately before or after the accident; 3. any alteration in mental state at the time of the accident, e.g., feeling dazed, disoriented, or confused; and/or

4. focal neurological deficit(s) that may or may not be transient; but where the severity of the injury does not exceed the following:

a. loss of consciousness of approximately 30 minutes or less;

b. at 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15; and

c. post-traumatic amnesia (PTA) not greater than 24 hours.

The patient should have no evidence of traumatically induced intracranial lesion on neuroimaging studies and have had other possible causes of alterations in mental status ruled out.

Moderate-Severe TBI is defined as a patient who has had a traumatically induced physiological disruption of brain function, as manifested as having at least one of the following:

1. loss of consciousness of greater than 30 minutes

2. PTA of greater than 24 hours

3. evidence of traumatically induced intracranial lesion on neuroimaging studies

A. TAKING A HISTORY OF INJURY:

In order to establish a diagnosis of TBI and to establish treatment goals and plans, it is a generally accepted and widely used practice for a qualified practitioner to obtain as thorough a history of the injury as possible. Recommended data obtained in the history-taking should generally include, but is not limited to:

1. Identification Data should include the patient's name, address, age, sex, and marital status.

2. Precipitating Event:

Information regarding the circumstances of the brain injury should include where and when the injury occurred, how the injury occurred, what the patient was doing at the time of the injury, and what happened. If the injury occurred as a result of a motor vehicle crash, information should be obtained as to the speed of the vehicle, use of restraints or helmet, etc. If the injury occurred as a result of a fall, information should be obtained regarding the type of fall, distance of the fall, type of surface, etc. Due to forensic implications, information should also include whether the injury was work-related or not. If there were witnesses, names should be included, if possible.

3. Neurological History should include review of chief complaints, presenting problems and symptoms. Generally accepted data should include information about alteration of consciousness or length of unconsciousness, degree and length of retrograde and post-traumatic amnesia, cognitive and behavioral impairments. Information should be collected regarding various time intervals:

a. Current Neurological Status: Patient's report of current neurological condition, symptoms, complaints, functional problems, etc. b. Initial Neurological Status: Patient's report of neurological condition at the time of the injury, symptoms, complaints, functional problems, etc.

c. Evolution of Neurological Status: Patient's report of change in neurological condition between the time of the injury and the present, including symptoms, complaints, and functional problems.

4. Review of Medical Records, in addition to patients' self-report, practitioners should attempt to obtain and review any external sources of data, including Police Reports, Ambulance Reports, Emergency Department Records, Eye Witness Reports, etc.

B. PAST MEDICAL/HEALTH HISTORY taking is a generally accepted practice and should include a history of past illnesses, injuries, previous brain injuries or other disabilities, epilepsy, pain, previous surgeries of any kind, mental health and medication history, or other medical/health data.

1. Family History should include neurological and medical history of illness, disability within the family that are relevant to the patient's condition.

2. Patient Social History should include marital history, living situation, leisure interests, avocational interests, significant others, etc.

3. Occupational History should include name of current company, job title, primary job duties, length of employment, prior places and dates of employment, and educational history.

4. Nonoccupational History should include common nonoccupational activities, such as the leisure activities of sports, hobbies, and personal interests.

5. Substance Abuse History should be obtained (particularly if there is data to suggest sub-stance abuse was involved in the injury) as well as information related to the amount and duration of alcohol and drug use, licit and illicit.

C. REVIEW OF SYSTEMS is a generally accepted practice and should include a complete review of body systems and functions.

D. PHYSICAL EXAMINATION should be performed by a qualified practitioner, and is a well accepted practice.

E. NEUROLOGICAL EXAMINATION should be performed by a qualified practitioner, and should include a mental status examination. The mental status examination can occur formally or informally and should include examination of patient presentation, personal hygiene, alertness, ability to provide history, and ability to follow direction. If a formal evaluation is conducted, further documentation should be provided. Subsequent referrals to other specialists may be indicated based upon presenting problems, medical treatment guidelines, and are at the discretion of the physician.

F. INITIAL NEUROPSYCHOLOGICAL ASSESSMENT is the evaluation of the relationship between the functioning of the brain, cognitive processes and behavior, using psychological testing to assay central nervous system function and to diagnose specific behavioral or cognitive deficits or disorders. They are generally accepted and widely-used as a valuable component of the diagnosis and management of patients with brain injury. Neuropsychological assessments are sensitive tests used to detect subtle cognitive changes, severity of injury, and improvement over time. Neuropsychological assessment can make a contribution to the differential diagnosis of neurobehavioral disorders, and the cumulative effect of multiple brain injuries.

Neuropsychological assessments can also be utilized as a basis for formulating rehabilitation strategies, and can provide information related to prognosis and outcome. Neuropsychological assessments can be utilized to formulate how the individual's underlying brain injury impacts interpersonal behavior and the ability to function effectively in daily life.

Neuropsychological assessment utilizes standardized testing procedures. Test reliability and validity are important considerations. Multiple sources of data (self-report information, medical history, psychosocial history, family report, etc.) are integrated with test performance factors to draw inferences about brainbehavior relationships.

1. Initial Neuropsychological Assessment - MTBI:

The referral of patients for focused neuropsychological testing during the first month post-MTBI is advantageous in that it facilitates the documentation of attentional, memory, and other cognitive deficits. This permits the adequate documentation of the severity of the injury and improvements over time. During the first month post-injury, neuropsychological testing is indicated when differential diagnosis is required (brain injury versus other diagnosis). Testing with a focused MTBI battery is indicated in the first month post-injury for:

a. patients with injuries at the upper end of the mild continuum (duration of coma greater than 10 minutes, duration of PTA greater than 4–6 hours)

b. patients with other risk factors such as very demanding or stressful vocations, employed in the current job for a short period of time

c. age above 40 years

d. injury complicated by the presence of intracranial lesions

e. history of prior head injury

f. associated orthopedic or soft tissue injuries

g. patients who have sustained MTBI who are not improving.

During the first month post-injury and up-to-3 months post-injury a focused MTBI battery that permits serial testing, and that focuses on attentional/concentration skills, memory, speed of information processing, executive functions, and emotional status may be indicated. There should be a clear cut rationale for undertaking testing on any occasion, and the influence of practice effects should be considered.

2. Initial Neuropsychological Assessment – Moderate-Severe TBI may be helpful in documenting when the patient comes out of PTA. Selective neuropsychological testing is indicated to help identify cognitive strengths and weaknesses in order to facilitate treatment planning, and to assist with patient and family education. Descriptive psychoeducational testing is commonly used in rehabilitation to help identify treatment goals and monitor progress over time. Test selection is dependent upon the patients' neurobehavioral status and other aspects of their medical condition (e.g. a broken dominant upper extremity would preclude the administration of a number of neuropsychological tests, and would require the substitution of other tests). The extent of testing undertaken at any point in time will be a function of the relevant clinical and planning decision-making process (e.g., Does the patient require a stay in an inpatient rehabilitation unit?). In most cases, the administration of a full neuropsychological test battery is not indicated until the patient is at least a month post-injury and clearly out of PTA.

A full neuropsychological test battery would include an interview of the patient, the relevant history, the administration of tests related to attention, concentration, speed of information processing, visual perception, constructional skills, language, verbal abilities, executive function, intellectual abilities, memory, psychomotor testing where appropriate, and assessment of emotional status. Patients with moderate to severe injuries may also be followed with selective neuropsychological testing in order to track their recovery of specific cognitive abilities over time (e.g., speed of information processing or memory).

During the initial acute rehabilitation treatment episode, certain serial tests and one full neuropsychological battery are typically administered. Testing time will vary as a function of the patient's deficits, behavioral excesses, fatigue tolerance, diagnosis, and referral questions. Testing may require 8– 10 hours of time, typically not at one sitting. Additional time is required to score and interpret the tests and write the report. When the referral question or diagnosis are more complex, more time may be required. Selective retesting to monitor clinical status may be required. The administration of full test batteries should be determined by clinical need, but typically is not needed more than once every six months. A full battery is often administered at 18–24 months to help assess status of recovery. Some patients with brain injury can become worse over time, and the administration or re-administration of neuropsychological testing may be appropriate in long-term assessment, treatment or maintenance.

G. INITIAL DIAGNOSTIC RECOMMENDATIONS:

1. If the patient regains normal consciousness in the ER and has normal neurological findings on examination and neuroradiological studies, the patient can be discharged home with close supervision for the initial 24 hours. Patients should be provided with educational and support information and written material describing possible future symptoms, guidelines for activity levels during the acute recovery period of the first week. Contingency instructions should be provided in the event of persistent symptoms, and strategies for physical and emotional health.

2. If the patient does not regain normal consciousness, has focal neurological findings, or persistent cognitive impairment, further neurological evaluation, treatment, management and follow-up are indicated; may include acute hospitalization and interdisciplinary team treatment.

H. OTHER INITIAL DIAGNOSTIC PROCEDURES:

1. Skull X-Rays are used to detect a fracture of the skull base or cranial vault. CT scanning is preferred if fractures are suspected because the CT scan can identify clinically significant fracture as well as potentially co-existent contusion or hemorrhage. Skull x-rays are generally accepted if CT Scans are not available. 2. Computerized Axial Tomography (CT) (Cranial Computer Tomography) is a brain imaging x-ray study comprising a mathematical reconstruction of the tissue densities of the brain. CT Scans require the use of computer-based scanning equipment. For acute brain trauma, iodine contrast enhancement is not necessary. CT Scans are non-invasive and should reveal the presence of blood, skull fracture, and/or structural changes in the brain. CT scans provide limited information about intrinsic cerebral damage involving deep brain structures.

CT scans are widely-accepted for acute diagnostic purposes, and for planning acute treatment. They are the screening image of choice in acute brain injury and are used to assess need for neurosurgery. CT scans are recommended for abnormal mental status, focal neurologic deficits, or acute seizure and should also be considered in the following situations:

a. Signs of basilar skull fracture

b. Pedestrian hit by motor vehicle

c. Victim of an assault

d. Acute traumatic seizure

e. Older age

f. An interval of disturbed consciousness

g. Pre– or post-event amnesia

3. Magnetic Resonance Imaging (MRI) is a brain imaging study in which the patient is positioned in a magnetic field, then a radio-frequency pulse is applied to the field. Hydrogen proton energy emission is translated into visualized structures. Normal tissues give off one signal, while abnormal structures give off a different signal. MRI scans are superior to CT sans in detecting intracranial pathology, but are not typically available on an emergency basis. MRI may reveal an increased amount of pathology as compared with CT. MRI scans are useful to assess transient or permanent changes, in determining the etiology of subsequent clinical problems, and in treatment planning. MRI is more sensitive than CT for detecting traumatic cerebral injury. Initially, MRI scans are clinically useful in the following situations to:

a. determine neurological deficits not explained by CT

b. evaluate prolonged interval of disturbed consciousness

c. define evidence of previous traumas superimposed on acute changes

4. Electroencephalography (EEG) is the monitoring of brain wave activity using scalp electrodes and provocative maneuvers such as hyperventilation and photic strobe. Information generated includes alterations in brain wave activity such as frequency changes (nonspecific) or morphologic (seizures). EEG is not generally indicated in the immediate period of emergency response, evaluation, and treatment. Following initial assessment and stabilization, the patient's course should be monitored. If during this period the patient fails to improve or deteriorates, EEG may be indicated to assist in the diagnostic evaluation. Potential diagnoses include seizures, focal encephaopathy due to persistent contusional effects of hemorrhage, or diffuse encephalopathy due to the injury, or complicating factors such as hydrocephalus or medications. 5. Quantified Electroencephalography (OEEG) (Computerized EEG) is a modification of standard EEG using computerized analysis of statistical relationships between power, frequency, timing and distribution of scalp recorded brain electrical activity. These statistically generated values are then compared to those recorded from selected control and patient populations, generally using multiple regression analysis of multiple measurements and calculated parameters. A statistically derived probability statement regarding the likelihood of the patient studied belonging to the patient pathological population in comparison to the control nonpathological population is then generated.

a. Indications for Use: QEEG is rarely indicated in the initial diagnostic assessment of MTBI. It may occasionally be used when seizures, dementia, or cerebrovascular disease are diagnostic considerations. In moderate and severe TBI the results of QEEG are almost always redundant with traditional electroencephalographic, neurologic and radiologic evaluations. As a diagnostic tool for MTBI, QEEG is considered investigational.

b. Practice Requirements of QEEG: QEEG is based upon sophisticated technical and statistical methodologies. Therefore, adherence to some type of technical standards such as outlined by the American Medical EEG Association is necessary. The physician QEEG practitioner should possess EEG board certification from a national certifying organization, documented additional training relevant to QEEG and “hands on” additional training with one or more qualified QEEG practitioner.

6. Single Photon Emission Computerized Tomography (SPECT) is a functional image of the brain created by a flow tracer or a receptor binding substance tagged with a radio-nucleotide and injected intravenously into the patient. Radiotracer is assumed to accumulate in different areas of the brain proportionately to the rate of delivery of nutrients to that volume of brain tissue. Using a gamma camera and the techniques of CT, a 3-D image of the distribution of a radionucleotide in the brain is obtained.

At this time, for MTBI, SPECT is an investigational tool. SPECT may be useful in patients with MTBI still symptomatic six months or longer after injury (SPECT demonstrates abnormalities 53% of the time compared with MRI 31% and CT 11%). For severe brain injury, SPECT may be useful for patients with prolonged low levels of responsiveness (i.e., persistive vegetative state), in cases of anoxia, or when additional data is needed.

SPECT cannot measure regional cerebral metabolism, but does provide a qualitative estimate of regional cerebral blood flow (CBF), which in many neurologic disorders is correlated with brain metabolism. Initially, SPECT after brain trauma is more sensitive to extensive, nonspecific perfusion abnormalities than may be expected from anatomic changes seen on CT.

7. Positron Emission Testing (PET) is a functional brain imaging procedure. A tracer molecule tagged with a positron emitting radioisotope is injected into the body. Biodistribution of the tracer is imaged, producing information about local cerebral glucose utilization and cerebral perfusion. This procedure requires on-site access to a cyclotron. Its routine use is limited by limited resolution and availability.

PET generates information regarding focal metabolic abnormalities of the brain. In patients with Moderate-Severe TBI, PET findings are closely correlated with the site and the extent of cerebral dysfunction derived from neurologic and neurobehavioral examinations. Little information is available about its use and results in MTBI. At this time, PET scans are not generally accepted for routine clinical use and are generally used for research.

8. Vascular Imaging Tests reveal arterial or venous abnormalities in the chest, neck, head, or extremities (e.g., thrombosis, dissection, spasm, emboli, or tearing). These tests are generally used if more standard CT/MRI fail to demonstrate suspected vascular abnormalities. They are useful in moderate to severe TBI but only rarely in MTBI. Procedures that are generally accepted include:

a. Noninvasive Vascular Assessment (NIVA) is the least invasive and can demonstrate direction of blood flow and general patency of the carotid and vertebral arterial systems in the neck, but not in the head.

b. Magnetic Resonance Angiography (MRA) or MRI/A) is indicated when vessel changes are suspected but not demonstrated by other simpler tests. Internal obstruction of an artery (e.g., thrombosis, spasm, dissection or emboli from a concomitant chest or neck injury) can be demonstrated. Arterial compression due to an external pressure (e.g., boney fracture or mass affect from a large intra-axial hemorrhage or cerebral edema) may be demonstrated. Vascular rupture with fistula formation may be seen, but as with other vascular abnormalities may need arteriography/venography to be more definitive. The source for intra or extra-axial bleeding may be seen. Sagittal or other sinus thrombosis is usually demonstrated as well as poor venous return.

c. Arteriography is generally accepted when the above-noted traumatic vascular abnormalities are still suspected and unproved with the techniques discussed so far. This is particularly true with fistulous change.

d. Venography is generally accepted if increased venous flow and pressure are suspected and still undemonstrated. This is done either by the jugular or orbital systems.

9. Lumbar Puncture is an examination of cerebrospinal fluid (CSF) in neurological disease and injury. It is a generally accepted, well-established diagnostic procedure. The procedure should be performed by qualified and trained physicians under sterile conditions. Lumbar puncture is contraindicated in acute trauma to the spinal column, certain infections, increased intracranial pressure due to space occupying lesions, and in coagulation disorders or defects. Additionally it should be avoided if there are cutaneous infections in the region of the puncture site.

In patients with suspected or known increased intracranial pressure, lumbar puncture should be proceeded by a CT scan or MRI. If no mass is found, lumbar puncture can proceed. If CT or MRI shows intracerebral or intraventricular blood, lumbar puncture should be bypassed.

Lumbar puncture is also used to inject contrast material or other agents for diagnostic purposes, beyond examination of the CSF. Lumbar puncture can also be used in order to administer agents for treatment. Lumbar puncture is rarely indicated in the early management of TBI.

10. Electrodiagnostic Studies include, but are not limited to, EMG, nerve conduction studies and multisensory evoked potentials including visual evoked potentials (VEP), somatosensory evoked potentials (SSEP), and brain stem auditory evoked responses (BSAER).

a. EMG and Nerve Conduction Studies are generally accepted, well-established and widely used diagnostic procedures. These studies may be useful for patients with brain injury and associated suspected neural involvement whose symptoms are persistent or unresponsive to initial conservative treatments. They are often used to differentiate peripheral vs central spinal cord and/or brain neural deficits. These electrodiagnostic studies are possibly complimentary to other imaging procedures such as CT, MRI, and/or myelography. These studies may provide useful correlative neuropathophysiologic information that would otherwise be unattainable from standard radiologic studies.

b. Dynamic Electromyographies are electrodiagnostic studies utilized to distinguish the voluntary capacity of a muscle from a spastic reaction. This aids the clinician in better planning specific rehabilitative treatment. This study is helpful in the differential diagnosis and diagnostic work-up of disordered muscle tone. This is a generally accepted procedure.

c. Evoked Potential Responses (EP) are electrophysiologic and neuropsychologic central nervous system responses to either external stimulation of one or more sensory modalities, or to internally generated brain responses associated with the processing of information. These EPs are obtained upon stimulation of various senses such as sight, hearing, touch. Multisensory EP studies include, but are not limited to visual evoked potentials, brain stem evoked potentials, somatosensory evoked potentials and cognitive evoked potentials. These are generally accepted, well-established diagnostic procedures. There is some utility in the early use of these studies for differential diagnosis, prognosis and to determine a patient's more specific level of neurologic functioning.

1) Visual Evoked Potential (VEP): Pattern reversal monocular VEP recording may detect pathology in the anterior-posterior visual pathway from the retina to the occipital cortex. It may be indicated in the event of compromised acuity, visual field defect, afferent pupil defect or optic atrophy. The VEP may occasionally be normal in cases of severe structural damage if there is enough preserved visual field close to center to image the patterned stimulus.

2) Electroretinogram (ERG): Direct ocular trauma accompanying the brain injury may produce a retinal detachment with reduced amplitude. A retained metallic foreign body will eventually cause siderosis and if ferromagnetic, can also reduce the amplitude.

3) Brain Stem Auditory Evoked Response (BSAER) is useful in assessing damage to the brain stem, midbrain and other neural structures that govern hearing and/or balance. It may be more useful than the SSEP in MTBI. A normal test does not rule out structural damage, and the test may be abnormal in middle ear and non- traumatic disease affecting the auditory pathway. Waves 1 and 3 but particularly 5 are most useful in assessing injury. While amplitude and the presence of wave is important, the latency and interwave latency is equally as important. This test is often sensitive and nonspecific.

4) Somatosensory Evoked Potential (SSEP) has less sensitivity than BSAER in MTBI; the more severe the brain injury, the greater this study becomes useful.

11. Diagnostic Nerve Blocks utilize percutaneous needle injection techniques to a specific nerve. These diagnostic blocks are typically performed with quick acting, short duration local anesthetics such as Lidocaine or Bupivocaine. Diagnostic nerve blocks are a generally accepted procedure. The purpose of this procedure will allow examiners to evaluate factors of range-of-motion, dystonia or spasticity. Diagnostic nerve blocks are intended to be temporary and to test a hypothesis which will determine the limb's possible range-of- motion. This allows for the planning of a subsequent more appropriate therapeutic procedure.

12. Audiometry and Otology a. Audiometry is a diagnostic procedure which measures hearing, generally accepted and well- established procedure. The results of the testing, performed by a trained, skilled technician is recorded on an audiogram which is a graph showing hearing (threshold) level at various frequencies, typically ranging from 125-to-8000 Hz. The threshold of hearing (hearing level or hearing loss) is the number of decibels that the patient is able to perceive beyond the zero reference, the latter of which is considered “normal”.

A TBI may result in hearing loss. The type and the degree of the hearing impairment is often dependent on the severity and location of the injury. Following a brain injury several pathological mechanisms can occur and include: localized middle or inner ear injury from trauma to the ear and temporal bone, labyrinthine concussion, injury to the seventh and eighth cranial nerves, and injury to the brain stem or higher cortical pathways.

Audiometers may be operated manually or automatically. It is recommended that if serial or periodic testing is done, the same type of audiometer be used. The data generated from an audiometer can be graphically displayed by plotting the results on a chart for each ear tested. The results of the display then can be interpreted by a trained audiologist and/or a qualified physician, in regards to the type of hearing loss detected, being either sensorineural, conductive, or a mixed pattern. The audiometer should meet specifications approved and published by the American National Standards Institute (ANSI).

Baseline testing done shortly following injury is likely indicated when the patient's chief complaint is hearing loss, tinnitus, dizziness, or facial nerve dysfunction following brain injury. In addition, acquisition of injury audiograms for comparison are important in assessing loss at baselines and/or following serial testing, subsequent to the injury. A portion of the conductive and the sensorineural hearing loss resulting from trauma may be reversible, therefore, serial audiograms performed several months after injury are likely worthy of consideration before determining the degree of permanent hearing impairment. b. Otologic consultation is generally accepted and widely used in cases of hearing loss, balance problems, and eighth cranial nerve dysfunction.

13. Vestibular Function Tests can be useful in the diagnosis and assessment of the etiology and site of lesion causing balance and equilibrium dysfunction. These tests are generally accepted. Vestibular dysfunction is often a result of combined peripheral and central lesions. Due to the degree of difficulty evaluating subjective patient report of symptoms in these instances, a history and physical, electronystagmography, brain stem auditory evoked responses, and rotary chair testing are generally accepted adjunctive tests. These physiologic tests, rather than functional tests, can evaluate the integrity of the inner ear mechanism. These tests (ENG and rotary chair testing) are often difficult for patients with TBI who have behavioral and cognitive deficits. Dynamic posturography may provide a more functionally oriented assessment of balance deficits and is also generally accepted.

a. Electronystagmography (ENG) assesses the site and side of peripheral lesions. Adjunctive tests include the Hallpike-Dix maneuver which is commonly used for the diagnosis of benign paroxysmal positional vertigo. Caloric testing is also useful in identifying the involved ear in peripheral lesions. Both these tests are generally accepted procedures for differentiating peripheral lesions from central lesions and for planning treatment.

b. Rotary Chair Testing measures the response of the vestibular system to high frequency stimuli and helps to identify the site and side of the lesion. It is a useful test to identify bilateral deficits or when changes are subtle and not detectable with caloric testing or low velocity rotation. Abnormal findings with rotary chair testing are usually related to peripheral vestibular system dysfunction. This testing is most likely to be useful in patients with potential peripheral vestibular lesions in whom caloric tests are uncertain or unobtainable. c. Dynamic Post-urography is a functional test of balance that allows separate evaluation of the sensory organization and motor coordination components of balance. The purpose of this procedure is to identify the integral components of a functional balance deficit which may help in treatment planning. This technique also may be useful in monitoring neurologic recovery in patients with TBI and balance deficits. A commonly used method for dynamic post-urography is the “equitest”. These “functional” methods of evaluation are considered generally accepted practice in the evaluation of “persistent” vestibular and balance deficits that may require specific treatment and remediation strategies.

d. Electrococheolography (ECoG) is an electrophysiologic test which can assist in the diagnosis of endolymphatic hydrops or perilymphatic fistula. Both of these pathologies can occur following brain injury. High endolymphatic pressure measured by electrocochleography can indicate either hydrops or may be secondary to a loss of perilymph due to a fistula. Although the clinical history and physical examination provide the most important evidence for traumatic perilymph fistula hydrops, a positive ECoG is strong evidence for both and can localize the affected ear in equivocal cases. A normal ECoG is less helpful. When surgical intervention is considered, a positive ECoG can help justify the risks of surgical exploration.

14. Vision Evaluation generates information regarding the presence or absence of ocular injury, pathology and vision loss; refractive error, oculomotor dysfunction and binocular vision disorder. Visual evaluation may be necessary to evaluate central and peripheral nervous system disorders including visual field loss, nystagmus, impairment of ocular motility, cranial nerve palsy, opthalmoplegia, pupillary reflex disorders, and visual perceptual disorders. Visual evaluation is a generally accepted series and combination of objective and subjective tests that measure a wide range of visual processes, functional status of the eyes and visual system, ocular health and related systemic health conditions for the presence or absence of pathology.

Visual evaluation is indicated when signs, or symptoms consistent with a visual problem are reported by the patient, or observed by others. Ocular disease, injury, pathology, or cranial nerve damage should be treated as per ocular medical treatment guidelines. Significant signs and symptoms not directly and solely attributable to other causes (e.g., cognitive, vestibular, medication, psychological) indicate the need for vision evaluation as soon as is reasonably possible post-injury. Mild signs and symptoms may be monitored for several weeks to allow for resolution or improvement. Signs and symptoms do not define or describe the need for the subsequent type, intensity, or frequency of treatment.

Signs and symptoms of visual dysfunctions include, but are not limited to: blurred vision, focusing problems, double vision, eye turn (strabismus), covers or closes an eye, headache or eye strain with use of eyes, impaired depth perception, poor tracking loses place when reading, words appear to move when reading, impaired peripheral vision, head tilt, dizziness with use of eyes, visual distortions (objects, floor, walls appear bowed, slanted or tipped), reduced visual attention or concentration for visual tasks. To establish the diagnosis of visual disorders, it is a generally accepted practice for a qualified practitioner to obtain a thorough vision evaluation. A vision examination can be intermediate, extended, or comprehensive depending on the nature of the deficits. Vision testing includes, but is not limited to: case history, visual acuity, refraction, ocular motility, binocularity, accommodation, stereopsis, ocular health, reflexes color vision, and visual field.

15. Swallowing Evaluations: a. Modified Barium Swallow Studies, videofluroscopic assessment of swallow, also referred to as the “cookie swallow,” is the most common and widelyaccepted radiographic procedure used to study swallowing function. The modified barium swallow is a radiographic study in which the patient's swallowing function is visualized while attempting various food consistencies in order to examine details of oral, pharyngeal, and cervical esophageal physiology during swallowing. Barium swallows are useful in ruling out aspiration which often cannot be ruled out during a clinical bedside evaluation; approximately 40% of bedside evaluations do not confirm aspiration seen through barium swallows. Barium swallow studies are used to assess oral function, oral transit, pharyngeal motility, cricopharyngeal function, and assess oral and pharyngeal transit times. They are designed not only to assess whether a patient is aspirating, but also the etiology of the aspiration so appropriate treatment can be initiated. The results of the study can help guide the treating team to determine if an oral intake program is appropriate of if alternative nonoral nourishment is required. Aside from determining the safety of oral intake, it also is used to determine appropriate therapy and compensatory strategies. Repeated studies may be necessary to determine changes in swallowing function over time. b. Fiberoptic Endoscopic Examination of Swallowing (FEES) is an accepted although not widely used procedure to assess the pharyngeal stage of the swallowing mechanism. The pharynx is observed by traditional fiberoptic endoscopic assessment and food is administered while the scope is in place. Observations are done just prior to the swallow and immediately after the swallow. While the modified barium swallow study is considered the most reliable and widely used assessment procedure, fees may be indicated for patients who may not tolerate the radiographic procedure or when such procedures are not readily available. Repeated studies may be necessary to determine changes in swallowing function over time.

IV. FOLLOW-UP DIAGNOSTIC PROCEDURES

A. COMPUTERIZED TOMOGRAPHY (CT) may be used to follow identified pathology or screen for late pathology. Subsequently, CT Scans are generally accepted when there is suspected intracranial blood, persistent depressed or altered mental status, development of focality, post-traumatic seizure (within the first days following trauma). MRI Scans are generally recommended as opposed to CT once the initial acute stage has passed.

B. MAGNETIC RESONANCE IMAGING (MRI) is the image of choice to detect late alteration in neurologic function including, but not limited to the identification of following neurological disorders: post-traumatic epilepsy, post-traumatic movement disorder, post-traumatic cranial neuropathy, post-traumatic infection, or failure to recover within the expected time frame. Newer “functional” MRI imaging techniques may further add diagnostic sensitivity, and impact diagnosis and treatment.

C. ELECTROENCEPHALOGRAPHY (EEG) may be indicated to assist in follow-up diagnostic evaluations. EEG is indicated if the patient does not improve, deteriorates, or there is suspicion of seizure. EEG also may be useful in verifying brain death.

Potential diagnoses can include seizures, focal encephalopathy due to persistent contusional effects of hemorrhage, or diffuse encephalopathy due to hydrocephalus or medications. Sensitivity in the diagnosis of seizures may be increased by using longer or multiple EEG studies, and by the use of provocative studies such as sleep deprivation, hyperventilation, and photic strobe stimulation.

Ambulatory and video EEG monitoring may be necessary when the diagnostic sensitivity of other studies are inconclusive.

D. SINGLE PHOTON EMISSION COMPUTERIZED TOMOGRAPHY (SPECT), at this time, is an investigational tool for MTBI. SPECT may be useful in patients with mild brain injury still symptomatic 6+ months after injury (SPECT abnormal 53% compared with MRI 31% and CT 11%). For severe brain injury it may be useful for patients in the vegetative state, with hypoxia or ischemia, or when additional data is needed.

Unlike PET, SPECT cannot measure regional cerebral metabolism, but does provide a qualitative estimate of regional CBF, which in many neurologic disorders is tightly coupled with brain metabolism.

E. POSITRON EMISSION TESTING (PET):

At this time, the subsequent clinical use of PET scanning for diagnosis and management is uncertain and is not recommended for routine use.

F. NEUROPSYCHOLOGICAL ASSESSMENT, past the acute period, is appropriate in identifying deficits that persist over time, gauging progress, identifying deficits that require treatment or management, and the planning of treatment to maximize longterm cognitive and overall functional outcomes.

Subsequent neuropsychological assessment is also appropriate when the patient fails to improve, when 1) the degree of disability is disproportionate to the clinical history, or where the nature of the patient's occupation necessitates more extensive testing prior to vocational re-entry, and 2) when the question arises as to whether or not the patient has achieved maximum medical improvement.

1. Mild TBI (MTBI):

Between 1-3 months post-injury, serial testing with specialized mild brain injury batteries will usually be appropriate and sufficient to gauge progress. However, the administration of a full neuropsychological test battery may become necessary in this time period when:

a. The patient fails to improve

b. The degree of disability is disproportionate to the clinical history

c. The patient's occupation necessitates more extensive testing before he/she returns to work.

d. Descriptive psychoeducational testing and achievement testing is appropriate in order to contribute to the planning of cognitive/behavioral rehabilitation services.

2. Moderate-Severe TBI:

In addition to the information obtained in the initial moderate to severe diagnostic section, the administration of a full neuropsychological test battery at MMI is appropriate to measure and document impairment, disability, and handicap.

G. AUDIOMETRY:

A portion of the conductive and sensorineural hearing loss resulting from trauma may be reversible. Therefore, serial audiograms performed several months after the injury are indicated before determination of permanent hearing impairment.

H. VISION EVALUATION:

Depending upon the nature and extent of visual impairment and diagnosis rendered from the initial vision evaluation, additional diagnostic tests may be indicated.

1. Visual Perceptual Testing is indicated in the presence of perceptual deficits such as visual spatial relations, visual memory, visual motor integration, and neglect.

2. Low Vision Evaluation is indicated in the presence of subnormal visual acuity or visual field.

3. Electrodiagnostic Studies are indicated in the presence of reduced visual acuity, ocular pathology or suspected optic nerve or pathway deficit (refer to Section III., H. Other Initial Diagnostic Procedures, Visual Evaluation).

I. RETURN-TO-WORK following TBI requires systematic evaluation and planning. Clinicians should use objective and established measures as a basis for determining ability to return-to-work.

1. Functional Capacity Evaluation (FCE) is used to determine the ability of the patient to safely and productively function within a work environment. FCE's include, but are not limited to, determinations of consistency of effort, range-of- motion, aerobic capacity, strength evaluations, lifting capacity, functional sitting/standing tolerances and/or functional correlations with vocational goals. FCEs are generally accepted, established and necessary evaluation procedures which have utility in objectively determining the functional capabilities of individuals with brain injury patients in determining return-to-work capabilities. FCEs are also used to determine function in the following areas: a. ability to perform the required tasks safely using good judgment b. ability to follow instructions and follow through with an activity c. short- and long-term memory d. attention and concentration e. communication: expressive and receptive aphasia f. maintenance of temperament, self-control, and selfregulation g. lethargy, drowsiness, decreased reactivity to others h. confusion/awareness: orientation to their surrounding as it relates to who they are, what time it is, what they are doing, where they are and why i. ability to solve problems in novel situations, make appropriate decisions, demonstrating insight and accurate self-appraisal, understanding, and abstract thinking j. proprioception, kinesthetic/body awareness, perceptual deficits k. apraxia – akinetic, ideokinetic and motor

FCE's are an extension of the basic physical examination and may be useful for determination of impairments, setting functional/cognitive restrictions, determination of progress, planning and monitoring of rehabilitation. FCEs should be supplemented with a neuropsychological assessment and report to determine cognitive and psychological abilities to safely and productively function on a job. FCEs are typically conducted in approximately 8 hours, but for patients with brain injury, 16-24 hours is appropriate to include the neuropsychological evaluation and to allow for the potential variability of patient cognitive and physical fatigue. It is also appropriate that FCE evaluation be conducted in a serial fashion over time, which will result in more valid and reliable conclusions.

2. Job Site Analysis involves the systematic evaluation of the job site to evaluate safety, ergonomic, cognitive and emotional factors which should be performed onsite for a defined job. Evaluation includes what the worker does in relation to data, people, things, methods and techniques employed, machines, tools, equipment, and work aides used. The evaluator should be a qualified practitioner. Modifications in the workplace, if applicable, should also be recommended as it relates to a safe workplace environment. Job site analysis is a generally accepted, established procedure and is primarily used to determine and document the patient's ability to safely return to a defined job, or whether job modifications, job coaching, etc., are necessary.

V. THERAPEUTIC PROCEDURES – OPERATIVE

It is not the intent of these medical treatment guidelines to provide an exhaustive list of surgical procedures associated with TBI. An overview of the general categories is presented to illustrate the widerange of procedures that are widely accepted for patients with TBI. Combinations and variations on procedures should be tailored to specific cases; hence, a variety of procedures based upon the clinical judgment of the treating physician is to be expected. Common procedures include, but are not limited to:

A. DIAGNOSTIC PROCEDURES AND INVASIVE MONITORING:

1. Intracranial: a. Ventriculostomy b. Subdural or intraparenchymal pressure monitor c. Regional or local blood flow monitors

2. Extracranial: a. Jugular venous oxygen saturation monitors b. Cardiovascular monitoring c. Cerebral angiography

1) Vascular injury at skull base

2) Delayed effects (spasm, traumatic aneurysm, etc.)

B. THERAPEUTIC PROCEDURES – ACUTE AND SUBACUTE:

1. Extracranial Soft Tissue: a. Debridement, closure b. Plastic or reconstructive

2. Maxillofacial: a. Repair and stabilization of fracture b. Facial nerve decompression c. Repair and/or reconstruction

3. Skull: debridement, elevation and/or repair of fracture or defect

4. Brain: a. Debride penetrating injury, GSW, foreign body b. Decompression and evacuation

1) Hematoma: epidural, subdural, intraparenchymal

2) Contusion

3) Infectious: abscess or empyema

5. Ophthalmologic: a. Direct trauma to globe and/or orbital contents b. Repair orbital fractures, decompression of orbital contents c. Optic nerve decompression

6. Otologic: a. Direct trauma or barotrauma b. Facial nerve decompression c. Acoustic nerve decompression d. Middle ear exploration

7. Other Oranial Nerve Repair or Decompression

8. Vascular Injury: a. Endovascular procedures (i.e., stent, embolism) b. Direct repair c. Occlusion, trapping, aneurysm repair

9. Cerebral Spinal Fluid: a. Repair of leak or fistula b. Ventriculostomy 1) Control of ICP

2) Acute hydrocephalus

a) Obstructive

b) Communicating (usually with subarachnoid hemorrhage)

10. Peripheral Nerve Injury

11. Fracture Management

C. OPERATIVE THERAPEUTIC PROCEDURES – DELAYED OR CHRONIC:

1. Reconstructive: a. Cranioplasty b. Associated maxillofacial and orbital injuries c. Peripheral nerve injuries

2. Ophthalmologic: a. Diplopia

3. Otologic: a. Ossicular dysfunction b. Endolymph fistula c. Hearing augmentation procedures

4. Orthopedic: a. Fracture management b. Adjunctive tenotomies and myotomies

1) Common upper extremity procedures may require pre-surgical evaluation inclusive of occupational therapy, range-of-motion, function, diagnostic nerve blocks and dynamic EMG. Definitive procedures include, but are not limited to:

a) Shoulder muscle release

b) Functional elbow release: brachial radialis myotomy, biceps, and brachialis lengthening

c) Fractional lengthening of wrist and/or finger flexors

d) Flexor digitorum superficialis (fds) to flexor digitorum profinous (fdp) transfer

e) Intrinsic muscle contracture release f) Surgical release of thenar muscles for thumb in palm deformity

g) Individualized and customized procedures for spastic upper extremity deformities with adjunctive selective musculotendinous transfers, neurotomy, and neurectomies

2) Common lower extremity procedures include, but are not limited to:

a) Fractional muscle lengthening of knee flexors/hamstrings

b) Hip flexor releases/myotomies

c) Percutaneous vs. open release of the hip adductors

d) Percutaneous tendon Achilles lengthening, ankle/foot motor balancing surgery adjunctive to TALs include: 1) toe flexor release 2) splat procedure 3) interphalangeal joint fusions and 4) ankle fusions.

e) Individualized and customized procedures for spastic lower extremity deformities with adjunctive selective musculotendinous transfers, neurotomy and neurectomies. c. Resection heterotopic ossification

5. Spasticity: a. Spinal cord procedures, including percutaneous and open rhizotomies b. Intrathecal Baclofen pump c. Other “tone management” procedures

6. Cerebral Spinal Fluid: a. Repair of chronic fistula b. Shunt for chronic hydrocephalus

VI. THERAPEUTIC MEDICAL PROCEDURES - NONOPERATIVE

A. ACUTE MEDICAL CARE

1. Resuscitation: a. The first priority in TBI is complete and rapid physiologic resuscitation. b. Special consideration for isolated communities without neurosurgical support.

1) Trauma surgeons may perform the initial resuscitation and neurologic treatment in the deteriorating patient.

2) Once stable, transport to a designated neurotrauma center for further evaluation and management should occur expeditiously. c. Sedation and neuromuscular blockade are appropriate if needed for transport. Short-acting agents are preferred to allow for serial exams. d. Hypotension and hypoxia must be avoided to optimize outcome. e. Avoid hyperventilation (pCO2<26) in the first 24 hours after injury

2. Intracranial Pressure (ICP) and Cerebral Perfusion Pressure (CPP):

Patients with brain injury should not be treated for intracranial hypertension (ICH) without clear evidence of brain injury such as a neurologically focal exam, evidence of herniation syndrome, Glasgow Coma Score (GCS) of <9 without systemic explanation (hypotension, hypoxia, significant intoxication), or CT evidence of intracranial pathology. a. ICP Monitoring is crucial in selected patients with low GCS (<9) &/or CT changes, especially in patients over 40 years old. b. Aggressive treatment should be initiated with clinical evidence of ICH, to include transient mild hyperventilation, euvolemia, and mannitol (if not hypovolemic), until intracranial pressure (ICP) monitoring can be initiated to measure ICP. c. Sedation, neuromuscular blockade, and CSF drainage (if ventriculostomy is in place) are appropriate if needed to control ICH. d. Interpretation and treatment of ICP should be corroborated by frequent clinical examination and cerebral perfusion (CPP) data. In general, it is desirable to:

1) Maintain ICP less than 20-25mmHg

2) Maintain mean arterial pressure (MAP) above 90

3) Maintain CPP (MAP at head level minus ICP) at minimum of 70mmHg e. Intracranial pressure monitoring technology:

1) Accuracy, reliability, therapeutic potential, and risks are considerations

2) Ventricular catheter to manometer

a) Potential for CSF drainage and very low cost

b) Easily obstructed

c) May become unreliable and inaccurate without warning during use.

3) Ventricular catheter to external strain gauge:

a) Potential for CSF drainage and low cost

b) Dampened waveform wants of unreliability

c) Easily obstructed, needs fixed reference, useless when obstructed

4) Ventricular catheter with internal strain or pressure sensor

a) Potential for CSF drainage, maintains reliability when obstructed, higher cost f. Other locations/devices for ICP are less accurate or don't allow CSF drainage. 3. Hyperventilation:

Options for use in treating ICP elevations: a. Controlled hyperventilation may be necessary for brief periods in acute neurologic deterioration not attributable to systemic pathology (i.e. hypotension) b. Avoid prophylactic hyperventilation paCO2<30mm within the first 24 hours after severe brain injury reduce the risk of secondary ischemia. c. Jugular venous oxygen saturation (SjO2), determination of arterial venous oxygen difference (AVdO2), and cerebral flow studies are useful to identify ischemia related to hyperventilation or hypoperfusion

1) Useful especially for lower CPPs or if arterial partial pressure of carbon dioxide (paCO2)<30mm

2) May require special technologies such as intracranial Doppler, jugular venous oxygen saturation catheters, other emerging technologees.

3) Jugular venous oxygen saturation determination is not necessary if other methods are adequate. d. Avoid chronic hyperventilation to pCO2 less than 26 e. Options for use of mannitol in treating ICP elevations:

1) Use prior to ICP monitoring only if:

a) Neurologic deterioration not attributable to systemic pathology (i.e. hypotension)

b) Signs of transtentorial herniation

2) Euvolemia must be established and maintained

3) Keep serum OSM <320/kg serum water, especially in ARF.

4) Bolus (rather than drip) mannitol is the more effective treatment for elevated ICP. f. Glucocorticoids (STEROIDS) are not useful or generally accepted to improve outcome or decrease ICP, and in some instances can be harmful. g. Barbiturates may be used to treat elevated ICP as a last resort.

4. Nutrition: a. Nutritional support should be aggressively initiated as soon as practicable b. Preferable route is jejunal by gastrojejunostomy c. Early aggressive establishment of positive nitrogen balance is probably beneficial. Appropriate caloric input should be established by the seventh day. d. Nutritionist or dietitian consultation may be indicated 5. Anticonvulsants: a. Anticonvulsant treatment may be used to prevent early posttraumatic seizures in the high risk patient b. Prevention of early seizures has no statistically significant impact on long-term outcome nor the development of seizures c. Prevention of early seizures is reasonable to reduce seizure associated complications during acute management. d. Anticonvulsants are not useful to prevent late post-traumatic seizures.

6. Hypothermia is an evolving technology for controlling ICP. It has possible utility in hypoxic or ischemic encephalopathy, however, its use in TBI is currently investigational.

B. TREATMENT OF NEUROMEDICAL CONDITIONS FOLLOWING MTBI are the result of trauma to cranial, adnexal, and neurologic structures. The resultant problems may be classified as follows:

1. Headaches caused by trauma are divided into “acute” traumatic headaches, and if persistent greater than 8 weeks, “post-traumatic” headaches. Acute headaches usually occur less than 2 weeks after trauma, and disappear by 8 weeks. There is a 41-69% incidence of headache following trauma, and a higher incidence with milder brain injury and with history of prior or pre-existing headache. Post-traumatic headache is typically chronic and daily (i.e., greater than 3 months, greater than 15 days per month). TBI can change a patient's perception of pain. Migraine features are common, as well as concurrent cervical pain and occipital neuralgia. If delayed recovery occurs, the following should be considered: inaccurate diagnosis, inadequate treatment, overuse of analgesics, depression or contributing psychological issues, including alcohol or drug abuse.

Treatment is based upon correct diagnosis of headache type and contributing factors, time from injury, and level of dysfunction. Identification, education, and intervention should begin as soon as possible. Treatment typically involves education, medication adjustment, and an interdisciplinary approach. Specialty head pain clinics may be necessary to treat headache (see algorithm).

Widely accepted treatments for post-traumatic headache include, but are not limited to interdisciplinary treatment, pharmacology, physical therapy, electrical stimulation, biofeedback, and psychotherapy, and diet. Biofeedback is generally accepted for relaxation training and stress management, and duration is typically 8-12 sessions. Physical therapy is generally accepted for stretching and aerobics training, and duration is typically 12-20 sessions. Psychology is generally accepted to identify factors for delayed recovery and potential need for cognitive assessment. Special procedures may be useful for various head pain syndromes including nerve blocks for neuralgia, trigger point injections for myofascial pain syndromes, and use of dental splinting for temporomandibular joint syndrome. Inpatient admission is sometimes required when intravenous medications (e.g. DHE) and close monitoring are necessary to control migraine or analgesia rebound, especially in patients with severe depression, suicidal ideation, or complicated medical problems. When greater than two disciplines are necessary, or when there is significant dysfunction secondary to headache, or when the patient has not returned to work for greater than three months, or when treatment is geographically inaccessible, a specialized interdisciplinary outpatient treatment program may be appropriate. Treatment programs should be individualized and delivered by a specialized head pain clinic. a. Headache Treatment Algorithm:

25% of patients recover in 1 month, and 50% recover in 6 months. After 6 months, headache tends to continue in 50% of cases. If headache persists greater than 1 year, there is a poor chance of remission, and 15-30% persist 3 years or more. Headache is thought to be permanent if adequately treated and after 6 months there is no change. Early intervention is indicated for improved prognosis.

Long-term maintenance plans are necessary in chronic headache management. Medications may be necessary for an indefinite period. All other treatment modalities should be independent and functional. Even if headaches are permanent, it is expected that the patient will be functional and able to return-to- work.

2. Neurotological Disorders:

Treatment for post-traumatic vertigo and imbalance should be diagnosis-specific. Benign paroxysmal positional vertigo can be treated with a canalith repositioning procedure. Early treatment of post-traumatic perilymphatic fistula includes rest, head elevation, and avoidance of straining. Chronic posttraumatic perilymphatic fistula may require surgical intervention. Treatment of post-traumatic Meniere's usually includes low salt diet, use of diuretics, and vestibular suppressant medications. Surgery (e.g. vestibular nerve section, labyrinthectomy) is indicated in rare circumstances. Vestibular exercises and balance training are widely accepted interventions for management of vestibular dysfunction of all types including central vestibular disorders. Conductive and/or sensorineural hearing loss many be associated with MTBI. Hearing aid amplification may be indicated. Surgical intervention may be required in some cases (e.g., ossicular discontinuity). Tinnitus may occur secondary to trauma to inner ear structures and may require use of medications, hearing aides, or use of a tinnitus masker.

3. Neurologic Sequelae:

Though seizures are rare in MTBI, they may require treatment with anticonvulsant medications. Cranial nerve injuries may require pharmacologic treatment (e.g. corticosteroids for facial nerve paralysis) or rehabilitative interventions (e.g., patching and vision exercises and ocular motor dysfunction). Surgical intervention is sometimes necessary in later stages (e.g. treatment of diplopia, facial nerve paralysis).

4. Other Symptoms:

Compensatory treatments for other symptoms including photophobia (transmittance absorbance lenses) and sonophobia (ear plugs) are appropriate. Rare neurological sequelae following MTBI include movement disorders such as post-traumatic tremor and choreo-athetosis. These problems may be managed with various pharmacologic agents and rehabilitative interventions.

C. TREATMENT OF NEUROMEDICAL CONDITIONS - MODERATE-SEVERE BRAIN INJURY:

There a number of associated neuromedical problems unique to Moderate-Severe TBI. These conditions often require specialized evaluation and therapeutic interventions, by physicians, nurses, and relevant interdisciplinary team disciplines. The resultant problems may be classified as follows:

1. Neurological Complications:

Ongoing evaluation to detect delayed development of space occupying intraparenchymal lesions, pneumocephalus, extra-axial lesions such as subdural and epidural hematomas and hygromas are necessary. If a patient's neurological status worsens or plateaus, neuroimaging studies may be warranted. Of special concern is the need to distinguish progressive ventriculomegaly (ventricular enlargement) of obstructive hydrocephalus from that of cerebral atrophy. This differential diagnosis requires imaging, follow-up and careful clinical correlation. a. Post-Traumatic Seizures (post-traumatic epilepsy PTE): Major risk factors for the development of PTE include penetrating head wounds, hematoma, depressed skull fracture and early seizures. The issue of seizure prophylaxis remains controversial in high risk patients. The role of routine seizure prophylaxis utilizing antiepileptic drugs (AEDs) is recommended for 7-10 days post brain trauma. Thereafter, there is no consensus regarding the role of prophylaxis, and this is generally not recommended but at times occurs on an individual basis. The management of late post-traumatic seizures follows the treatment of “epilepsy”. This includes principles of monotherapy, compliance, and considerations of cognition, behavioral and psychosocial functioning. b. Spasticity and Hyperreflexia are defined as velocity dependent hyperactivity of stretch reflexes secondary to upper motor neuron disease. It is characterized by exaggerated deep tendon reflexes, increased muscle tone which result in a range of abnormal reflexes and motor patterns. If spasticity is interfering with the patient's general functioning which may include range-of-motion limitations, limitations in care and/or activities of daily living and mobility, then treatment is often warranted. Treatment approaches involve disciplines of rehabilitation nursing, physical therapy and occupational therapy.

1) Postural control

2) Therapeutic modalities, exercise, casting and orthotic techniques

3) Consideration of various oral and transdermal antispasticity medications. This will include medications such as baclofen, diazepam, dantrolene sodium, clonidine and tizanidine. Other invasive techniques include chemical denervation (nerve blocks) and botox type A injections. For intractable spasticity, the use of intrathecal baclofen may be indicated. More aggressive neurosurgical procedures such as thermal and selective rhizotomies are reserved for the most severe situations. Medications, nerve blocks and other surgical interventions serve as an adjunct to physical therapy and occupational therapy programs. 2. Cardiopulmonary Complications: a. Cardiac System: ASN (autonomic nervous service) is at risk from injury to the hypothalamus, cardiac regulating centers of the brain, elevated intracranial pressure and hypoxia. Clinical manifestations may cause a dysautonomia inclusive of fever, hypertension, tachycardia, hyperhydrosis (increased sweating and flushing). TBI hypertension is specifically associated with tachycardia and increased cardiac output and normal or decreased peripheral vascular resistance. This is different than essential hypertension in which there is normal cardiac output with increased peripheral vascular resistance. The preferred treatment for this type of hypertension from hyperadrenergic activity is a beta adrenergic blocking agent or alpha-2 central agonist. b. Pulmonary System: TBI and related trauma to the patient's chest wall can adversely affect respiratory function by compromising the patient's respiratory drive, swallow reflex, and cough. Brain and brain stem injuries also cause abnormal neurogenic breathing patterns, dysfunctional swallowing mechanism with the potential for aspiration and a weakened cough with poor mobilization of secretions. These patients are at increased risk for hypoxemia leading to further CNS injury, pneumonia and adult respiratory distress syndrome. The main principle of therapeutic intervention is the avoidance of respiratory failure with appropriate oxygenation, ventilation and airway control. Treatments may include mechanical ventilation, tracheostomy, routine swallow evaluations to evaluate for aspiration risk and aggressive pulmonary toileting.

3. Musculoskeletal Complications: a. Long-Bone Fractures: When long-bone fractures occur in TBI patients, the same aggressive level of treatment should be provided as in non-TBI patients. Maximal functional use of all extremities should be the goal in this early phase of care. Fracture healing unique to TBI includes the deforming effect spasticity exerts on fracture alignment. Patient compliancy secondary to confusion and agitation often requires reinforced immobilization strategies and prolonged time frames of immobilization. Also, fractures do seem to heal quicker and in an abnormal fashion, i.e., the development of exuberant callus in TBI patients when compared to control subjects. Therefore, it is generally accepted that reinforced and more prolonged immobilization strategies be implemented in this patient population. b. Heterotopic Ossification (HO) is defined as the development of new bone formation in soft tissue planes surrounding neurologically affected joints. If diagnosis and treatment is delayed, ankylosis (bony fusion) can occur with consequent functional limits in mobility. Additional risk factors beyond TBI include spinal cord injury, tissue hypoxia, venous stasis, spasticity and autonomic dysfunction. The greatest risk for development is within the first six months post-injury. Surveillance by nurses and physical therapists is essential and may include documentation of decreased range-of-motion, joint inflammation and/or a low grade fever. Appropriate work-up may include laboratory studies revealing an elevated sedimentation rate, and/or alkaline phosphatase with a normal CBC. Plain x-rays are necessary and appropriate, however, the most sensitive radiologic study is the three-phase bone scan and is recommended. This may be necessary both in the initial diagnostic and follow-up phases to guide treatment. Optimal treatment outcome involves early diagnosis, range-of-motion, exercise and the use of disodium etidronate which prevents mineralization. Other options include NSAIDs, radiation and surgery in the chronic state.

4. Gastrointestinal Complications:

TBI patients have demonstrated delays in gastric emptying with frequent regurgitation of nasogastric administered feedings. This accompanied with dysphagia and/or an inadequate swallow reflex, place the patient at risk for aspiration pneumonia. Dysphagic patients and patients at risk may require total parenteral nutrition (TPN), gastric and/or postpyloric feeding techniques. Either a percutaneous or surgically placed gastrostomy and/or jejunostomy may be necessary for adequate ongoing nutritional support. Patients with gastrointestinal hypomotility may require medications such as cisapride. Also erosive gastritis may be a frequent complication, and the use of H2 blockers and antacid treatments are usually efficacious. Patients may also be at risk for constipation, impactions, bowel obstructions and/or loose stools. A nursing care regimen on a routine and then consultative basis may be necessary to establish routine bowel programs.

5. Genitourinary Complications:

Moderate-severe diffuse and/or focal TBI may involve cerebral structures controlling bladder storage and emptying functions. This may result in a “neurogenic bladder”. Treatment of a neurogenic bladder is aimed at adequate emptying, prevention and treatment of infection, preservation of upper renal tract function, and avoidance of skin soiling from incontinence. An indwelling urethral catheter is often appropriate in the early stages of recovery. Once the urethral catheter is discontinued, either a condom catheter or diaper is used for incontinence.

Following assessment of bladder emptying utilizing postvoid residual checks, decisions can be made regarding longer term management strategies. This may include intermittent catheterization or rehabilitative bladder training utilizing anticholinergic medications and time interval voiding techniques. Sexual dysfunction may also occur secondary to TBI and is appropriate for assessment. Urologist consultation may be necessary.

6. Neuroendocrine Complications are a uncommon consequence of Moderate-Severe TBI. Manifestations vary in severity, time of onset, duration and clinical expression. This may include abnormalities of appetite regulation or control, lability of temperature, hypertension and other cardiovascular abnormalities, thyroid dysfunction, difficulties in fluid regulation, reproductive and/or sexual dysfunction and immunosuppression. Specialized medical evaluation and treatment may be necessary if these symptoms exist and/or persist.

7. Fluid and Electrolyte Complications in patients with TBI are usually iatrogenic or trauma induced. Specific problems may result in water and salt retention with decreased urine output. There also can be problems with hyponatremia from inappropriate antidiurectic hormone, cerebral salt wasting, and increased production of aldosterone. Also hypernatremia from dehydration or diabetes insipidus (DI), may occur. This may require careful evaluation with laboratory studies initially and serially on a follow-up basis.

8. Immobilization and Disuse Complications:

In an unresponsive patient, skin is at risk for the development of ischemic decubiti ulcers that can slowly progress and increase length of hospital stays and cost. Tissue pressure and deformation cause the ischemia. Vigilant rehabilitation nursing, specialized beds, padding, positioning and weight shift management protects the patient from these complications.

9. Vascular Complications:

The vasculature of the musculoskeletal system in TBI patients is at risk for developing deep venous thrombosis (DVT) and pulmonary embolus (PE). Since diagnosis by clinical examination is difficult in this population, a high degree of suspicion is warranted. While in the hospital, daily nursing screening with lower extremity measurements is recommended. Abnormalities requiring confirmation may entail noninvasive studies such as Doppler ultrasonographic flow examination and impedance plethysmography. It is generally accepted that prophylaxis with low molecular weight heparin and/or sequential compression stockings can reduce the incidence of both complications. If the diagnostic use of noninvasive studies as mentioned are equivocal and/or nonconfirmatory, then venography and/or angiography may be necessary. If thrombotic complications occur, standard treatment includes intravenous heparinization followed by oral warfarin sodium. If neuromedical risks of anticoagulation are present and/or complications related to anticoagulation or progressive thrombosis arise, then placement of an inferior vena cava filter may be necessary.

D. MEDICATIONS are frequently useful for patients with TBI for a variety of indications related to both the neuropathological effects of injury, associated injuries to the brain, skull, spinal axis, soft tissues, etc., and secondary cognitive and emotional sequelae of TBI. The use of medications requires careful monitoring and collaboration between the patient, physician, family/support system, and other members of the interdisciplinary team. Common symptom categories targeted for medication treatment include, but are not limited to:

1. Pain (headache, axial, soft tissue, etc)

2. Sensory alterations (dysesthesias)

3. Emotional (depression, lability, anxiety, etc.)

4. Behavioral (poor self monitoring, dyscontrol, irritability, aggression, poor initiation, etc.)

5. Thought process and content

6. Motor (spasticity, Parkinsonism, tremor, etc.)

7. Neurological (seizures, etc.)

Indications for the use of medications following TBI frequently differ from those outlined by the federal drug administration (FDA) due to the paucity of clinical research on the use of medications for these indications.

E. NURSING INTERVENTIONS include assessment and identification of current and potential medical, rehabilitation, psychosocial, educational and spiritual needs. Therapeutic interventions are integrated with the interdisciplinary treatment plan, and involve continual evaluation of the patient's response to therapeutic intervention and patient/family education. The focus of nursing interventions may include, but are not limited to: cardiopulmonary status, fluid and electrolyte balance, nutritional status, skin integrity, sexual function, activities of daily living, mobility, urinary and bowel elimination, emotional response to injury, and patient safety.

The intensity of nursing intervention depends on the severity of injury, needs, and condition of the patient. Patients with moderate-severe injury may require additional nursing hours per patient day due to medical acuity, risk of skin breakdown, need for supervision for agitation and/or behavioral problems.

VII. THERAPEUTIC REHABILITATION PROCEDURES

The complex nature of the brain and brain injury requires coordinated interdisciplinary treatment, and usually deficits are appropriately treated by more than one therapeutic discipline. Treatment should emphasize functional, outcome-oriented and community re-integration goals. Treatment often involves longer treatment sessions, with variable frequencies. The location of treatment sessions may begin in a clinical setting, but eventually may be more effective in the home, workplace, or community, based upon functional goals. TBI results in lifetime deficits, and a longterm disease or disability management model is appropriate. Frequency and duration of specific nonacute treatments should be included in every treatment plan, and should be re-evaluated at every 4 weeks per the Section I., General Guideline Principles. Experienced practitioners should not necessarily use all of the therapies and modalities listed in the guidelines. Periodic upgrading or consultation may be necessary throughout a patient's lifetime following TBI. Therapy for specific impairments and disabilities may be re-initiated for goal specific, time- limited treatment as new goals are identified and developed. Treatment should be based upon diagnosis, clinical evaluations, anticipated functional gains, progress, etc.

A. TREATMENT OF COGNITIVE IMPAIRMENTS

Cognition is defined as the “process of knowing” by which individuals 1) make decisions as to the most functional ways of interacting with their environment, 2) execute those decisions, 3) monitor their responses to determine appropriateness and accuracy of their decisions, and 4) adjust their behavior if it is determined to be inappropriate and/or inaccurate. Deficits in cognition are a consistent and frequent result of TBI and may vary from mild to severe. Cognitive processes that are often impaired after TBI may include, but are not limited to:

1. Impaired arousal, attention, and inefficient processing of information (rate, amount and complexity)

2. Impaired perception of auditory, visual and tactile information

3. Impaired acquisition, retention, and retrieval of verbal and visual information which affects new learning and functional memory skills

4. Impaired executive functioning skills: problem solving, reasoning and judgment, self- awareness of strengths and weaknesses, goal setting, planning, organizing, self- initiating, self-inhibiting, self-monitoring, and self-evaluating.

5. Impaired or inappropriate social awareness and behavior.

In MTBI, acute cognitive deficits are common and rapid cognitive improvement is expected. Rehabilitation of cognitive impairments should only be initiated if the patient is not demonstrating the expected cognitive improvement or if they exhibit more severe cognitive impairments on formal evaluation.

In patients with moderate-severe injury rehabilitation of cognitive deficits is appropriate for individuals recovering from TBI when they reach a level that allows them to benefit from rehabilitative efforts as demonstrated by adequate arousal, responsiveness to stimulation, and a minimum ability to focus attention. Prior to demonstration of these skills, rehabilitation efforts should focus on monitoring and attempting to elicit responses, environmental structuring, and staff/family education.

Treatment is indicated following a cognitive evaluation which identifies cognitive impairments. The evaluation should include statements of severity and prognosis for improvement, outline recommended goals/objectives and methodologies of treatment, and establish frequency and duration parameters.

Rehabilitation procedures for cognitive deficits are widely used and generally accepted in the treatment of individuals with brain injury. Rehabilitation includes procedures designed to improve cognitive efficiency, develop specific cognitive skills, enhance awareness of impairments and skills, and develop appropriate compensation strategies for residual cognitive deficits.

Computer-based procedures are frequently used within rehabilitation programs but they are not a generally accepted method of treatment in isolation. The use of computers as a primary and independent form of treatment in cognitive remediation has limited application because of 1) limitations in the rationale and specific application of software programs to address the needs of the patient with TBI and, 2) difficulty with generalization of learned computer skills into functional environments. It is generally accepted that rehabilitation treatment for cognitive deficits be provided by speech/language pathologists, neuropsychologists, occupational therapists, or paraprofessionals closely supervised by these professionals. It may frequently be necessary for other disciplines to apply cognitive rehabilitation techniques while addressing noncognitive goals (i.e., mobility, and daily nursing activities). Physicians may also be involved in pharmacological treatment and management of cognitive disorders.

1. Frequency:

- Acute and post-acute: daily

- Subacute outpatient and home/community setting: daily-to-weekly

2. Optimum duration: 8 weeks with 4-week reevaluations

3. Maximum duration: beyond 8 weeks requires documentation of progress with the exception of periodic consultations and new treatment goals.

A treatment plan outlining current goals is recommended with each evaluation. If documented improvement is not shown, the treatment goals and program should either be modified or discontinued. Periodic upgrading or consultation may be necessary throughout a patient's life time following TBI. Therapy may be re-initiated for time-limited, goal-specific treatment as new goals are developed.

B. TREATMENT OF COMMUNICATION IMPAIRMENTS following brain injury can be classified into the following groups: 1) motor speech and voice is orders and 2) language disorders (aphasia) c) cognitive/communication disorders.

1. Motor Speech Disorders include neurologically-based speech disorders and exclude disorders of language and cognition (thinking). They can be divided into the subcategories of dysarthria and apraxia of speech. There are also voice disorders caused by nonneurogenic pathologies. These disorders may co-exist with one another, with aphasia, or with cognitive deficits, or they may occur in isolation.

a. Dysarthria is a neurogenic speech disorder of motor control characterized by weakness, slowness, and/or incoordination of the speech musculature. It may include changes in respiration, phonation (voice), resonance, articulation, and prosody. It may range in severity from a disorder so mild that it is just noticeable during connected speech to a disorder so severe that intelligible speech is not present (anarthria).

b. Apraxia of speech is a sensorimotor disorder of articulation and prosody. Although apraxia may exist alone, it frequently accompanies aphasia and may also co-exist with dysarthria. The patient shows impaired ability to program muscle movements for speech. Apraxia may range in severity from a disorder so mild that speech is characterized by infrequent articulatory errors in connected speech to a disorder so severe that it results in the inability to volitionally produce any functional speech.

c. Voice Disorders (nondysarthric) are voice disorders that are a result of structural changes in the larynx, not caused by central or peripheral nervous system pathology (i.e., vocal nodules, polyps, granulomas). They may range in severity from a disorder causing only mild dysphonia to a disorder so severe it causes the absence of functional phonation.

2. Aphasia is a language disorder represented by a variety of impairments in auditory comprehension, reading (dyslexia), oral-expressive language, and writing (dysgraphia). Aphasia may effect one or all of the above language modalities and range from mild deficits noted in only one language modality to severe deficits across all modalities resulting in the absence of functional communication. Of the communication disorders, aphasia is often the most disabling. In even it's mildest form, aphasia can significantly effect an individual's functional outcome.

3. Cognitive/Communicative Language Disorders are defined as alterations in communication due to deficits in cognition including cognitive process of executive function, attention, information processing, memory, new-learning, retrieval of stored information, visuospatial Percetion, reasoning/problem solving, and psychosocial behavior. Cognitive/communication disorders may range in severity from a mild deficit characterized by decreased organization and pragmatics only in unstructured or abstract contexts, to a severe disorder in which confusion inhibits functional communication of basic needs.

A speech/language evaluation is indicated if the patient displays evidence of decreased speech intelligibility, changes in voice quality, difficulty in comprehension or expression of language, or if cognitive deficits are interfering with communication. It is recommended that the evaluation include the following 1) diagnosis of communication impairment(s); 2) severity; 3) prognosis for improvement; 4) recommendations; 5) goals/objectives of treatment; and 6) recommended frequency and duration.

Speech/language therapy is a generally accepted and widely used treatment of communication impairments and disabilities. Referral to medical specialist(s) may be necessary to assist in the diagnosis of communication disorders. In the case of voice disorders, referral to an otolaryngologist (END) is always required prior to the initiation of voice therapy to assist in the diagnosis and appropriate treatment. Involvement of other medical specialists, such as physiatrists, neurologists, neuropsychologists, psychologists and psychiatrists may assist in the diagnosis and ongoing treatment of aphasia and/or cognitive/communicative disorders. Medical procedures and/or medications may be recommended by specialists to assist in clinical progress. Although speech/language pathologists are the primary providers in the treatment of communication disorders, an interdisciplinary approach is beneficial in generalizing learned skills.

During the later stages of rehabilitation, emphasis of treatment should be on enhancing awareness of impairments/skills and exploration of appropriate compensatory strategies to address residual deficits. a. Frequency:

- Acute and post-acute setting: daily sessions

- Subacute outpatient, home/community setting: 1-5 sessions per week b. Optimum duration: 8 weeks with 4-week reevaluations c. Maximum duration: beyond 8 weeks requires documentation of progress

If documented improvement is not shown, the treatment goals and program should either be modified or discontinued. Continued treatment is not deemed appropriate without evidence of documented progress. A treatment plan outlining current goals is recommended with each evaluation. Periodic upgrading or consultation may be necessary throughout a patient's lifetime following TBI. Therapy for communication disorders may be re-initiated for goal specific, time-limited treatment as new goals are identified and developed.

Impaired cognition significantly affects the rate, degree, and manner of progress in the treatment of communication disorders. In the case of cognitive/communicative disorders, reduced cognition can be the foundation for language deficits, and treatment to improve cognition should be included as a component of therapy for communication disorders. The extent of recovery may be limited by the extent of cognitive deficits. In the cases of motor speech disorders and aphasia, therapy and progress are impacted by reduced cognition in the following ways: a. Slower acquisition of skills and compensatory strategies b. Slower and more gradual response to therapy c. Decreased ability to generalize skills to other environments/situations d. Decreased awareness of self and decreased self-monitoring of performance and accurate self- appraisal of abilities

Augmentative or alternative communication devices (AAC) may be indicated when speech is inadequate for functional communication. AAC may range from simplistic use of alphabet boards and gestures, to more sophisticated use of computerized technology to assist in functional communication. These are generally accepted and widely used. Indications for use include: a. Severity of communication is so severe that the patient is without functional communication b. There is evidence that augmentative communication systems can make functional communication possible c. Use of AAC device is reasonable and necessary to relieve the effects of the severe communication impairment d. Communication devices should only be recommended following a comprehensive evaluation of cognitive, motor, language, and sensory abilities e. The patient has demonstrated ability to use the device during a reasonable trial period prior to prescribing the rental or purchase of equipment f. There is evidence of initiation and motivation for use of the device g. The patient shows potential for carryover and use in functional settings

It is generally accepted that the speech/language pathologist assumes the responsibility for the recommendation of augmentative communication systems, and for the necessary follow-up treatment. An interdisciplinary approach is beneficial to address positioning, motor skills, and access (switch use) in order to determine the most appropriate system. Therapy provided in community settings is crucial to effective use of augmentative communication.

Palatal lifts are recommended when severe hypernasality is noted caused by lack of soft palate movement (velopharyngeal incompetence) as a result of neurological impairment. A referral to an otolaryngologist (ENT) and videoflouroscope is necessary for the diagnosis. Subsequent referral to an experienced orthodontist or prosthodontist is necessary in the fitting of a patient with a palatal lift.

Home and community-based speech/language services are recommended to assist in transition of learned skills from institutional to community settings. During the community-reintegration phase of rehabilitation, emphasis of treatment should be on enhancing awareness of impairments/skills and training of appropriate compensatory strategies to promote functional independence and compensate for residual impairments.

C. SWALLOWING IMPAIRMENTS (Dysphagia) are a frequent occurrence following a traumatic brain injury. Following early identification of swallowing problems, appropriate intervention programs are necessary to establish safe oral intake programs. Swallowing dysfunction results from one or a combination of any of the following: 1. Disturbances of the oral stage of the swallow

2. Delayed or absent swallowing reflex

3. Disturbances in the pharyngeal stage of the swallow

Treatment for dysphagia is indicated following identification of swallowing problems. It is generally accepted that dysphagia treatment programs be established by speech/language pathologists and/or occupational therapists. Other team members may include physicians, nurses, dieticians, and primary care givers. Dysphagia programs are designed to help the patient develop conscious control of swallowing. Programs can be started when the patient demonstrates adequate arousal, demonstrates ability to follow directions, and exhibits some reflexive swallowing. Swallowing programs include 1) exercises for increasing oral muscular strength, coordination and range-of-motion; 2) instruction in swallowing physiology; 3) exercises for improving control of laryngeal movement; 4) techniques to stimulate swallowing reflex; 5) instruction in proper positioning; 6) selection of proper food consistencies; 7) development of compensatory strategies to reduce risk of aspiration; and 8) training of patient, family, and/or care givers to transition strategies into functional oral intake. Medical consultation may be necessary to assist with clinical improvements of swallowing function. Medical interventions may include, but are not limited to, the use of medications and treatment such as botox injections for cricopharyngeal dysfunction.

1. Frequency:

- Acute and post-acute setting: daily sessions

- Subacute outpatient home/community setting: 1-5 sessions weekly

2. Optimum duration: 6-8 weeks with 4-week reevaluations

3. Maximum duration: beyond 8 weeks requires documentation of progress

If documented improvement is not shown, the treatment goals and program should either be modified or discontinued. Continued treatment is not deemed appropriate without evidence of documented progress. A treatment plan outlining current goals is recommended with each evaluation. Impaired cognition significantly affects the rate, degree, and manner of progress towards independent oral feeding. Simple- to-complex adaptive devices may be necessary to enhance independence and safety of oral feeding and relieve the effects of the injury.

D. NEUROMUSCULAR MANAGEMENT:

Neuroskeletal impairments may include reflexes, sensory integration, range-of-motion, muscle tone, strength, endurance, postural control, postural alignment, and soft tissue integrity. Functional abilities that are effected can include gross coordination, crossing midline, laterality, bilateral integration, motor control, praxis, fine coordination/dexterity, visual motor coordination. Patients with neuromuscular impairments may require medical, surgical and physical therapeutic management to improve their movement and mobility. Common impairments and treatment can be divided into three major areas:

1. Motor Control:

Treatment in this area involves therapeutic techniques to improve voluntary movement in the head and axial skeleton, the shoulder and pelvic girdles and the appendicular skeleton or extremities. a. Frequency: daily, up-to-several hours per session b. Optimum duration: 3 months c. Maximum duration: 6 months with re-evaluation every 4 weeks

As the patient progresses, treatment frequency should be decreased. Continued treatment is based upon attainment of functional goals as outlined in the treatment plan established upon initial interaction with all members of the treatment team.

2. Tone and Joint Restrictions Management:

Hypertonicity or spasticity influence motor control and can vary according to the patient's position, the time of day or emotional state of the patient. Treatment would begin immediately following medical stabilization. This may include positioning techniques, splinting, serial casting and range-of-motion treatment. Medical and surgical intervention are also generally accepted to influence tone such as anti spasticity medication, phenol or other anesthetic blocks and surgical techniques such as tendon lengthening, muscle transfers and orthopedic reconstruction to reduce joint deformity. As the patient improves or the severity is less, therapeutic techniques provided by a physical therapist or occupational therapist designed to normalize tone in functional positions and activities are performed with instruction of the patient and family in the proper positions. a. Frequency: inpatient setting - initially, twice a day, then decreasing in frequency as patient progresses; outpatient setting - twice per day initially then decrease to 2-3 sessions per week b. Optimum duration: 6 months c. Maximum duration: 2 years

Periodic functional upgrading or consultation may be necessary throughout a patient's life time following TBI. Therapy may be re-initiated for time-limited, goalspecific treatment as new goals are developed.

Therapeutic nerve and motor point blocks are useful in targeting specific muscles or muscle groups for diagnostic and therapeutic maneuvers. The purpose of the nerve or motor point block is to reduce force produced by a contracting spastic muscle or muscle group. This reduction in “spasticity” may lead to improved range-of-motion and enhanced functioning. Therapeutic nerve and motor point blocks are primarily performed with aqueous solutions of phenol. When injected in or near a nerve bundle, phenol denatures protein in the myelin sheath or cell membrane of axons with which it makes contact. Either percutaneous or open neurolytic procedures are considered useful in a variety of spastic disorders related to TBI and are generally accepted procedures.

Botulinum toxin injections have strong neuromuscular blocking properties that inhibit the release of acetylch-oline and cause flaccid paralysis. The clinical effect of the toxin is thought to be due primarily to its action at the neuromuscular junction. Injection of botulinum toxin is currently FDA approved for the treatment of blepharospasm, facial spasm, strabismus and torticollis. There have been recent studies suggesting its use in spasticity following stroke, multiple sclerosis and TBI. EMG technique is necessary for appropriate botulinum toxin therapy. The duration and degree of effectiveness of these techniques ranges between two to four months. This technique often serves as a temporizing measure when spasticity is evolving and its utility in chronic persistent conditions is as yet unknown. There is enough data to support its clinical usefulness in TBI both initially and in the chronic phases of treatment with appropriate functional follow-up.

3. Treatment of Coordination Impairments:

Ataxia is a common impairment in coordination resulting from inability to control muscle timing and sequencing of agonist and antagonist contraction. This will affect fine motor and gross motor skills as well as general mobility and activities of daily living. Therapeutic treatment (neuromuscular reeducation) includes physical and/or occupational therapy to facilitate or inhibit normal muscle activity as needed with specific exercises to increase motor learning and control. Biofeedback and functional electrical stimulation may assist in treatment. Patient level of cognitive functioning can interfere and prolong a patient's course of therapy. Reasonable and necessary equipment may include splints, functional electrical stimulation, access to exercise equipment, and bracing.

E. SENSORY SYSTEMS:

1. Treatment of Hearing Impairments:

Persistent hearing loss that is documentable by audiology and is not correctable by surgery, may be amenable to a low salt diet and agents such as diamox that reduce endolymph volume or, to a hearing aid, if function is hampered by the hearing loss.

2. Treatment of Visual Impairments are common secondary to TBI. Treatment of visual impairments is generally accepted, provided that treatment plans are based upon a comprehensive evaluation and diagnosis. Treatment should be functionally-based, goal directed, and are reevaluated every 4 weeks or more often per Section I., General Principle Guidelines.

Visual/perceptual treatment may be performed by an ophthalmologist or optometrist, supplemented with treatment and coordination by other interdisciplinary treatment team members in functional settings. Patient progress in other rehabilitation therapies may be dependent on adequate visual system functioning, (e.g., reading, driving, etc.).

Impairments can be divided into three major categories: a. Ability to see involves the optic system of the eye, accommodation, eye health, visual pathways and occipital/related cortex. Specific diagnoses and treatment include:

1) Accommodative spasm/insufficiency - the loss, or decrease of the ability to accurately focus eye(s) from near to far, and far to near as measured by amplitude or plus and minus lenses.

2) Reduction in visual acuity is measured by Snellen letters or other visual acuity instruments. If visual acuity deficits are caused by optic nerve trauma, treatment is directed toward reduction of edema with steroids or diuretics. If deficits are caused by intracranial visual pathway damage, treatment is directed toward control of CFS pressure and cortilosteroids for sheer injury. Low vision aids may be prescribed for documented and permanent loss.

3) Visual field deficits are measured with appropriate visual field apparatus. b. Visual efficiency skills refers to the effectiveness of the visual system to clearly, efficiently and comfortably use eyes together to gather visual information. The component skills include ocular motility, and binocular vision. Specific deficits include:

1) convergence and/or divergence insufficiency/infacility: the loss or decrease of ability to accurately shift the visual angle of the eyes from near to far, and far to near.

2) comitant heterophoria/tropia is a conjugate gaze disparity with the deviation of one eye's optical axis from the other.

3) noncomitant heterophoria/tropia is a dysconjugate gaze disparity with the deviation of one eye's optical axis from the other varying in different fields of gaze. 4) deficient fusion and stereopsis is measured by tests that demand binocular fusion and stereopsis, where at least two different test results are compatible. c. Visual/perceptual information processing skills refers to the ability to analyze, interpret, integrate, and utilize visual information. Specific deficits include visual agnosias and/or impairments in visual motor integration, visual memory, visual form constancy and impairment of visual spatial relationships. Treatment of visual perceptual deficits is generally treated by various members of the interdisciplinary treatment team within the context of accomplishing functional tasks (e.g., mobility, ADLs, reading, driving, etc.) that require visual perceptual skills.

A patient's cognitive understanding of his/her visual difficulties, memory, judgment and behavior may impact an individual's participation, and compliance with treatment of visual impairments. Freuency, duration and patient/family training may vary according to the patient's cognitive abilities to fully benefit in treatment.

Equipment and adaptive devices may be required in the treatment of visual impairments. In addition to appropriate eye glass prescriptions, other equipment may include lenses, prisms, occlusion, low vision devices, and orthoptic equipment.

F. BALANCE AND VESTIBULAR TREATMENTS:

A large percentage of patients with TBI suffer from symptoms of traumatic vestibular pathology. Patients with vestibular dysfunction suffer from complaints of dizziness as well as imbalance. TBI has a confounding influence on vestibular pathologies commonly seen in patients with these complaints. Symptoms can include vertigo, eye-head incoordination, and dysequilibrium. A neurologic, neurotologic, ENT, audiologic and visual evaluation as well as a functional vestibular evaluation should be performed to determine the type of dysfunction and diagnosis. This may be a peripheral vestibular lesion or central vestibular lesion secondary to trauma, fracture, hemorrhage, or intracranial pressure changes.

Assessment includes evaluation of the sensory, motor and cognitive limitations that affect functional independence. This includes vertigo assessment, eye-head coordination for stabilizing gaze, and postural control in sitting, standing, and walking on various surfaces and under different sensory conditions.

Emphasis of treatments performed by a physical or occupational therapist are head exercises for habituation of vertigo, eye-head coordination exercises for improvement of gaze stabilization and sensorimotor retraining to remediate postural dyscontrol in all functional movement positions. Treatment may also include surgery or pharmacologic interventions.

1. Frequency: daily initially, decreasing to 1 session per week after 1 month; patients are expected to perform self-directed exercises twice daily at home

2. Optimum duration: 6 months with re-evaluation

3. Maximum duration: may require follow-up for up-to-2 years

Patients with traumatic vestibular lesion take longer to improve than from other causes. Studies indicate that at 6 months, only one-third of patients with unilateral loss from trauma were symptom-free as compared with other causes. At 18 months, many patients continued to show symptoms. Of patients with central vestibular loss 60-70% had persisting symptoms at 5 years and half were unable to return-to-work.

Postural control treatment involves remediation of stability within the constraints following TBI. These include musculoskeletal, neuromuscular, sensory/perceptual, and cognitive. Biochemical limitations may limit a patient's ability to move in ways necessary for compensation. Treatment in this area may include physical modalities to increase range-of-motion, joint mobility, and flexibility. Treatment for muscular incoordination may include therapeutic exercise, electrical stimulation, and biofeedback. A vestibular rehabilitation program needs to be individualized considering cognitive impairments and involves:

1. Increase physical assistance because of movement problems

2. Increased supervision because of cognitive and behavioral problems.

3. Slower progression of program (studies cited above)

If it is found that the vestibular problem is from a visual disturbance, special lenses or prisms may be necessary. Special equipment for vestibular treatment such as balance master, “Equitest”, or a foam/dome apparatus modeled after the clinical test of sensory integration on balance, may be used as well as tilt or rocker boards in the clinic. No special equipment is needed for the patient at home unless identified by the treating professional and documented as medically necessary.

G. MOBILITY:

Patients who have sustained a TBI can experience changes in their mobility control and may require medical, surgical, physical, and functional therapeutic management to improve their movement and mobility. Impairments may range from mild to severe. Impairments seen may include the following: bed mobility, wheelchair mobility, seating and positioning, functional transfers, and ambulation.

Therapeutic intervention is generally accepted and widely used treatment to improve performance of mobility impairments. Treatment is generally carried through by occupational therapists or physical therapists. Treatment may include, but is not limited to the areas of developmental sequence, bed mobility skills, mat programs, patient and family training for wheelchair mobility skills, proper seating and positioning, transfer training, general strengthening, range-of-motion, endurance, gaiting, and gaiting programs and the use of modalities (functional electrical stimulation, TENS, ultrasound, phonopheresis, biofeedback). Other indicated therapies would include pool therapy, casting/splinting programs, exercise equipment such as stationary exercise bike, treadmill, and mechanical weight training equipment. Orthopedic and/or neuromuscular problems may develop along with mobility impairments. These may include, but are not limited to heterotopic ossification, limb contractions, abnormal tone which interfere with the advancement of independence with mobility skills.

1. Frequency: daily/discipline/session (number of hours will vary depending upon patient's ability and treatment activity, treatment frequency should decrease when patient goals are met and independence is gained.

2. Optimum duration: 3-6 months with re-evaluation every 4 weeks

3. Maximum duration: beyond 6 months requires documentation of progress

Short-term goal-directed intervention may be periodically indicated on an ongoing basis as new changes occur in an individual's functional mobility. Impaired cognition significantly affects mobility as noted by problems with attention, judgment, organization of auditory and/or visual instructions, memory, concentration, problem solving, behavior, and initiation (refer to discussion at the beginning of this Section VII.).

Patients with TBI may be compromised in their mobility and accessibility to their home, work, and community environments. In order to relieve the effects of the injury, certain equipment, adaptive devices, and home modifications may be reasonable and necessary. Equipment, devices, and adaptive equipment can be necessary to reduce impairment and disability, and to enhance functional independence and safety.

Adaptive devices may be necessary to relieve the effects of the injury, or to enhance independence and safety of mobility. Possible equipment and devices may include, but are not limited to: Hospital bed Transfer boards Lift equipment (Hoyer lift) Standing frames Manual wheelchair- lightweight Manual reclining wheelchair Power wheelchair Power reclining wheelchair Wheelchair positioning aids (laterals, headrests, seating systems, backs, lapboards) Wheelchair cushions Lower extremity bracing Ambulation aids (walkers, crutches, canes) Shower commode chair Shower bath bench Hand held shower Raised toilet seat Padded toilet seat Orthotics/Prosthetics

Environmental modifications may include, but are not limited to: ramping, modifications of the living environment to achieve reasonable levels of independence, adaptive equipment for mobility, and safety. Periodic upgrading or consultation may be necessary throughout a patient's life time following TBI. Therapy may be re-initiated for time-limited, goalspecific treatment as new goals are developed.

H. ACTIVITIES OF DAILY LIVING (ADLs)

(also called daily living skills, life skills or living skills) are tasks necessary for an individual's day-to-day functioning, and include both basic and higher level tasks. Disabilities and handicaps in these abilities are common following TBI when due to changes in physical, cognitive, and emotional/behavioral impairments. Disability and handicap in these areas may range from mild to severe, as well as from short-term to lifelong.

Treatment for ADLs are generally accepted and widely used. The goal of treatment is to improve one's ability to perform such tasks, in order to increase functional levels of independence. Also, by including ADLs in treatment, cognitive improvements may occur by applying cognitive rehabilitation principles to the task performance. Likewise, physical deficits may be improved by applying neuromuscular rehabilitation principles to the task performance.

1. Basic ADLs include daily activities which tend to be repetitive, routine, and which can more readily be gained through procedural learning, such as grooming, personal hygiene, bathing/showering, toileting, dressing, feeding/eating, basic social skills, functional communication (e.g. writing, keyboarding, appropriate use of phone), and functional mobility.

2. Higher Level ADLs include a wide-range of activities that require higher level cognitive skills, including the ability to plan, execute and monitor performance, evaluate information, and make sound judgments. This ability is essential to safe, independent functioning. It may include home management, child care, time management, financial management, food management, management of interpersonal relationships and social skills, driving, and higher level mobility skills (including wayfinding, public transportation.)

Therapeutic intervention is generally accepted to improve performance of ADLs. Procedures and techniques may include, but are not limited to 1) task analysis to develop methods of performance of problem steps of task; 2) development of strategies to compensate for deficits in performance; 3) guided practice and repetition to develop consistent and safe performance; 4) training in safe use of adaptive equipment; and 5) training of care givers.

Treatment in subacute and acute rehabilitation is provided by one or more therapeutic disciplines including therapists from physical therapy, occupational therapy, speech therapy, mental health, nursing, and/or vocational rehabilitation as tolerated. In post-acute settings (which may include residential, outpatient), treatment sessions may be provided by more than one discipline. In-home and community- based treatment, continued treatment in the appropriate setting is indicated until 1) functional goals/outcomes are achieved; 2) plateau in progress is reached; 3) the patient is unable to participate in treatment due to medical, psychological, or social factors; or 4) skilled services are no longer needed.

1. Frequency: 1-7 sessions per week depending upon individual progress; sessions may vary from 1-to- several hours depending upon patient's ability to respond to treatment

2. Optimum duration: 1-6 months

3. Maximum duration: 24 months or beyond, requires documentation of progress

Treatment may be provided on an episodic basis, with suspension of treatment for periods of time to allow for practice toward reaching goals. Periodic upgrading or consultation may be necessary throughout a patient's life time following TBI. Therapy may be re-initiated for time-limited, goal-specific treatment as new goals are developed.

Impaired cognition significantly affects the rate, degree, and manner of progress toward independence in ADLs. In addition, skills learned in one setting or circumstance may not easily generalize to a different setting, and additional treatment may be required to facilitate transfer of skills. All treatment to improve performance in this area must include techniques to improve cognition as well.

Standard equipment to alleviate the effects of the injury on the performance of ADLs may vary from simple to complex adaptive devices to enhance independence and safety. Certain equipment related to cognitive impairments may also be required. Equipment needs may need to be re-assessed periodically.

The results of treatment intervention provided throughout the continuum of progress beginning with acute care can be realized in the final stages of integration back into the individual's community setting. As noted above, treatment is often indicated at this stage to ensure that the individual is able to re-integrate as successfully as possible, given the parameters of the injury.

I. PSYCHOLOGICAL INTERVENTIONS – MTBI:

1. Acute Psychological Interventions in MTBI:

MTBI can result in a variety of cognitive deficits and symptoms (e.g. slowed speed of thinking, memory problems, heightened fatigue, heightened irritability) that are difficult to cope with. Early mental health interventions that educate patients about the symptoms of MTBI and the management symptoms are appropriate. Mental health interventions to educate the patient and to support coping may occur with the patient and with the family/or alternatively with close friends and co-workers. Such treatment sessions may occur in the hospital before the patient is discharged, and/or may be provided on an outpatient basis.

When significant risk factors are present (e.g. history of multiple brain injuries, the desire to return to a highly demanding job, significant injury stress, preinjury psychiatric disorder, injury learning disability, PTA greater than 4-6 hours, loss of consciousness greater than 10 minutes, CT or MRI scan evidence of parenchymal lesion or extradural hematoma, chronic pain, or other associated orthopedic and soft tissue injuries), physician referrals are appropriate for mental health interventions to promote positive coping and to manage symptoms. The presence of injury disorders should not exclude patients from appropriate treatment.

2. Problem-Specific Referrals During the First Three Months Following MTBI for mental health services are appropriate to address specific problems that are directly caused by the injury (e.g., memory deficits, slowed speed of thinking, difficulties with decision making, heightened irritability, and problems relative to excessive fatigue) or that are secondary to the injury (e.g., anxiety, reactive depression, difficulties with self-acceptance, and difficulties in adapting one's work schedule to diminished cognitive capacity). Mental health interventions to address such problems may take a variety of forms including individual psychotherapy, cognitive/behavioral therapy, instruction in specific techniques such as relaxation, training or biofeedback, instruction in symptom management, marital therapy, group therapy, and interventions in the community. Licensed mental health professionals may work with occupational therapists and speech therapists may work with the patient in their own home or other community settings in order to teach patients adaptive skills, compensatory techniques, or new ways of solving problems that assist patients in coping more effectively during recovery. Consultation with other professionals and organizations may also be provided to help improve the patient's adjustment. Treatment may include the use of training techniques to enhance attention-concentration, reduce distractibility, and improve confidence in cognitive abilities. Mental health professionals often teach patients practical decision-making strategies in order to enhance coping and reduce stress. Mental health professionals typically work collaboratively with physicians when they are seeing patients during the first three months post-injury. Medications are frequently helpful in terms of addressing symptoms that patients present.

3. Referrals of Patients Who Are Three or More Months Post-MTBI:

Patients are often referred for mental health services after 3 months post-injury when their efforts to cope with their symptoms are failing, or when secondary psychological symptoms such as intolerance to certain types of environmental stimuli or reactive depression are reaching problematic proportions. Pre- existing personality traits (e.g. perfectionism), demanding responsibilities, or lack of experience on the current job may also interact with cognitive deficits and symptoms secondary to MTBI to necessitate the provision of ongoing psychotherapeutic services. Treatment can include individual psychotherapy, marital therapy, group therapy, instruction in relaxation and related techniques, cognitive/behavioral therapy, social skills training, and interventions/consultation in the community.

J. PSYCHOLOGICAL INTERVENTIONS – MODERATE-SEVERE INJURY:

1. During Post-Traumatic Amnesia, the insight of patients is compromised, and behavioral problems such as impulsivity, agitation, uninhibited behaviors, and confabulation may emerge. At this stage, psychological interventions are typically focused on 1) development of specific environmental strategies to manage problematic behaviors and increase patient and staff safety; 2) consultation with other team members, support of the nursing staff, and ongoing contacts with the patient's family; and 3) education of the family about the brain injury and its behavioral manifestations. The patient's cognitive status is monitored during this time period. The psychological interventions described here typically occur throughout the period of post-traumatic amnesia. Furthermore, psychological consultation to help manage problematic behaviors such as perseveration, aggressive behaviors, and disorders of memory typically continue into the acute rehabilitation phase of treatment as the patient comes out of post-traumatic amnesia. Psychological interventions may be delivered by a variety of licensed and qualified mental health clinicians.

2. Promote Insight and Support Coping:

Once the patient is out of post-traumatic amnesia, mental health clinical services are typically provided to educate the patient about his/her injury, promote the development of insight into deficits, support the development of positive coping. Treatment also typically involves psychotherapeutic intervention to assist the patient in dealing with feelings of anxiety, loss, frustration and grief. Psychological treatment is often required to address reactive depression, heightened irritability, and anxiety. Psychological interventions including psychotherapy, cognitive behavior modification, and environmental restructuring may be required to address social skills, deficits, and behavioral excesses. In addition to psychological services provided directly to the patient, consultation by mental health professionals with other team members is appropriate to train team members and family members as to how they can positively support the process of recovery. Family therapy sessions and educational sessions are often indicated, and are appropriate.

3. Support Transition to the Community and Functioning in the Community:

Alterations in cognitive and emotional functioning (e.g., mood disorders, emotional lability, heightened irritability, perseverative behaviors, memory problems, and disorders related to reduced judgment) may necessitate ongoing mental health treatment. Patients typically receive mental health services before discharge from the hospital in order to address specific deficits and abilities that will play an important role in successful functioning in their own home environment. These services are typically individualized and may take a variety of forms including individual psychotherapy, skills training (e.g., parenting), marital psychotherapy, and group psychotherapy.

Cognitive deficits may necessitate that such forms of treatment are specially tailored to the needs of the patient. For example, a patient with significant memory problems may need to have information from psychotherapy sessions video or audio recorded. Depending upon the severity of the behavioral problems, outpatient psychotherapy may initially be held as frequently as once a day for severe problems (e.g., rage reactions, sexually disinhibited behaviors, or other behaviors that constitute safety risks). Sessions may occur several times a week to address adjustment issues in psychotherapeutic format.

In view of the fact that deficits from moderate to severe brain injury typically persist throughout the patient's lifetime, intermittent mental health interventions may be required during the course of the patient's lifetime in order to address the behavioral problems and emotional distress that can arise secondary to developmental issues or changes in environmental structure. Periodic upgrading or consultation may be necessary throughout a patient's life time following TBI. Therapy may be reinitiated for time-limited, goal-specific treatment as new goals are developed.

4. Consultation in Regard to Use of Medications:

Physicians often utilize medications to help improve the emotional and behavioral functioning of individuals who have sustained moderate to severe brain injury. Physicians often request that psychologists, social workers, family service counselors and other team members provide data and input regarding behavioral observations that can assist physicians in assessing how the patient is responding to various medications.

K. BEHAVIORAL TREATMENT:

TBI often results in behavioral disabilities and handicaps as a result of neuropathological deficits in executive skills, judgment, self monitoring, and behavioral or emotional regulation. These organic disabilities may be compounded by secondary emotional reactions (i.e. depression).

Behavioral control and therefore behavioral problems are always based upon multiple factors in multiple systems. Treatment must therefore address underlying pathologies indicated by appropriate medical, neurosurgical, neurological, psychiatric, psychological and social assessment.

Neuropathologically based behavioral problems may be exacerbated by individual co-morbidities such as personality or family issues, major psychiatric illnesses and substance abuse. Successful resolution of the behavioral problem will usually require treatment of these associated pathologies. Behavioral problems are also influenced by developmental issues. Treatment requires appropriate consideration of developmental and life-state issues (i.e., child, adolescent, elderly), including potentially specialized treatment settings or professionals experienced in the management of these populations. Treatment may also require focused behavioral analysis available only in a specialized rehabilitation or psychiatric setting. Behavioral analysis and treatment involves:

1. identification and prioritization of target behaviors to be managed or eliminated

2. identification of behavioral strengths to be encouraged and positively reinforced

3. analysis of internal and environment to reduce or eliminate precipitants of maladaptive behaviors

4. environmental positive reinforcement of adaptive behaviors 5. attempts to modify internal precipitants of maladaptive behaviors (i.e., pain, sleep deprivation, anxiety, depression, though disturbance)

6. analysis of the effects of internal and environmental modification on behavior

7. progressive refinement of the strategies of internal and environmental modifications in response to an analysis of changes in behavior.

Effective behavioral management and treatment requires individualized approaches. The setting of treatment must consider individual resources and circumstances. Inpatient and outpatient settings may require one to one supervision at critical phases of recovery. Coordination of treatment resources and professionals is essential. Analysis of the environment and personnel during periods of transition between treatment settings is generally essential to minimize the stress of change and to avoid the loss of critical environmental reinforcers.

In long-term maintenance programs, treatment may be appropriate on an episodic basis as follows: treatment may be “on hold” for several weeks or months until certain goals are reaches, or until additional goals emerge. At such times therapy can be restarted for a time-limited, goal specific treatment. Progress should be re-evaluated and documented every 4 weeks, per the Section I., General Guideline Principles.

L. PATIENT/FAMILY EDUCATION and support for patients with moderate-severe brain injury are appropriate, generally accepted and widely used in brain injury rehabilitation. Initial family adjustment is generally accomplished at between 18-24 months.

1. For MTBI patients:

a. Frequency: 1 hour sessions

- 1 per week for 2-3 months, then

- 1 per month for 12-16 months

b. Optimum duration: 18 months

2. For moderate-severe brain injury patients/family:

a. Frequency: 1 hour sessions

- daily for the first month, then

- twice a week for 2-3 months, then

- weekly for 2-3 months,

- 2-3 times a month for 18 months

b. Optimum duration: 18– 24 months During the initial 12 months, formal patient/family/case manager/insurance conferences should be held monthly as needed. Education should focus on the brain, brainbehavior relationships, medical and health maintenance, family interventions, patient and family emotional adjustment, and family role changes. Families may require long-term education and support as part of the long-term maintenance plan. Patient/family education is typically provided by social workers, rehabilitation counselors, family counselors, licensed mental health professionals, and/or nurses. M. DRIVING:

Independent driving is considered a complex activity of daily living. An individual's potential for safe driving is influenced by a complex interaction of physical, cognitive, visual, and behavioral impairments in areas common to brain injury. An individual's ability to drive is typically evaluated and treated under physician orders by a registered occupational therapist who may be certified as a rehabilitation driving specialist. The treatment process may also require services of a:

1. Commercial driver trainer for driving practice

2. Ophthalmologist or optometrist for visual evaluation

3. Commercial vendors and rehab engineers for adaptive equipment

4. Neuropsychologist for cognitive evaluation

5. Speech/language for communication evaluation and strategies

Public and personal safety and compliance with state department of motor vehicles procedures ultimately determine individual driving privileges. Evaluation and treatment typically occur during the community re- entry phase of rehabilitation. In general, successful driving results are obtained within the first two years post-injury, but this is not always the case. Evaluation and treatment typically consist of:

1. Time to produce effect: evaluation time of a minimum of 1-2 sessions to evaluate physical, perceptual, cognitive, and behavioral skills and for collaboration with other interdisciplinary team members.

2. Optimum duration: behind-the-wheel driving evaluation and training on the road of between 2-6 sessions.

If the patient fails the evaluation, the patient may be required to participate in 1–2 hours of additional driving practice and repeat the behind-the-wheel test, or to wait 3 months or longer to repeat the evaluation. The evaluation may be repeated at 3–12 month intervals as determined by the evaluator and physician. Several repeat assessments may be necessary to determine safe driving readiness.

Recommendations and physician prescriptions for necessary adaptive equipment and vehicle modification for safe driving or for dependent passenger transport in vehicles may be necessary. Therapeutic assistance is necessary to help the patient and physician comply with state department of motor vehicles' standards for practices and procedures for drivers' licensure.

Significant and multiple cognitive impairments, as well as motor and visual impairments can decrease, delay, or prevent an individual from achieving functional driving independence. Important cognitive factors include ability to make complex judgments, organize information, anticipate, maintain self-control and others. Patients may or may not be able to successfully compensate for these impairments.

Van lifts and other adaptive equipment and vehicle modifications may be necessary for dependent patients in order that patients can access community services, and have accessibility to society.

N. RETURN-TO-WORK:

In addition to the treatment strategies described below, practitioners should be familiar with how various state and federal statutes and regulations may impact return-to-work planning. These may include, but are not limited to, Family and Medical Leave Act (FMLA), Americans with Disabilities Act (ADA), Occupational Health and Safety Administration (OSHA), and Department of Transportation (DOT).

1. Return-to-Work MTBI: Following MTBI, a majority of patients are able to resume normal work duties with little or no therapeutic intervention. A smaller percentage of patients with MTBI have deficits, with functionally disabling consequences. Patients with MTBI may be instructed to temporarily reduce the amount, type, and/or intensity of their work duties, or temporarily remain out of work entirely, depending on their clinical condition. Physicians should attempt to be clear and specific in documenting vocational restrictions, a plan for re-entry to work, and communication with the employer (e.g., supervisor, safety officer, employee health nurse). For patients with significant deficits, an interdisciplinary team approach may be recommended which can include a neuropsychological assessment, vocational evaluation and job site analysis, early contact with employer, assessment of vocational feasibility, supervisor education, transferable skills analysis, skillful increased titration of job duties and demands, job coaching, physical, occupational, and speech therapy, mental health services. For patients with MTBI who have persistent deficits, or who have difficulty once back at work, a return-to-work program should occur, which requires a carefully designed and managed plan by the patient, employer, and treatment team. Communication among all involved parties, and the avoidance of fragmentation among treatment professionals is critical to successful outcome. Following return-to-work, maintenance support services are appropriate to best insure the durability of outcome.

2. Return-to-Work Moderate-Severe TBI:

Following Moderate-Severe TBI, many patients are unable to return-to-work. Successful return-to-work among patients with moderate-severe injury requires an interdisciplinary approach including neuropsychological assessment, functional capacity evaluation, job site analysis, early contact with employer, assessment of vocational feasibility, transferable skills analysis, supervisor education and coaching, co-worker education, pre-vocational job trials, job placement, job coaching, skillful increased titration of job duties and demands, mental health and family counseling, and follow-up services.

O. COMPLIMENTARY MEDICINE includes a wide-range of interventions that at this time have not been supported by empirical data or have widespread use for brain injury. These alternative treatments include, but are not limited to, acupuncture, art therapy, craniosacral trauma release, EEG Neurofeedback, dance therapy, herbal and homeopathic treatment, hippotherapy, hyperbaric oxygen, hypnosis, horticulture therapy, and music therapy. Alternative therapies should not be employed as the primary treatment modality, but may be considered for individual cases, when other treatments have failed to produce functional gains, or when there is a valid clinical rationale for their use, and when treatment goals are directed to improvement in measurable functional activities. Treatment requires prior authorization from the payer and agreement on fees in accordance with criteria in Division Rules XVI and XVIII. Complementary Medicine uses methods of treatment based upon a broad range of knowledge with roots in both eastern and western medicine, and many Complementary Medicine providers integrate more than one procedure. Some of the exercise-based procedures are currently integrated into rehabilitation programs. In general, most approaches place major focus on the important relationship between physical and emotional well-being.

1. Time to produce effect: 3–6 treatments.

2. Frequency: 1–3 treatments per week.

3. Optimum duration: 4–6 weeks.

4. Maximum duration: not well-established for Complementary Medicine and should be based upon the physician's clinical judgment and demonstration of positive symptomatic and functional gains.

P. LONG-TERM MAINTENANCE PLANS:

Following MTBI, a large percentage of patients make a good neurological and functional recovery with little or no intervention, despite the possibility of subtle residual impairments or functional changes. Other patients with MTBI experience significant impairments and disabilities. At this time, definitive pre-injury, injury, or post-injury predictors of outcome are not fully understood.

Many individuals with moderate-severe brain injury experience life long impairments, disabilities, and are at a greater risk for the remainder of their lives for ongoing medical, psychiatric, physical and cognitive complications. Second brain injuries, late onset seizures, maladaptive social skills, aggressive behaviors, substance abuse, psychiatric disorders are common examples of some negative long-term consequences of brain injury.

Therefore, patients with brain injury generally require long-term supports to prevent secondary disability, and to maintain the level of medical and psychological health and functional independence achieved in rehabilitation. Providers and carriers should adopt a disease state management model for patients with brain injury. Common lifetime supports include physician oversight, nursing services, periodic therapy oversight, supported living programs, attendant care, supported employment or productive activity, transportation, and patient family education and support. The above services may be reasonable and necessary for patients with chronic disabilities. The specific type and amounts of support necessary will vary in each individual case, and may change over time. Practitioners are encouraged to analyze risk factors, and to establish viable long-term maintenance plans. Long-term maintenance programs should be managed by an experienced case manager who can intervene quickly when necessary. Case management should not be discontinued when a patient finishes acute rehabilitation.

Medical and rehabilitation providers are encouraged to educate patients and family members regarding anticipated ongoing medical and rehabilitation needs. Because the medical future of patients with TBI is uncertain and is at risk, patients, families and providers should plan for unforeseen medical, psychiatric, physical, and cognitive complications as patients age over their lifetimes with brain injury.

RULE XVIII MEDICAL FEE SCHEDULE

A. STATEMENT OF PURPOSE

Pursuant to Section 8-42-101(3)(a)(I), C.R.S., the director promulgates this medical fee schedule to review and establish maximum allowable fees for health care services falling within the purview of the Act. The director adopts and hereby incorporates by reference as modified herein the 2003, edition of the Relative Values For Physicians (RVP), developed by Relative Value Studies, Inc., published by Ingenix®; St. Anthony Publishing. The incorporation is limited to the specific edition named and does not include later revisions or additions. For information about inspecting or obtaining copies of the incorporated material, contact the Medical Fee Schedule Administrator, 1515 Arapahoe, Tower 2, Suite 610, Denver, Colorado 80202-2117. These materials may be examined at any state publications depository library. All guidelines and instructions are adopted as set forth in the Relative Values For Physicians, unless otherwise specified in this rule.

This rule applies to all services rendered on or after January 1, 2004. All other bills shall be reimbursed in accordance with the fee schedule in effect at the time service was rendered.

B. STANDARD TERMINOLOGY FOR THIS RULE

1. RVP - the 2003 edition of Relative Values for Physicians, incorporated by reference in Rule XVIII.A.

2. For other terms, see Rule XVI.B, Utilization Standards.

C. HOW TO OBTAIN COPIES

All users are responsible for the timely purchase and use of this Rule XVIII and its supporting documentation as referenced herein. The Division shall make available for public review and inspection copies of all materials incorporated by reference in this Rule XVIII. Copies of the RVP may be purchased from St. Anthony Press, and the Workers' Compensation Rules of Procedures, 7 CCR 1101-3, may be purchased from Weil Publishing, Augusta, ME. Unofficial copies of all rules, including Rule XVIII, are available on the Colorado Department of Labor and Employment web site at www.coworkforce.com/dwc.

D. CONVERSION FACTORS

The following conversion factors shall be used to determine the maximum allowed fee. The maximum fee is determined by multiplying the following section conversion factors by the established relative value unit(s) (RVU) found in the corresponding RVP sections: RVP SECTION CONVERSION FACTOR Medicine $7.16/RVU Evaluation & $7.52/RVU Management (E&M) Physical Medicine (Codes $4.74/RVU 97000-97999) Anesthesia $36.33/RVU Surgery X Codes (see $ 36.95/RVU Rule XVIII.E.1.a.4) Surgery $84.27/RVU Radiology $16.60/RVU Pathology $12.36/RVU

E. INSTRUCTIONS AND/OR MODIFICATIONS TO THE RVP

1. Maximum allowance for all providers under Rule XVI.E is 100 percent of the fees as defined in this Rule XVIII.

2. Interim relative value procedures (marked by an “I” in the left-hand margin of the RVP) are accepted as a basis of payment for services; however deleted Current Procedural Terminology codes (CPT codes marked by an “M” in the RVP) are not, unless otherwise advised by this rule. The American Medical Association's CPT 2003 may be referenced for further clarification of descriptions and billing, but if conflicts arise between the RVP and the CPT 2003, the RVP shall prevail.

3. Surgery/Anesthesia a. Anesthesia Section:(Codes range from 00100 — 01999, and 99100–99140)

1) All anesthesia base values shall be established by the use of the codes 00100 – 01999 as set forth in the RVP.

2) Justifying documentation shall be submitted with the billing for all stand-by anesthesia.

3) When justified by a report, a second anesthesiologist can be reimbursed as recommended by the anesthesia guidelines in the RVP.

4) Surgery X Codes

(a) The following codes limit the list found in the table under the “Anesthesia Value Guidelines” of the RVP, Section X, “Anesthesia Services Where Time Units Are Not Allowed”. The maximum reimbursement for these codes shall be based upon the anesthesia value listed in the table in Section X multiplied by $36.95 conversion factor. No additional unit values are added for time when calculating the maximum values for reimbursement. Modifier —51 may be applied to these codes when multiple surgical procedures are performed on the same day during the same operative setting. 01995 36600 62319 64420 01996 36620 64400 64421 31500 36625 64402 64425 36400 36660 64405 64430 36420 62273 64408 64435 36425 62280 64410 64445 36488 62281 64412 64450 36489 62282 64413 64470 36490 62310 64415 64472 36491 62311 64417 64475 62318 64418 64476

(b) Codes from Table X not found above may be found in another section of the RVP (e.g., surgery). Any codes found in the table under the “Anesthesia Value Guidelines” of the RVP, Section X, “Anesthesia Services Where Time Units Are Not Allowed” but not contained in this list (Rule XVIII.E.3.a.4).(a)) are reimbursed in accordance with the assigned units from their respective sections times their respective conversion factor. b. Surgical Section: (Codes range from 10040 – 69990)

1) The use of assistant surgeons shall be limited according to the American College Of Surgeons' 2002 Study: Physicians as Assistants at Surgery (April 2002), available from the American College of Surgeons, Chicago, IL, or from their web page at www.facs.org, (accessed June 3, 2003). The incorporation is limited to the edition named and does not include later revisions or additions. Copies of the material incorporated by reference may be inspected at any State publications depository library. For information about inspecting or obtaining copies of the incorporated material, contact the Medical Fee Schedule Administrator, 1515 Arapahoe, Tower 2, Suite 610, Denver, Colorado, 80202–2117. Where the publication restricts use of such assistants to “almost never” or a procedure is not referenced in the publication, prior authorization for payment shall be obtained from the payer.

2) Incidental procedures are commonly performed as an integral part of a total service and do not warrant a separate benefit.

3) No payment shall be made for more than one assistant surgeon or more than one minimum assistant surgeon without prior authorization unless a trauma team was activated due to the emergent nature of the injury(ies).

4) The payer may use available billing information such as provider credential(s) and clinical record(s) to determine if an appropriate modifier should be used on the bill. To modify a billed code refer to Rule XVI.K.2.c.

5) Non-physician providers, used as surgical assistants, shall use the modifier —81 and shall be reimbursed at 10 percent of the listed value.

6) Starred (*) surgical procedures may not be billed in conjunction with an office visit except: (a) When a starred (*) surgical procedure is performed at the initial visit, the initial visit maximum reimbursement shall be based upon the value of code 99025 unless the documentation demonstrates other significant identifiable services were involved (see (c) below).

(b) When a starred (*) surgical procedure is performed on an established patient and the documentation clearly substantiates other separate and identifiable services from the starred procedure, the office visit can be reimbursed separately from the starred (*) procedure (see (c) below).

(c) When the starred (*) procedure is carried out at the time of an initial or established patient office visit involving other significant, identifiable services, the appropriate office visit code shall append the modifier “—25”.

7) Intradiscal Electrothermal Annuloplasty (IDEA) –

This is a new procedure and prior authorization is required. A wire is guided into the identified painful disc using fluoroscopy. The wire is then heated within the disc. The goal of the procedure is to burn the nerves and to tighten the injured tissue within the disc. A physician well trained in the procedure must perform this procedure. Please refer to Rule XVII, Exhibit A, Section F.8 for the required surgical indications for this procedure.

Billing code and maximum fees are as follows:

Billing Code: S2370 $2,086.00

Fees are inclusive of all levels and all professional services except, fluoroscopy guidance; see code 76005.

8) The following surgery code relative value units, anesthesia base units and global days replace those existing in the 2003 RVP. All surgery code descriptors are based upon the 2003 RVP. Code Unit Value Anes Base Units Global Days 11771 7.2 5 090 11772 8.8 5 090 11971 3.6 3 090 13160 4.2 3 090 14000 7.2 3 090 14001 8.3 3 090 14040 10.5 5 090 14041 13.2 5 090 14060 14.3 5 090 14350 8.8 3 090 15050 4.2 3 090 15100 7.0 3 090 15120 12.7 5 090 15200 5.5 3 090 15220 7.2 5 090 15240 10.9 5 090 15260 13.8 5 090 15600 5.8 3 090 15610 5.8 5 090 15620 6.3 5 090 15630 7.5 5 090 15650 9.2 3 090 15760 10.4 5 090 15770 13.2 5 090 15783 2.2 3 090 15788 7.7 5 090 15789 9.9 5 090 15792 5.5 3 090 15793 7.7 3 090 15810 1.0 3 090 15811 2.4 3 090 15819 20.6 5 090 15820 11.0 5 090 15821 11.6 5 090 15822 10.2 5 090 15823 9.9 5 090 15831 22.0 5 090 15832 18.3 3 090 15833 18.3 3 090 15834 18.3 3 090 15835 18.3 3 090 15836 11.0 3 090 15837 9.1 3 090 15838 8.8 5 090 15950 2.3 5 090 15951 6.6 6 090 19110 5.2 3 090 19112 5.0 3 090 19120 6.0 3 090 19125 8.4 3 090 19140 7.7 3 090 19160 6.6 3 090 19162 18.7 5 090 19180 11.4 3 090 19182 11.0 3 090 19240 20.9 5 090 20661 4.4 5 090 20662 6.2 6 090 20663 6.2 4 090 20664 10.5 5 090 20680 4.9 5 090 20690 6.2 3 090 20692 11.1 3 090 20693 5.5 3 090 20694 2.5 3 090 21110 7.8 5 090 21440 15.6 7 090 21445 19.2 7 090 21501 5.5 5 090 21502 7.6 6 090 21510 4.9 10 090 21600 6.1 6 090 21610 22.0 6 090 21615 17.6 6 090 21616 22.4 6 090 21620 22.0 6 090 21627 8.8 10 090 21630 27.5 13 090 21632 44.0 13 090 21700 7.2 5 090 21705 13.8 6 090 21720 7.2 5 090 21725 9.4 5 090 21800 1.2 6 090 21805 11.0 6 090 21810 26.4 10 090 21820 3.0 6 090 21825 11.0 10 090 21925 3.3 5 090 21930 3.3 5 090 23000 6.8 5 090 23020 12.5 5 090 23035 14.4 5 090 23040 12.5 5 090 23044 8.1 5 090 23100 12.5 5 090 23101 12.5 5 090 23120 8.8 5 090 23125 17.6 6 090 23130 8.8 5 090 23140 6.8 5 090 23150 14.4 5 090 23172 7.2 5 090 23182 7.2 5 090 23184 12.0 5 090 23190 7.2 5 090 23195 18.0 5 090 23200 14.4 6 090 23210 19.2 6 090 23220 19.2 6 090 23395 11.6 5 090 23397 13.8 5 090 23400 16.5 5 090 23405 9.4 5 090 23406 12.9 5 090 23412 16.7 5 090 23415 11.0 5 090 23545 2.6 4 090 23550 12.7 5 090 23650 3.2 0 090 23655 4.7 4 090 24000 12.1 4 090 24006 15.6 4 090 24075 3.7 3 090 24076 6.0 3 090 24100 7.6 4 090 24101 12.1 4 090 24105 5.5 3 090 24110 11.0 5 090 24120 9.0 4 090 24130 9.4 3 090 24134 14.4 4 090 24136 14.4 3 090 24138 14.4 3 090 24140 13.2 4 090 24145 9.6 3 090 24147 8.3 3 090 24155 13.6 4 090 24160 10.7 4 090 24164 10.2 4 090 24201 4.7 3 090 24301 16.8 3 090 24305 6.4 3 090 24310 6.0 5 090 24350 6.0 3 090 24351 7.2 3 090 24352 9.6 3 090 24354 8.4 3 090 24365 11.0 4 090 24366 12.1 4 090 24495 13.2 3 090 24576 1.4 3 090 24577 4.4 3 090 24600 2.8 0 090 24605 3.5 3 090 24650 2.2 3 090 24670 2.2 3 090 24925 3.7 6 090 25000 5.4 3 090 25020 6.6 3 090 25023 7.2 3 090 25028 4.8 3 090 25031 2.4 3 090 25035 5.5 3 090 25040 6.1 3 090 25075 3.6 3 090 25076 5.5 3 090 25085 5.9 3 090 25100 5.5 3 090 25101 6.5 3 090 25105 8.8 3 090 25107 7.7 3 090 25110 4.2 3 090 25111 5.4 3 090 25112 6.8 3 090 25115 11.0 3 090 25116 11.0 3 090 25118 7.7 3 090 25119 11.0 3 090 25120 9.1 3 090 25130 6.6 3 090 25150 7.0 3 090 25151 8.3 3 090 25170 16.5 3 090 25210 7.7 3 090 25215 11.0 3 090 25230 5.9 3 090 25240 5.9 3 090 25248 5.5 3 090 25250 12.0 3 090 25251 18.0 6 090 25260 8.8 3 090 25263 9.4 3 090 25270 5.5 3 090 25272 6.6 3 090 25280 7.9 3 090 25290 4.7 3 090 25295 5.8 3 090 25500 2.4 3 090 25530 3.6 3 090 25560 3.2 3 090 25565 6.5 3 090 25600 3.3 3 090 25622 3.9 3 090 25630 3.9 3 090 25635 4.6 3 090 25675 3.4 3 090 25680 3.3 3 090 25695 11.0 3 090 25907 3.7 3 090 25915 11.6 3 090 25922 3.8 3 090 25929 3.7 3 090 26020 6.1 3 090 26025 6.6 3 090 26030 10.8 3 090 26034 7.2 3 090 26035 16.0 3 090 26037 14.4 3 090 26040 3.6 3 090 26045 5.5 3 090 26055 5.4 3 090 26070 6.1 3 090 26075 6.0 3 090 26080 5.4 3 090 26100 6.1 3 090 26105 6.0 3 090 26110 5.4 3 090 26115 3.6 3 090 26116 6.0 3 090 26160 4.8 3 090 26170 5.4 3 090 26180 6.0 3 090 26200 6.8 3 090 26210 5.9 3 090 26230 6.1 3 090 26235 5.5 3 090 26236 5.5 3 090 26320 6.0 3 090 26370 8.8 3 090 26372 12.4 3 090 26392 12.1 3 090 26410 5.1 3 090 26412 7.7 3 090 26415 9.4 3 090 26416 11.0 3 090 26432 7.2 3 090 26433 7.2 3 090 26437 6.6 3 090 26440 6.4 3 090 26442 7.7 3 090 26445 6.6 3 090 26449 8.8 3 090 26450 4.8 3 090 26455 6.0 3 090 26460 4.2 3 090 26560 11.5 3 090 26561 16.3 3 090 26600 1.7 3 090 26605 2.8 3 090 26607 5.5 3 090 26608 8.1 3 090 26615 7.7 3 090 26641 2.2 3 090 26645 4.6 3 090 26650 8.6 3 090 26665 11.6 3 090 26670 1.8 0 090 26675 2.9 3 090 26676 2.9 3 090 26685 6.6 3 090 26686 8.8 3 090 26700 2.3 0 090 26705 2.5 3 090 26706 4.6 3 090 26715 8.1 3 090 26720 1.7 3 090 26725 2.4 3 090 26727 3.7 3 090 26735 6.6 3 090 26740 2.8 3 090 26742 3.9 3 090 26746 6.6 3 090 26750 0.9 3 090 26755 1.2 3 090 26756 1.8 3 090 26765 4.4 3 090 26770 1.2 0 090 26775 1.7 3 090 26776 1.8 3 090 26785 3.3 3 090 26951 6.3 3 090 26952 8.1 3 090 26990 4.8 6 090 26991 1.3 6 090 26992 6.0 6 090 27000 2.4 4 090 27001 3.6 4 090 27003 8.1 4 090 27005 6.6 4 090 27006 7.7 4 090 27060 6.1 4 090 27062 4.4 4 090 27065 5.5 6 090 27070 6.6 8 090 27071 13.2 6 090 27087 2.8 6 090 27200 1.8 6 090 27250 3.9 0 090 27301 3.6 4 090 27303 6.6 6 090 27305 6.9 4 090 27306 2.9 4 090 27307 3.6 4 090 27315 13.2 4 090 27320 13.2 4 090 27340 8.8 4 090 27345 9.9 4 090 27350 13.2 4 090 27355 12.1 5 090 27372 6.2 4 090 27390 7.2 4 090 27391 9.2 4 090 27392 13.8 4 090 27393 8.4 4 090 27394 10.8 4 090 27395 15.6 4 090 27520 2.9 3 090 27550 2.6 0 090 27552 3.8 3 090 27560 2.6 0 090 27562 4.0 3 090 27600 7.2 3 090 27601 9.6 3 090 27602 13.2 3 090 27603 5.5 3 090 27604 1.3 3 090 27607 4.8 3 090 27610 10.0 3 090 27612 11.0 3 090 27618 3.7 3 090 27619 6.0 3 090 27620 10.0 3 090 27630 4.6 3 090 27635 11.6 3 090 27656 6.9 3 090 27675 6.6 3 090 27676 7.2 3 090 27680 5.5 3 090 27681 6.6 3 090 27704 13.2 3 090 27831 3.6 3 090 27840 2.1 0 090 27842 3.1 3 090 28003 2.5 3 090 28005 5.8 3 090 28008 3.5 3 090 28010 1.2 3 090 28011 1.8 3 090 28020 6.8 3 090 28022 4.4 3 090 28024 3.3 3 090 28030 13.2 3 090 28035 12.0 3 090 28043 3.7 3 090 28045 6.2 3 090 28050 6.8 3 090 28052 4.4 3 090 28054 3.3 3 090 28060 6.1 3 090 28080 5.4 3 090 28086 11.0 3 090 28088 7.2 3 090 28090 4.6 3 090 28092 3.0 3 090 28100 6.8 3 090 28104 5.4 3 090 28108 4.4 3 090 28110 3.3 3 090 28111 5.4 3 090 28112 4.4 3 090 28113 6.0 3 090 28114 13.2 3 090 28116 7.7 3 090 28118 7.7 3 090 28119 5.5 3 090 28120 6.6 3 090 28122 5.3 3 090 28124 4.0 3 090 28126 3.9 3 090 28140 6.6 3 090 28150 4.2 3 090 28153 4.8 3 090 28160 4.8 3 090 28192 3.6 3 090 28193 5.4 3 090 28220 5.5 3 090 28222 6.6 3 090 28225 3.1 3 090 28226 4.0 3 090 28230 3.6 3 090 28232 1.7 3 090 28234 1.2 3 090 28238 7.6 3 090 28240 4.0 3 090 28250 6.6 3 090 28260 10.3 3 090 28261 11.8 3 090 28270 2.6 3 090 28272 1.9 3 090 28280 3.9 3 090 28285 5.3 3 090 28286 5.3 3 090 58288 5.3 3 090 28309 7.7 3 090 28470 2.4 3 090 28475 2.8 3 090 28476 3.5 3 090 28490 1.2 3 090 28495 1.3 3 090 28496 2.2 3 090 28505 4.6 3 090 28510 0.8 3 090 28515 1.3 3 090 28525 3.6 3 090 28530 2.2 3 090 28531 3.2 3 090 28540 3.5 0 090 28545 5.2 3 090 28546 6.3 3 090 28570 2.8 0 090 28575 4.5 3 090 28576 6.2 3 090 28600 2.3 0 090 28605 3.0 3 090 28606 4.1 3 090 28675 4.6 3 090 28820 3.6 3 090 28825 2.8 3 090 29804 14.3 5 090 29819 13.2 4 090 29820 14.3 4 090 29821 17.6 4 090 29822 16.5 4 090 29823 17.1 4 090 29825 7.7 4 090 29826 15.4 4 090 29834 11.0 3 090 29835 13.2 3 090 29836 17.6 3 090 29837 11.0 3 090 29838 11.6 3 090 29843 8.3 3 090 29844 8.4 3 090 29845 9.9 3 090 29846 10.8 3 090 29847 10.8 3 090 29871 8.3 3 090 29874 11.0 3 090 29875 15.4 3 090 29876 17.6 3 090 29877 15.4 3 090 29879 15.4 3 090 29880 19.9 3 090 29881 15.4 3 090 29882 19.3 3 090 29883 23.1 3 090 29884 17.6 3 090 29885 17.6 3 090 29886 17.6 3 090 29887 19.3 3 090 29888 34.1 3 090 29889 34.1 3 090 29894 9.9 3 090 29895 9.9 3 090 29897 9.9 3 090 29898 11.0 3 090 30118 9.0 5 090 30120 9.9 5 090 30124 2.0 5 090 30125 10.2 5 090 30130 2.4 5 090 30320 7.4 5 090 30430 7.5 5 090 30435 14.4 5 090 30450 18.4 5 090 30460 15.8 5 090 30462 28.8 5 090 30540 15.1 5 090 30545 19.1 5 090 30915 15.0 5 090 30920 18.0 5 090 31320 8.8 6 090 31613 5.3 6 090 31614 11.9 6 090 31800 24.0 6 090 32800 14.4 13 090 32810 22.0 13 090 32820 33.0 10 090 34001 11.0 10 090 34051 22.0 15 090 34101 8.8 6 090 34111 8.8 6 090 34151 16.5 15 090 34201 13.2 6 090 34203 13.2 6 090 35201 23.1 10 090 35206 23.1 4 090 35207 23.1 6 090 35301 22.0 10 090 35321 19.8 6 090 36261 7.5 4 090 36819 16.8 6 090 36821 15.6 6 090 36822 13.2 6 090 36823 13.2 6 090 36825 17.4 6 090 36830 15.6 6 090 36834 17.4 6 090 36835 15.6 6 090 37565 12 5 090 37600 9.0 5 090 37605 9.6 5 090 37606 11.0 5 090 37607 9.6 5 090 37615 9.6 5 090 37616 22.0 15 090 37617 16.5 15 090 37618 12.0 4 090 37650 8.4 3 090 37700 4.8 3 090 37720 8.4 3 090 37730 12.0 3 090 37735 19.3 3 090 37780 2.4 3 090 37785 1.4 3 090 38100 18.4 7 090 38101 18.4 7 090 38115 18.4 7 090 38305 2.4 6 090 38308 6.0 5 090 38380 5.8 6 090 38381 15.4 13 090 38382 15.4 6 090 38542 6.6 6 090 38550 6.6 6 090 38555 11.0 6 090 38564 13.2 6 090 38700 13.2 6 090 38720 23.1 6 090 38724 23.1 6 090 38740 8.8 5 090 38745 15.4 5 090 38760 8.8 3 090 38765 19.8 6 090 38770 19.8 6 090 38780 29.7 6 090 40500 9.8 5 090 40510 9.0 5 090 40520 8.3 5 090 40525 9.5 5 090 40530 8.6 5 090 40650 3.6 5 090 40652 4.8 5 090 40654 7.2 5 090 40814 2.4 5 090 40816 3.3 5 090 40818 2.2 5 090 41500 6.0 5 090 40510 12.0 5 090 41520 2.4 5 090 42325 1.2 5 090 42326 1.4 5 090 42335 2.9 5 090 42340 7.2 5 090 42410 6.8 5 090 42415 18.2 5 090 42420 22.4 5 090 42425 15.0 5 090 42426 30.8 6 090 42440 11.6 5 090 42450 11.6 5 090 42500 7.8 5 090 42505 11.6 5 090 42507 14.3 5 090 42508 14.3 5 090 42509 24.2 5 090 42510 14.9 5 090 24600 11.0 5 090 42810 4.6 5 090 42815 12.4 5 090 42820 6.1 5 090 42821 6.6 5 090 42825 5.9 5 090 42826 6.4 5 090 42830 3.5 5 090 42831 3.8 5 090 42835 3.2 5 090 42836 3.5 5 090 42842 18.2 7 090 42844 21.8 7 090 42845 21.8 7 090 42860 3.6 5 090 42870 6.2 5 090 42890 13.2 7 090 42892 17.6 7 090 42894 20.9 7 090 42950 13.8 5 090 42953 13.8 7 090 43500 15.5 7 090 43501 19.0 7 090 43502 21.9 7 090 43510 16.1 7 090 43520 13.2 7 090 43605 15.5 7 090 43610 17.3 7 090 43638 30.8 7 090 43639 31.9 7 090 43640 20.4 7 090 43641 22.0 7 090 43800 16.7 7 090 43810 17.5 7 090 43820 17.5 7 090 43825 21.0 7 090 43830 13.2 7 090 43831 10.7 7 090 43832 18.4 7 090 43840 16.1 7 090 43850 22.0 7 090 43855 25.3 7 090 43860 22.0 7 090 43865 25.3 7 090 43870 11.5 7 090 43880 18.4 7 090 44010 16.4 7 090 44020 16.1 6 090 44021 15.4 6 090 44025 17.2 6 090 44055 15.4 7 090 44110 16.6 6 090 44111 18.7 6 090 44120 19.4 7 090 44125 19.4 6 090 44130 16.5 6 090 44160 20.9 7 090 44300 9.9 6 090 44310 16.0 6 090 44312 3.1 6 090 44314 17.6 6 090 44316 24.2 6 090 44320 12.7 6 090 44322 13.2 6 090 44340 2.8 6 090 44345 13.2 6 090 44346 13.8 6 090 44602 14.9 6 090 44603 19.3 6 090 44604 19.3 6 090 44605 17.3 6 090 44615 19.5 6 090 44620 11.0 6 090 44625 16.0 6 090 44626 28.6 6 090 44640 14.3 6 090 44650 15.4 6 090 44660 15.4 6 090 44661 24.2 6 090 44680 19.8 6 090 44800 13.8 6 090 44820 11.5 6 090 44850 12.1 6 090 44900 11.5 6 090 44950 11.5 6 090 44960 12.7 6 090 45020 5.4 5 090 45170 3.6 5 090 46200 4.4 5 090 46210 1.8 5 090 46285 2.4 5 090 46288 12.6 5 090 47010 17.6 7 090 47015 15.4 7 090 47100 11.5 7 090 47120 33.4 13 090 47122 44.9 13 090 47125 44.9 13 090 47130 44.9 13 090 47135 180.0 30 090 47136 156.0 30 090 47400 24.2 7 090 47420 21.9 7 090 47425 25.9 7 090 47460 24.2 7 090 47480 14.4 7 090 47510 8.1 4 090 47600 16.3 7 090 47605 18.4 7 090 47610 23.0 7 090 47612 24.2 7 090 47620 25.3 7 090 47700 20.7 7 090 47701 48.3 7 090 47711 27.5 7 090 47712 38.5 7 090 47715 22.0 7 090 47716 18.7 7 090 47720 16.5 7 090 47721 20.9 7 090 47740 18.7 7 090 47741 27.5 7 090 47760 23.1 7 090 47765 22.0 7 090 47780 26.4 7 090 47785 39.6 7 090 47800 24.2 7 090 47801 12.1 7 090 47802 19.8 7 090 47900 25.3 7 090 48000 18.7 7 090 48001 20.9 7 090 48005 18.7 7 090 48020 22.0 7 090 48100 16.5 7 090 48120 19.3 7 090 48140 22.0 8 090 48145 26.4 8 090 48146 33.0 8 090 48148 19.8 7 090 48150 38.5 8 090 48152 36.3 8 090 48153 38.5 8 090 48154 36.3 8 090 48155 26.4 8 090 48180 27.5 7 090 48500 16.5 7 090 48510 22.0 7 090 48520 18.7 7 090 48540 22.0 7 090 48545 20.4 7 090 48547 28.1 7 090 49200 15.4 6 090 49201 23.1 6 090 49215 18.2 10 090 49220 24.2 7 090 49250 8.8 6 090 49255 11.0 7 090 49425 15.0 7 090 49426 24.0 7 090 49505 9.8 4 090 49507 13.0 4 090 49520 12.7 4 090 49521 15.9 4 090 49525 10.4 4 090 49540 11.8 6 090 49550 10.2 4 090 49553 13.5 4 090 49555 12.1 4 090 49557 15.3 4 090 49560 13.2 6 090 49561 16.4 6 090 49565 15.0 6 090 49566 18.2 6 090 49570 4.6 4 090 49572 7.8 4 090 49580 8.1 4 090 49582 11.3 4 090 49585 9.2 4 090 49587 12.4 4 090 49590 10.4 4 090 49600 12.1 7 090 49605 29.9 7 090 49606 24.2 7 090 49610 13.2 7 090 49611 13.2 7 090 49900 7.4 6 090 50205 9.6 7 090 51580 42.7 8 090 52700 8.8 3 090 53010 7.2 3 090 53040 3.6 3 090 53210 15.4 3 090 53215 20.1 3 090 53220 11.0 3 090 53230 14.3 3 090 53235 14.3 3 090 53400 11.0 3 090 53405 16.0 3 090 53410 17.6 3 090 53415 26.4 3 090 53420 22.0 3 090 53442 5.5 3 090 53450 4.8 3 090 53460 6.0 3 090 53502 12.2 3 090 53505 12.2 3 090 54110 10.0 3 090 54111 22.2 3 090 54112 24.6 3 090 54115 6.6 3 090 54120 12.0 3 090 54300 9.6 3 090 54380 9.6 3 090 54385 12.0 3 090 54390 12.0 6 090 54400 14.4 4 090 54401 16.8 4 090 54420 15.0 3 090 54430 15.0 3 090 54435 3.6 3 090 54520 7.6 3 090 54530 11.4 4 090 54535 14.4 6 090 54550 10.0 4 090 54560 13.8 6 090 54640 13.2 4 090 54660 4.6 3 090 54670 9.2 3 090 54680 11.5 3 090 54820 6.7 3 090 54830 7.2 3 090 54840 9.2 3 090 54860 9.2 3 090 54861 13.8 3 090 55040 9.2 3 090 55041 13.8 3 090 55060 7.0 3 090 55150 3.6 3 090 55175 9.6 3 090 55180 14.4 3 090 55200 4.3 3 090 55250 5.4 3 090 55530 9.2 3 090 55535 10.9 6 090 55540 10.9 4 090 55600 7.7 6 090 55650 23.0 6 090 55680 23.0 6 090 55620 12.1 4 090 56625 17.1 4 090 57010 6.6 4 090 57120 13.5 4 090 57240 9.5 4 090 57250 8.8 4 090 57260 14.3 4 090 57265 16.0 4 090 57268 11.0 4 090 57270 13.8 6 090 57280 15.4 6 090 57282 15.4 6 090 57289 13.8 4 090 57330 18.7 6 090 57520 5.8 3 090 57522 5.2 3 090 57530 5.8 3 090 57540 13.8 6 090 57545 17.3 6 090 57550 13.8 6 090 57555 17.3 6 090 57556 17.3 6 090 57700 10.9 4 090 57720 5.8 4 090 58140 13.8 6 090 58150 19.6 6 090 58152 26.5 6 090 58180 17.3 6 090 58260 21.9 6 090 58262 23.0 6 090 58263 25.3 6 090 58267 25.3 6 090 58270 23.0 6 090 58275 23.0 6 090 58280 23.0 6 090 58400 13.9 6 090 58410 19.0 6 090 58520 12.7 6 090 58540 20.7 6 090 58600 11.5 6 090 58605 8.6 6 090 58740 19.0 6 090 58750 24.2 6 090 58752 19.0 6 090 58760 19.6 6 090 58770 19.6 6 090 58805 13.8 6 090 58822 11.5 6 090 58825 13.8 6 090 58900 12.1 6 090 58920 12.7 6 090 58925 12.7 6 090 58940 12.7 6 090 58943 23.0 6 090 58950 17.6 6 090 58951 27.5 8 090 58952 25.9 8 090 59100 18.4 6 090 59120 16.1 6 090 59121 16.1 6 090 59130 16.7 6 090 59135 20.1 6 090 59136 23.0 6 090 59140 16.1 3 090 59150 12.7 6 090 59151 20.7 6 090 59870 6.0 3 090 60200 12.0 6 090 60210 15.0 6 090 60212 21.0 6 090 60220 18.4 6 090 60225 21.6 6 090 60240 25.2 6 090 60252 31.2 6 090 60254 34.8 6 090 60260 20.4 6 090 60270 27.6 13 090 60280 14.4 6 090 60281 14.4 6 090 60500 21.0 6 090 60502 20.7 6 090 60505 27.6 13 090 60540 23.4 10 090 60545 27.0 10 090 60600 24.0 6 090 60605 29.4 10 090 61120 12.0 9 090 61140 26.4 9 090 61150 26.4 9 090 61151 27.0 9 090 64732 8.4 5 090 64734 8.4 5 090 64736 12.0 5 090 64738 12.0 5 090 64740 6.0 5 090 64742 12.0 5 090 64744 9.0 5 090 64746 6.0 5 090 64752 16.7 13 090 64755 25.3 7 090 64760 16.1 7 090 64761 5.8 3 090 64763 6.9 3 090 64766 11.5 4 090 64771 13.2 11 090 64772 7.2 10 090 64774 4.8 5 090 64776 4.8 3 090 64782 7.2 3 090 64784 10.8 4 090 64786 12.6 4 090 64788 7.6 5 090 64790 9.9 5 090 64792 12.1 5 090 64802 16.0 10 090 64804 22.0 10 090 64809 22.0 13 090 64818 13.2 7 090 65091 12.0 5 090 65093 15.0 5 090 65101 15.0 5 090 65103 16.8 5 090 65105 20.4 5 090 65110 24.0 5 090 65112 27.0 5 090 65114 31.2 5 090 65125 7.2 5 090 65130 13.8 5 090 65135 15.0 5 090 65140 18.0 5 090 65150 13.2 5 090 65155 14.4 5 090 65175 9.0 5 090 65235 17.3 5 090 65260 23.0 5 090 65265 23.0 5 090 65275 8.6 5 090 65280 15.4 5 090 65285 16.5 5 090 65286 12.0 5 090 65290 12.0 5 090 65400 9.6 5 090 65420 6.0 5 090 65426 8.4 5 090 65600 7.2 5 090 65820 12.6 4 090 65850 18.4 5 090 65860 5.9 5 090 65865 12.6 5 090 65870 11.4 5 090 65875 12.0 5 090 65880 12.6 5 090 65900 15.6 5 090 65920 24.0 5 090 65930 12.0 5 090 66130 4.6 5 090 66150 16.7 5 090 66155 16.1 5 090 66160 16.1 5 090 66165 17.3 5 090 66170 17.3 5 090 66172 20.7 5 090 66180 16.7 5 090 66185 12.1 5 090 66500 8.4 5 090 66505 8.4 5 090 66600 16.1 6 090 66605 25.3 6 090 66625 11.5 6 090 66630 11.5 6 090 66635 11.5 6 090 66680 13.8 5 090 66682 17.3 5 090 66700 10.4 5 090 66710 10.4 5 090 66720 10.4 5 090 66740 10.4 5 090 66761 11.5 6 090 66762 7.2 6 090 66770 9.0 5 090 66820 6.3 6 090 66821 6.3 6 090 66825 12.9 6 090 67015 12.1 6 090 64725 12.1 6 090 67027 5.5 6 090 67030 17.3 6 090 67031 12.7 6 090 67036 38.5 6 090 67038 44.0 6 090 67039 35.2 6 090 67040 37.4 6 090 67115 10.8 5 090 67120 10.8 5 090 67121 14.4 6 090 67141 10.8 6 090 67145 14.4 6 090 67311 18.0 5 090 67312 21.6 5 090 67314 18.0 5 090 67316 22.8 5 090 67318 19.2 5 090 67343 17.4 5 090 67400 16.8 5 090 67405 16.8 5 090 67412 22.0 5 090 67413 24.0 5 090 67414 25.2 5 090 67420 27.6 5 090 67430 25.2 5 090 67440 24.0 5 090 67445 26.4 5 090 67450 24.0 5 090 67550 14.4 5 090 67560 12.0 5 090 67570 10.8 5 090 67835 15.6 5 090 67880 5.4 5 090 67882 7.8 5 090 67900 6.8 5 090 67901 15.4 5 090 67902 17.6 5 090 67903 18.7 5 090 67904 18.7 5 090 67906 17.6 5 090 67908 14.4 5 090 67909 14.4 5 090 67911 21.6 5 090 67916 10.8 5 090 67917 14.4 5 090 67923 10.8 5 090 67924 13.8 5 090 67935 9.6 5 090 67950 13.8 5 090 67961 16.0 5 090 67966 17.6 5 090 67971 18.7 5 090 67973 19.8 5 090 67974 22.0 5 090 67975 8.8 5 090 68320 15.6 5 090 68325 16.8 5 090 68326 16.8 5 090 68328 19.2 5 090 68330 12.0 5 090 68335 16.8 5 090 68360 7.2 5 090 68362 13.2 5 090 68500 14.4 5 090 68505 13.8 5 090 68520 15.0 5 090 68540 17.3 5 090 68550 19.6 5 090 68700 14.4 5 090 68720 16.5 5 090 68770 9.0 5 090 69110 7.2 5 090 69440 13.2 5 090 69450 13.8 5 090

4. Radiology Section: (Codes range from 70010 – 79999) a. General

1) The cost of dyes and contrast shall be reimbursed at 80 percent of billed charges.

2) Copying charges for X–Rays and MRIs shall be $15.00/film regardless of the size of the film. b. Modifiers

1) The five–digit CPT code without a modifier indicates the provider performed both the professional and technical components of the radiological procedure.

2) If the provider supplies only the professional component, as defined in the “Radiology Guidelines section of the RVP,” then the five–digit CPT code must carry a modifier —26.

3) Modifier —27 is not recognized for the technical component of a radiological procedure. If the provider supplies only the technical component, as defined in the Radiology Guidelines section of the RVP, the five–digit CPT code must carry a modifier TC.

1) The physician supervising and interpreting the thermographic evaluation shall follow recognized protocols and be board certified by the examining board of one of the following national organizations:

American Academy of Medical Infrared Imaging;

American Academy of Thermology;

American Chiropractic College of Thermology;

American Chiropractic Association.

2) Indications for thermographic evaluation must be one of the following:

Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy (CRPS/RSD);

Sympathetically Maintained Pain (SMP);

Autonomic neuropathy;

Chronic Neuropathic Pain (involving small caliber sensory fiber neuropathy).

3) Protocol for stress testing is outlined in the Medical Treatment Guidelines found in Rule XVII. 4) Thermography Billing Codes:

79993 Upper body w/ Autonomic Stress Testing $800.00

79995 Lower body w/Autonomic Stress Testing $800.00

79997 Whole Body w/Autonomic Stress Testing $1,200.00

When whole body thermography is performed, only “whole body” billing codes can be used; do not use separate upper and lower body billing codes and fees.

5) Prior authorization for payment is required for thermography services only if the requested study does not meet the indicators for thermography as outlined in this radiology section. The billing shall include a report supplying the thermographic evaluation and reflecting compliance with this Rule XVIII.E.4.c.

5. Pathology Section: (Codes range from 80002 – 89399) a. Modifiers

1) The five digit CPT code without a modifier indicates the provider performed both the professional and technical components of the pathological procedure.

2) If the provider supplies only the professional component, as defined in the Pathology Guidelines section of the RVP, then the five digit CPT code must carry a modifier —26.

3) Modifier —27 is not recognized for the technical component of a pathology procedure. If the provider supplies only the technical component, as defined in the Pathology Guidelines section of the RVP, the five–digit CPT code must carry a modifier –TC.

6. Medicine Section: (Codes range from 90281 – 96999 and 98925 – 99199) a. Biofeedback (Codes: 90901, 90911)

Prior authorization for payment shall be required from the payer after 12 visits. A licensed physician or psychologist shall prescribe all services and include the number of sessions. Session notes shall be periodically reviewed by the prescribing physician to determine the continued need for the service. All services shall be provided or directly supervised by a recognized provider as listed under Rule XVI.E. Persons providing biofeedback shall be certified by the Biofeedback Certification Institution of America, or be a licensed physician or psychologist, as listed under Rule XVI.E.1.a.1) and 2) with evidence of equivalent biofeedback training. b. Osteopathic (DO) and Medical (MD) Manipulation: (Codes range from 98925 – 98929)

Evaluation and Management (E&M) services can be billed separately when the provider's records document significant and identifiable services that are above and beyond the usual services required to perform manipulation. A modifier —25 on the E&M Service is required when manipulation is also billed at the same visit for the same patient.

Prior authorization from the payer shall be obtained before billing for more than four body regions in one visit. Manipulative therapy is limited to no more than 34 visits. The provider's medical records shall reflect medical necessity and prior authorization for payment if treatment needs to exceed 34 visits.

For purposes of DO and MD manipulation, Body regions referred to are: head region; cervical region; thoracic region; lumbar region; sacral region; pelvic region; lower extremities; upper extremities; rib cage region; abdomen and viscera region. c. Chiropractic (DC) Manipulation: (Codes range from 98940 – 98943)

E&M services can be billed separately when the provider's records document significant and identifiable services that are above and beyond the services required to perform manipulation. A modifier —25 on the E&M Service is required when manipulation is also billed at the same visit for the same patient.

For purposes of DC manipulation, the five spinal regions referred to are: cervical regions (includes atlanto-occipital joint); thoracic region (includes costovertebral and costotransverse joints); lumbar region; sacral region; and pelvic (sacro-iliac joint) region. The five extraspinal regions referred to are: head region (including temporomandibular joint, excluding atlanto-occipital); lower extremities; upper extremities; rib cage (excluding costotransvers and costovertebral joints) and abdomen. d. Psychiatric/Psychological Services: (Codes range from 90801-90899 and 96100-96117)

1) A licensed clinical psychologist is reimbursed a maximum of 90 percent of the medical fee listed in the RVP. Other non-physician providers performing psychological/psychiatric services shall be paid at 75 percent of the fee allowed for physicians.

2) Most initial evaluations for delayed recovery can be completed in two (2) hours. Prior authorization for payment is required any time the following limitations are exceeded: Evaluation Code: 90801-90802 limit: 4 hours Testing Code: 96100-96117 limit: 6 hours Psychotherapy Codes: 90804-90829 maximum allowance of 50 minutes per visit.

Psychotherapy for work-related conditions requiring more than 20 visits or continuing for more than three (3) months after the initiation of therapy, whichever comes first, requires prior authorization from the payer. e. Hyperbaric Oxygen Therapy Services (Code 99183)

The maximum unit value shall be 24 units, instead of 14 units as listed in the RVP for code 99183.

7. Physical Medicine and Rehabilitation: (Codes range from 97001 — 97799)

Restorative services are an integral part of the healing process for a variety of injured workers. a. Recommendations

For recommendations on the use of the physical medicine and rehabilitation procedures, modalities, and testing, see Rule XVII, Medical Treatment Guidelines exhibits. b. Special Note to All Physical Medicine and Rehabilitation Providers Prior authorization shall be obtained from the payer for any physical medicine treatment exceeding the recommendations of the Medical Treatment Guidelines as set forth in Rule XVII.

For condition(s) not covered under the Medical Treatment Guidelines, the injured worker shall be re- evaluated by the prescribing physician within thirty (30) calendar days from the initiation of the prescribed treatment. Prior authorization for payment shall be required for treatment of a condition not covered under the Medical Treatment Guidelines and exceeding sixty (60) days from the initiation of treatment. c. Interdisciplinary Rehabilitation Programs — (Requires prior authorization)

An Interdisciplinary Rehabilitation Program is one that provides focused, coordinated, and goal-oriented services using a team of professionals from varying disciplines to deliver care. These programs can benefit persons who have limitations that interfere with their physical, psychological, social, and/or vocational functioning. As defined in Rule XVII, rehabilitation programs may include, but are not limited to: Chronic Pain, Spinal Cord, or Brain Injury programs.

Billing Restrictions: The billing provider shall detail to the payer the services, frequency of services, duration of the program and their proposed fees for the entire program, inclusive for all professionals. The billing provider and payer shall attempt to mutually agree upon billing code(s) and fee(s) for each Interdisciplinary Rehabilitation Program. d. Procedures 97110 — 97542

Unless The Provider's medical records reflect medical necessity and the provider obtains prior authorization for payment from the payer to exceed the one hour limitation, the maximum amount of time allowed is one hour of procedures per day, per discipline. e. Modalities

Codes 97010 — 97028, unattended

Codes 97032 — 97039, attended

Billing Restrictions: There is a total limit of two (2) modalities (whether attended or unattended) per visit per discipline.

NOTE: Instruction and application of a TENS unit for the patient's independent use shall be billed using attended therapy 97032. f. Evaluation Services for Therapists: Physical Therapy (PT), and Occupational Therapy (OT) [97001 — 97004]

1) Before the initial or re-evaluation services are reimbursable, the medical record shall specify the appropriate history, physical examination, treatment plan or evaluation of the treatment plan

2) Payers are only required to pay for evaluation services, directly performed by a physical therapist (97001-97002) or occupational therapist (97003-97004). All evaluation notes or reports must be written and signed by the PT, OT. Physicians shall bill the appropriate E&M code from the E&M section (99201-99499) of the RVP

3) A patient may be seen by more than one health care professional on the same day. An evaluation service may be charged for each professional per patient per day.

4) Reimbursement to physical therapists, occupational therapists, speech language pathologists and audiologists for coordination of care with professionals shall be based upon codes 99371-99373. Coordination of care reimbursement is limited to telephone calls made to professionals outside of the therapist's/pathologist's/audiologist's employment facility(ies) and/or to the injured worker or their family and the prescribing physician.

5) All interdisciplinary team conferences shall be billed under the case management services section in the RVP using codes 99361 or 99362. g. Special Tests

The following codes should be used for the respective tests: 97537 Job Site Evaluation 97750 Computer– Enhanced Evaluation Functional Capacity Evaluation Work Tolerance Screening 96105 – 96115 Speech

1) Billing Restrictions:

(a) 97537 requires prior authorization if exceeding 2 hours. 97750 requires prior authorization for payment for more than 4 hours.

(b) The provider shall specify the time required to perform the test in 15-minute increments.

(d) No E&M services or PT, OT, or acupuncture evaluations shall be charged separately for these tests.

(e) Reports from computerized equipment include a supporting analysis developed by the physical medicine professional performing the evaluation.

2) Provider Restrictions: all special tests must be fully supervised by a physician, a physical therapist, an occupational therapist a speech language pathologist/therapist or audiologist. Final reports must be written and signed by the physician, the physical therapist, the occupational therapist, the speech language pathologist/therapist or the audiologist. h. Speech Therapy/Evaluation and Treatment

Reimbursement shall be according to the unit values as listed in the RVP multiplied by their section's respective conversion factor. i. Supplies

See Rule XVIII.F.8 j. Unattended Treatment

When a patient uses a facility or its equipment but is performing unattended procedures, in either an individual or group setting, bill:

97152 fixed fee per day 1.5 RVU k. Non-Medical Facility

Fees, such as gyms, pools, etc., and training or supervision by non-medical providers require prior authorization from the payer and a written negotiated fee. l. Unlisted Service Physical Medicine

All unlisted services or procedures require a report. m. Work Conditioning, Work Hardening, Work Simulation

1) Work conditioning is a non-interdisciplinary program that is focused on the individual needs of the patient to return to work. Usually one discipline oversees the patients in meeting goals to return to work. Refer to Rule XVII, Medical Treatment Guidelines.

Restriction: Maximum daily time is two (2) hours per day without additional prior authorization.

2) Work Hardening is an interdisciplinary program that uses a team of disciplines to meet the goal of employability and return to work. This type of program entails a progressive increase in the number of hours a day that an individual completes work tasks until they can tolerate a full workday. In order to do this, the program must address the medical, psychological, behavioral, physical, functional and vocational components of employability and return to work. Refer to Rule XVII, Medical Treatment Guidelines.

Restriction: Maximum daily time is six (6) hours per day without additional prior authorization.

3) Work Simulation is a program where an individual completes specific work-related tasks for a particular job and return to work. Use of this program is appropriate when modified duty can only be partially accommodated in the work place, when modified duty in the work place is unavailable, or when the patient requires more structured supervision. The need for work simulation should be based upon the results of a functional capacity evaluation and/or job analysis. Refer to rule XVII, Medical Treatment Guidelines.

4) For Work Conditioning, Work Hardening, or Work Simulation, the following apply.

(a) Prior authorization is required.

(b) Provider Restrictions: All procedures must be performed by or under the onsite supervision of a physician, physical therapist, occupational therapist, speech language pathologist or audiologist.

8. Evaluation and Management Section (Codes range from 99201 — 99499) a. Section Conversion Factor

The E&M conversion factor shall be used for this section to calculate the maximum dollar reimbursement for each procedure. b. E&M Service Medical Record Documentation to Determine Correct Billing/Reimbursement Code

Medical record documentation shall encompass the RVP E&M Guideline criteria to justify the billed Evaluation and Management service. If 50 percent of the time spent with an injured worker during an E&M visit is disability counseling, then time can determine the level of E&M service.

Disability counseling should be an integral part of managing workers' compensation injuries. The counseling shall be completely documented in the medical records, including, but not limited to, the amount of time spent with the injured worker. Disability counseling shall include, but not be limited to, return to work, temporary and permanent work restrictions, self management of symptoms while working, correct posture/mechanics to perform work functions, job task exercises for muscle strengthening and stretching, and appropriate tools and equipment use to prevent re-injury and/or worsening of the existing injury. c. New or Established Patients

An E&M visit shall be billed as a “new” patient service for each “new injury” even though the provider has seen the patient within the last three years. Any subsequent E&M visits are to be billed as an “established patient” and reflect the level of service indicated by the documentation when addressing all of the current injuries. d. Number of Office Visits

The billing provider is limited to one office visit per patient per day, including injured workers who have multiple injuries, unless prior authorization is obtained from the payer. The E&M Guideline criteria as specified in the RVP E&M Section shall be used in all office visits to determine the appropriate level. e. Case Management

1) Case management codes 99361 – 99373 found in the Evaluation and Management Section of the RVP may be billed if the services are performed on a separate day from an E&M office visit and when the medical records/documentation specifies all the following:

(a) the amount of time and date;

(b) the person or person(s) talked to; and

2) An interdisciplinary team conference, consisting of medical professionals caring for the injured worker, shall select a team member to perform the following duties:

(a) Prepare the billing statement in accordance with Rule XVI, Utilization Standards,

(i) One conference charge per facility per patient per day.

(ii) Reimbursement for each interdisciplinary team conference shall be determined in 15- minute increments. Fifteen-minute conferences shall be reimbursed using code 99361 reducing the maximum allowance to 50 percent of the total value of the code.

(b) Prepare and submit a written report for each conference including at least the following information:

(i) Patient's identifying information;

(ii) Diagnosis;

(iii) Medical professionals attending the conference; (iv) A brief statement of conference recommendations and actions (no additional allowance shall be made for this statement); and

(v) Length of time of meeting.

F. DIVISION ESTABLISHED CODES AND VALUES

1. Conferences Held at the Request of a Party

Telephonic or face-to-face conferences shall be related to the injured worker's treatment. All parties shall receive actual notification from the requesting party in advance and within 24 hours of scheduling.

99901 Maximum of $225.00 per hour;

billed at $56.25 per 15-minute increments.

2. Cancellation Fees For Payer Made Appointments a. A cancellation fee is payable only when a payer schedules an appointment the injured worker fails to keep, and the payer has not canceled three (3) business days prior to the appointment. The payer shall pay:

One-half of the usual fee for the scheduled services, or

$150.00, whichever is less.

Cancellation Fee Billing Code: 99910 b. Missed Appointments:

When claimants fail to keep scheduled appointments, the provider should contact the payer within two (2) business days. Upon reporting the missed appointment, the provider may request whether the payer wishes to reschedule the appointment for the claimant. If the claimant fails to keep the payer's rescheduled appointment, the provider may bill for a cancellation fee according to this Rule XVIII.F.2.

3. Copying Fees

The payer, payer's representative, injured worker and injured worker's representative shall pay a reasonable fee for the reproduction of the injured worker's medical record. Reasonable cost shall not exceed $14.00 for the first 10 or fewer pages, $0.50 per page for pages 11-40, and $0.33 per page thereafter. Actual postage or shipping costs and applicable sales tax, if any, also may be charged. The per-page fee for records copied from microfilm shall be $1.50 per page.

Copying Fee Billing Code: 99911

4. Deposition and Testimony Fees a. When requesting deposition or testimony from physicians or any other type of provider, guidance should be obtained from the Interprofessional Code, as prepared by the Colorado Bar Association, the Denver Bar Association, the Colorado Medical Society and the Denver Medical Society. If the parties cannot agree upon fees for the deposition or testimony services, or cancellation time frames and/or fees, the following Deposition and Testimony rules and fees shall be used: b. Deposition:

Payment for a physician's testimony at a deposition shall not exceed 35 RVU per hour times the medicine conversion factor ($7.16) billed in 0.5-hour increments. Calculation of the physician's time shall be “portal to portal.”

The physician may request a full hour deposit in advance in order to schedule the deposition.

By prior agreement with the deposing party, the physician may charge for preparation time or for reviewing and signing the deposition.

The physician shall refund to the deposing party, any portion of an advance payment in excess of time actually spent preparing and/or testifying when the physician is notified of the cancellation of the deposition at least three (3) business days prior to the scheduled deposition.

However, if the provider is not notified at least three (3) business days in advance of a cancellation, or the deposition is shorter than the time scheduled, the provider shall be paid the number of hours he or she has reasonably spent in preparation and has scheduled for the deposition.

Deposition Billing Code: 99075 at 35 units per hr. c. Testimony:

Calculation of the physician's time shall be “portal to portal.”

For testifying at a hearing, the physician may request a four (4) hour deposit in advance in order to schedule the testimony.

By prior agreement, the physician may charge for preparation time for testimony.

The physician shall refund any portion of an advance payment in excess of time actually spent preparing and/or testifying when the physician is notified of the cancellation of the hearing at least five (5) business days prior to the date of the hearing.

However, if the provider is not notified of a cancellation at least five (5) business days prior to the date of the hearing, or the hearing is shorter than the time scheduled, the provider shall be paid the number of hours he or she has reasonably spent in preparation and has scheduled for the hearing.

Testimony Billing Code: 99085

Maximum Rate of $400.00 per hour

5. Mileage Expenses

The payer shall reimburse an injured worker for reasonable and necessary mileage expenses for travel to and from medical appointments. The reimbursement rate shall be 30 cents per mile. The injured worker shall submit a statement to the payer showing the date(s) of travel and number of miles traveled, with receipts for any other reasonable and necessary travel expenses incurred.

Mileage Expense Billing Code: 99912

6. Permanent Impairment Rating a. The payer is only required to pay for one combined whole-person permanent impairment rating per claim, except as otherwise provided in these Workers' Compensation Rules of Procedures. The authorized treating provider is required to submit in writing all permanent restrictions and future maintenance care related to the injury or occupational disease. b. Provider Restrictions

The permanent, impairment rating shall be determined by the authorized treating physician, if Level II accredited, or by a Level II accredited physician selected by the authorized treating provider. c. Maximum Medical Improvement (MMI) Determined Without any Permanent Impairment

When physicians determine the injured worker is at MMI and has no permanent impairment, the physicians should be reimbursed an appropriate level of E&M service and the fee for completing the Physician's Report of Workers' Compensation Injury (Closing Report), WC164 (See Rule XVIII F.7.b.). Reimbursement for the appropriate level of E&M service is only applicable if the physician examines the injured worker and meets the criteria as defined in the RVP. d. MMI Determined with a Calculated Permanent Impairment Rating

1) Calculated Impairment: The total fee includes the office visit, a complete physical examination, complete history, review of all medical records, determining MMI, completing all required measurements, referencing all tables used to determine the rating, using all report forms from the AMA's Guide to the Evaluation of Permanent Impairment, Third Edition (Revised), (AMA Guides), and completing the Division form, titled “Physician's Report of Workers Compensation Injury (Closing Report)” (Form WC164).

2) Billing Codes and Reimbursement for MMI with a Calculated Permanent Impairment Rating:

(a) Fee for the Level II Accredited Authorized Treating Physician Providing Primary Care:

99455 Reimbursed for 1.5 hours with a maximum not to exceed $293.28.

(b) Fee for the Referral, Level II Accredited Authorized Physician:

99456 Reimbursed for 2.5 hours with a maximum not to exceed $564.00.

All physicians providing consulting services for the completion of a whole person impairment rating shall bill using the appropriate E&M consultation code and shall forward their portion of the rating to the authorized physician determining the combined whole person rating.

7. Report Preparation a. Routine Reports

Completion of routine reports or records are incorporated in all fees for service and include:

Diagnostic Testing Procedure Reports Progress notes Office notes Operative reports Supply invoices, if requested by the payer

Requests for second copies of routine reports are reimbursable under the copying fee section of this Rule XVIII. b. Completion of WC164 Form

1) Initial Report

The completed “Physician's Report of Workers' Compensation Injury” (WC164) initial report, is submitted to the payer after the first visit with the injured worker.

2) Closing Report

The “Physician's Report of Workers' Compensation Injury” (WC164) closing report, is required from the authorized treating physician when an injured worker is at maximum medical improvement and/or has a permanent impairment. A physician may bill for the completion of the WC164 if neither code 99455 nor 99456 (see Rule XVIII.F.6.d.) are billed.

3) Payer Requested WC164 Form

If the payer requests the provider to complete the WC164 report, the payer shall pay the provider for the completion and submission of the WC164 form.

4) Provider Initiated WC164 Form

If the provider wants to use the WC164 Form as a progress report or for any purpose other than those designated here in Rule XVIII.F.7.b.1), 2) or 3), and seeks reimbursement for completion of the form, the provider shall get prior approval from the payer.

5) Billing Codes and Maximum Allowance for completion and submission of WC164 Form

Maximum allowance for the completion and submission of the WC164 form is: 99960 $42.00 Initial Report 99961 $42.00 Progress Report (Payer Requested or Provider Initiated) 99962 $42.00 Closing Report 99963 $42.00 Initial report including closing report on the same date of service c. Special Reports

The term special reports includes reports falling outside the requirements set forth in Rule XVI, Utilization Standards, Rule XVII, Medical Treatment Guidelines and this Rule XVIII and includes any form, questionnaire or letter with variable content. Reimbursement for preparation of special reports or records shall require prior agreement with the requesting party. In special circumstances (e.g., when reviewing and/or editing is necessary) and when prior agreement is made with the requesting party, institutions, clinics or physicians' offices may charge additional sums.

Special Report Preparation Billing Code:

99080 not to exceed $225.00-per hour. Billed in half hour increments.

Because narrative reports may have variable content, the content and total payment shall be agreed upon by the provider and the report's requester before the provider begins the report.

8. Supplies, Durable Medical Equipment (DME), Orthotics and Prosthesis a. Payment for supplies shall reflect actual cost plus a 20 percent markup. Cost includes shipping and handling charges. b. Reimbursement for DMEs, orthotic and prosthetic devices may be based upon an appropriate Medicare HCPC Level II Code as a reasonable means for determining a fee unless Medicare fees do not meet the provider's cost in which case the reimbursement would be cost plus 20 percent. c. Any single supply, durable medical equipment (DME), orthotic, prosthesis, or implantable device exceeding a billed amount of $500.00 per item shall have a maximum allowance of actual cost plus 20 percent. d. Payment for professional services associated with the fabrication and/or modification of orthotics, custom splints, adaptive equipment, and/or adaptation and programming of communication systems and devices shall be paid in accordance with the provisions outlined in the “Physical Medicine and Rehabilitation” section of the RVP.

Supplies Billing Code: 99070

9. In-Patient Hospital Services a. Provider Restrictions

Determination of in-patient status shall be made by applying the Medicare Diagnostic Related Group (DRG) classification system, medical or surgical, to the discharge diagnosis.

The Medicare DRG Classification System, hereby incorporated by reference, is published in THE FEDERAL REGISTER, VOLUME 65, NUMBER 148, PAGE 47160 (August 1, 2000), and is also available on the U.S. Government website (U.S. Department of Health of Human Services) at www.access.gpo.gov (accessed June 3, 2003). The incorporation is limited to the edition named and does not include later revisions or additions. Copies of the material incorporated by reference may be inspected at any state publications depository library. For information about inspecting or obtaining copies of the incorporated material, contact the Medical Fee Schedule Administrator, 1515 Arapahoe, Tower 2, Suite 610, Denver, Colorado 80202-2117.

The hospital shall indicate the DRG code number in the remarks section (form locator 78) of the UB-92 billing form and maintain documentation on file showing how the DRG was determined. The attending physician shall not be required to certify this documentation unless a dispute arises between the hospital and the payer regarding DRG assignment. b. Bills for Services

Required Billing Form – See Rule XVI.G, Utilization Standards.

All services billed on the UB-92 do not require itemization but do require summary level billing by revenue code. Providers may be required to submit itemized bills along with the UB-92 when requested to do so by the insurer. In calculating the length of stay, do not count the discharge day.

Non-emergency, in-patient admissions require prior authorization for payment. c. In-Patient Billing Per Diem Billing Rates:

Acute Care Hospital 99940 Medical DRG $1,281.28 per day 99941 Surgical DRG $2,329.60 per day

Per diem includes all charges made by the hospital except for television, long distance telephone and personal item charges; these are the responsibility of the injured worker when agreed to in writing at the time of admission. d. Exceptions to Per Diem System

Hospitals shall be paid 80 percent of billed charges:

1) When the hospital charges for a medical DRG exceed the following medical per diem amount (it includes a 3.0 outlier factor):

99950 – $3,843.84 per day

2) When the hospital charges for a surgical DRG exceed the following surgical per diem amount (it includes a 3.0 outlier):

99951– $6,988.80 per day

3) 99952 When the length-of-stay is no more than two (2) days

4) 99953 When the services are provided by a psychiatric unit of an acute care hospital, or

5) 99954 When the services are provided by a free-standing psychiatric hospital (licensed), or

6) 99955 When the services are provided by a free-standing rehabilitation hospital (licensed).

It shall be the responsibility of the hospital to notify the payer these exceptions to the per diem system are being applied. Such notification shall be sent with the discharge billing. e. Agreements

Nothing in this section precludes the payer from entering into payment agreements for lower reimbursement rates with hospitals to promote the continuity of care and the reduction of hospital costs. f. Bill Review

Nothing in this rule precludes the payer's right to review the hospital bill. g. Supplies and Implantable Hardware

1) Any single supply, durable medical equipment (DME), orthotic, prosthesis, or implantable device (“supply et al.”) exceeding a billed amount of $500.00 per item shall have a separate maximum allowance of actual cost plus 20 percent. See Rule XVIII F.8.b. for DME, orthotics, and prosthetic devices.

2) To determine the remaining inpatient maximum allowance, the amount billed for the “supply et al.” is subtracted from the total billed charges. Then, the actual cost plus 20 percent is added back into the balance of the billed charges to determine whether the per diem amount or 80 percent of billed charges is the maximum allowance for the remaining billed charges of the inpatient hospital bill. For total payment to be made in a timely manner, the provider should send a copy of the “supply et al.” invoivce with the initial bill.

3) The total maximum allowance for the inpatient, billed charges is the sum of the allowance for the “supply et al.” plus the per diem or 80 percent of the remaining billed charges.

10. Outpatient Facility Services a. Provider Restrictions

All non-emergency, outpatient surgery requires prior authorization for payment by the payer. All professional charges are subject to the RVP and Dental Fee Schedule as incorporated in this Rule XVIII. Outpatient facility fees are only reimbursable if the facility is credentialed at the appropriate level for the service provided. Such credentials include:

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation for hospitals; or

Colorado Department of Public Health and Environment licensure as an ambulatory surgery center; or

The facility has the same or equivalent level of safety, monitoring and quality of care as the JCAHO or Colorado Department of Public Health and Environment licensure requires and has documented use showing these processes and procedures are in practice.

In all other cases, a facility fee is not reimbursable without prior agreement of the payer regardless of location of service. b. Bills for Services:

A qualifying “outpatient facility” shall use the CMS 1500 (formerly HCFA 1500) for professional services and the UB-92 billing form for facility services. Outpatient hospital services are to be billed on the UB-92 and the following revenue codes require CPT coding:

30X — Laboratory

31X — Laboratory, Pathological

32X — Radiology, Diagnostic

33X — Radiology – Therapeutic

34X — Nuclear Medicine

35X — CT Scan

40X — Other Imaging Services

42X — Physical Therapy

43X — Occupational Therapy 44X — Speech Language Pathology

51X — Clinic

52X — Freestanding Clinic

53X — Osteopathic Services

57X — Home Health — Home Health Aide

58X — Home Health — Other Visits

59X — Home Health — Units of Service

61X — Magnetic Resonance Technology (MRI)

64X — Home IV Therapy Services

73X — EKG/ECGT

74X — EEG

90X — Psychiatric/Psychological Treatments

91X — Psychiatric/Psychological Services

92X — Other Diagnostic Services

94X — Other Therapeutic Services

96X — Professional Fees

97X — Professional Fees

98X — Professional Fees c. Billing Restrictions

1) Examples of reimbursable facility fees, such as but not limited to:

(a) After hours/weekend urgent follow-up care in an emergency room facility of a JCAHO accredited hospital (e.g., weekend or holiday burn); or

(b) Anesthesia – when any procedure requires regional or general anesthesia; or

(d) Spinal blocks requiring fluoroscopic guidance; or

(e) Stellate ganglion blocks.

2) Examples of non-reimbursable facility fees, such as, but not limited to:

(a) When a fluoroscopic fee is charged for procedures other than spinal blocks or IDEA, a facility fee would not be appropriate; or (b) When billing a routine clinical visit; or

(c) When the visit is to an urgent care facility or is an urgent physician office visit, unless ambulatory surgery is performed requiring regional or general anesthesia.

3) Fees for authorized outpatient facilities shall be reimbursed at 80 percent of billed charges. The following billing codes shall be used: Emergency Room (ER) 99956 Ambulatory Surgical 99957 Centers Other Out-Patient 99958 Facilities

(a) Outpatient charges requiring itemization by CPT code (see Rule XVIII.F.10.b) will be reimbursed at the current fee schedule rate. No separate facility fee may be billed when services are CPT code itemized for a routine clinical visit, such as PT or routine follow-up visits with physicians.

(b) Any single supply, durable medical equipment (DME), orthotic, prosthesis, or implantable device (“supply et al.”) exceeding a billed amount of $500.00 per item shall have a maximum allowance of actual cost plus 20 percent.

To determine the remaining outpatient facility fee maximum allowance, the amount billed for the “supply et al.” is subtracted from the total billed charges. Then, the maximum allowance for the remainder is 80 percent of the remaining balance of billed charges.

(c) The total maximum allowance for the outpatient billed charges is the sum of the allowance for any CPT itemized services, the allowance for the “supply et al.,” and the allowance for the remaining balance of billed charges.

11. Home Therapy

Prior authorization is required for all Home Therapy. The payer and the Home Health entity should agree in writing on the type of care, skill level of provider, frequency of care and duration of care at each visit, and any financial arrangements to prevent disputes. a. Home Infusion Therapy

The per diem rates for home infusion therapy shall include the initial patient evaluation, education, coordination of care, products, equipment, administration sets, supplies, supply management, and delivery services. Nursing fees should be billed as indicated in Rule XVIII.F.11.b.

1) Parenteral Nutrition: 0-1 liter $140.00/day 1.1-2.0 liter $200.00/day 2.1-3.0 liter $260.00/day

2) Antibiotic Therapy:

$105.00/day + AWP (Average Wholesale Price)

3) Chemotherapy:

$85.00/day + AWP

4) Enteral nutrition: Category I $ 43.00/day Category II $ 41.00/day Category III $ 52.00/day

5) Pain Management: $ 95.00/day + AWP

6) Fluid Replacement: $ 70.00/day + AWP

7) Multiple Therapies:

Highest cost therapy + AWP

only for remaining therapy

Medication/Drug Restrictions – the payment for drugs may be based upon the average wholesale price (AWP) of the drug as determined through the use of industry publications such as the monthly Price Alert, First Databank, Inc. b. Nursing Services 99970 Skilled Nursing (LPN & RN) $95.79 per hour There is a limit of 2 hours without prior authorization. 99972 Certified Nurse Assistant (CNA): $31.67 per hour for the first hour; $9.46 for each additional half hour. Service must be at least 15 minutes to bill an additional half hour charge.

The amount of time spent with the injured worker must be specified in the medical records and on the bill. c. Physical Medicine

Physical medicine procedures are payable at the same rate as provided in the Physical Medicine and Rehabilitation Services Section of this Rule XVIII. d. Travel Allowances

Travel is typically included in the fees listed. Any extensive travel may need to be billed separately. Travel allowances should be agreed upon with the payer and should not exceed $28.00 per visit, portal to portal. The $28.00 allowance includes mileage.

Bill code: 99971

12. Pharmacy Fees a. Average Wholesale Price (AWP) + $6.00 b. All bills shall reflect the National Drug Code (NDC) c. All prescriptions shall be filled with bio-equivalent generic drugs unless the physician indicates “Dispense As Written” (DAW) on the prescription.

1) The above formula applies to both brand name and generic drugs.

2) The provider shall dispense no more than a 60-day supply per prescription.

3) A line-by-line itemization of each drug billed and the payment for that drug shall be made on the payment voucher by the payer.

4) AWP for brand name and generic pharmaceutical may be determined through the use of such monthly publications as Price Alert, First Databank, Inc. d. Compounding Pharmacies

Reimbursement for compounding pharmacies shall be based on the cost of the materials plus 20 percent, $50.00 per hour for the pharmacist's documented time, and actual cost of any mailing & handling.

Bill Code: 99913 Materials, mailing, handling 99914 Pharmacist e. Hospital Reimbursement

Medications dispensed to a hospitalized patient shall be exempt from this Rule XVIII.F.12.a-c and shall be reimbursed in accordance with Rule XVIII.F.9.

Chart orders:

A chart order is defined as an order for inpatient or outpatient medications entered on a patient's chart or medical record to be dispensed by a pharmacist, pharmacy intern under the direct supervision of a pharmacist, or withdrawn from a medicine storage unit by, or on the order of, a physician. The medication is to be administered by an authorized person only during the patient's stay in a hospital facility. In addition, on the specific order of a physician, a quantity dose, not to exceed a 72-hour supply, may be dispensed to a registered emergency room patient and such quantity dose shall be compensated in accordance with hospital supplies. Other prescriptions filled in a hospital or non-hospital pharmacy shall have a maximum allowance in accordance with this Rule XVIII.E.12.a-d. f. Injured Worker Reimbursement

The payer is responsible for timely payment of pharmaceutical costs (see Rule XVI.K). In the event the injured worker has directly paid pharmaceutical costs, the payer shall reimburse the injured worker for actual costs incurred for authorized pharmacy services. If the actual costs exceed the maximum fee allowed by this rule, the payer may seek a refund from the dispensing provider for the difference between the amount charged to the injured worker and the maximum fee. Each request for a refund shall indicate the prescription number and the date of service involved. g. Dietary Supplements, Vitamins and Herbal Medicines

Reimbursement for outpatient dietary supplements, vitamins and herbal medicines dispensed in conjunction with acupuncture and complementary alternative medicine are authorized only by prior agreement of the payer, except for specific vitamins supported by Rule XVII. h. Prescription Writing

Physicians shall indicate on the prescription form that the medication is related to a workers' compensation claim. i. Provider Reimbursement

Provider offices that prescribe and dispense medications from their office have a maximum allowance of AWP plus $6.00.

All medications administered in the course of the provider's care shall be reimbursed at actual cost incurred. j. Required Billing Forms

1) All parties shall use one of the following forms:

(a) CMS 1500 (formerly HCFA 1500) – the dispensing provider shall bill by using the procedure code 99070 and shall include the metric quantity and National Drug Code (NDC) number of the drug being dispensed; or

(b) WC-M4 form or equivalent – each item on the form shall be completed.

(c) With the agreement of the payer, a nationally recognized electronic billing transaction containing the same information as in (a) or (b) in this sub-section.

2) Items prescribed for the work-related injury that do not have an NDC code shall be billed as a supply, using procedure code 99070 for the billed supply.

3) The payer may return any prescription billing form if the information is incomplete.

4) A signature shall be kept on file indicating the patient or his/her authorized representative has received the prescription.

13. Complementary Alternative Medicine (CAM) (Requires prior authorization) Complementary Alternative Medicine (CAM) is a term used to describe a broad range of treatment modalities, some of which are generally accepted in the medical community and others that remain outside the accepted practice of conventional western medicine. Providers of CAM may be both licensed and non-licensed health practitioners with training in one or more forms of therapy. Refer to Rule XVII, Medical Treatment Guidelines for the specific types of CAM modalities.

14. Acupuncture

Acupuncture is an accepted procedure for the relief of pain and tissue inflammation. While commonly used for treatment of pain, it may also be used as an adjunct to physical rehabilitation and/or surgery to hasten return of functional recovery. Acupuncture may be performed with or without the use of electrical current on the needles at the acupuncture site. a. Provider Restrictions

All providers must be Registered Acupuncturists (RAc) or certified by an existing licensing board as provided in Rule XVI, Utilization Standards, and must provide evidence of training, registration and/or certification upon request of the payer. b. Billing Restrictions

For treatments of more than fourteen (14) sessions or for services beyond the following billing codes, the provider must obtain prior authorization from the payer: c. Billing Codes:

1) Acupuncture (represents whole body): 97780;

2) Acupuncture with electrical Stimulation (represents whole body): 97781;

3) Non-Physician Evaluation Services

(a) “New or Established Patient” services are reimbursable only if the medical record specifies the appropriate history, physical examination, treatment plan or evaluation of the treatment plan. Payers are only required to pay for evaluation services directly performed by an RAc. All evaluation notes or reports must be written and signed by the RAc.

(b) RAc New Patient Visit: 97041;

(i) Maximum value $75.84

(i) Maximum value $51.19

4) Herbs require Prior Authorization and fee agreements as in this Rule XVIII.F.12;

5) See the appropriate Physical Medicine and Rehabilitation section of the RVP for other billing codes and limitations (Rule XVIII.E.7).

B. DENTAL FEE SCHEDULE

The following dental schedule is adopted using the American Dental Association's Current Dental Terminology, Fourth Edition (CDT-4). However, surgical treatment for dental trauma and subsequent, related procedures shall be billed using codes from the RVP. Reimbursement shall be in accordance with the surgery/anesthesia section of the RVP, its corresponding conversion factors, the Division's Rule XVI, Utilization Standards, and Rule XVII, Medical Treatment Guidelines. The following dental billing codes begin with the letter “D”:

RULE XIX PERMANENT IMPAIRMENT RATING GUIDELINES

A. STATEMENT OF PURPOSE

Pursuant to § 8-42-101(3.5)(a)(II), C.R.S., all permanent impairment ratings shall be based upon the American Medical Association Guides to the Evaluation of Permanent Impairment, Third Edition (Revised), in effect as of July 1, 1991, (AMA Guides). This rule implements the Division's permanent impairment rating guidelines on how to appropriately utilize and report permanent impairment ratings. B. PROVIDER RESPONSIBILITIES

1. Where the authorized treating physician has determined that the injured worker is at maximum medical improvement (MMI) and has not returned to his/her pre-injury state, physically and/or mentally, said treating physician shall determine or cause to be determined a permanent medical impairment rating in accordance with this Rule XIX.

2. Any Level II accredited physician determining permanent impairment shall rate in accordance with their administrative, legal and medical roles as established by Level II accreditation.

C. APPORTIONMENT OF PERMANENT IMPAIRMENT RATING

Pursuant to § 8-42-104(2), C.R.S., a Level II accredited physician shall apportion the pre-existing permanent medical impairment from that of a work-related injury or occupational disease using the AMA Guides, 3rd Edition, Revised, where medical records or other objective evidence substantiate a preexisting impairment. Any such apportionment shall be made by subtracting from the injured worker's impairment the pre-existing impairment as it existed at the time of the subsequent injury or occupational disease. The physician shall fully explain in their written report the basis of any apportionment. If there is insufficient information to measure the change accurately, the Level II accredited physician shall not attempt to do so.

D. PERMANENT PHYSICAL IMPAIRMENT RATINGS

Any physician determining permanent physical impairment shall:

1. Limit such rating to physical impairments not likely to remit despite medical treatment; and

2. Use the instructions and forms contained in the AMA Guides.

E. PERMANENT MENTAL AND BEHAVIORAL DISORDER IMPAIRMENT RATINGS

1. Any physician determining permanent mental or behavioral disorder impairment shall:

a. Limit such rating to mental or behavioral disorder impairments not likely to remit despite medical treatment; and

b. Use the instructions contained in the AMA Guides giving specific attention to:

(1) Chapter 4, “Nervous System”; and

(2) Chapter 14, “Mental and Behavioral Disorders”; and

c. Complete a full psychiatric assessment following the principles of the AMA Guides, including:

(1) A nationally accepted and validated psychiatric diagnosis made according to established standards of the American Psychiatric Association as contemplated by the AMA Guides; and

(2) Complete history of impairment, associated stressors, treatment, attempts at rehabilitation and premorbid history so that a discussion of causality and apportionment can occur.

2. If the permanent impairment is due to organic deficits of the brain and results in disturbances of complex integrated cerebral function, emotional disturbance or consciousness disturbance, then Chapter 4, “Nervous System,” shall be consulted and, may be used, when appropriate, with Chapter 14, “Mental and Behavioral Disorders.” The same permanent impairment shall not be rated in both sections. The purpose is to rate the overall functioning, not each specific diagnosis. Determination of the appropriate chapter(s) is left to the professional judgment of the physician.

3. The permanent impairment report shall include a written summary of the mental evaluation and the work sheet incorporated herein as part of this rule (Division form WC-M3-PSYCH). The impairment rating shall be established using the “category definition guidelines” set forth in this rule and in subsection e.5., and which shall supplement the related instructions in the AMA guides. When appropriate, the physician shall address apportionment.

4. Where other work-related permanent impairment exists, a combined whole-body permanent impairment rating may be determined by the authorized treating physician providing primary care if Level II accredited. Where the authorized treating physician providing primary care is not determining permanent impairment, it shall be determined by the Level II accredited rating physician designated by the authorized treating physician providing primary care.

F. PERMANENT IMPAIRMENT RATINGS OF THE EXTREMITIES

1. The AMA guides do not provide for permanent impairment ratings specifically for the partial loss of use of the following:

a. Forearm at the albow;

b. Joints at the wrist or ankle;

c. Leg at the knee; or

d. Toes at the metatarsal.

The AMA Guides define these as permanent impairments of the

a. Entire finger, whole hand, or whole upper extremity; or

b. Entire toe, whole foot, or whole lower extremity.

2. When an injury causes the partial loss of use of any member specified in the scheduled injuries, as set forth in § 8-42-107(2)., C.R.S., the physician shall use the most distal body part. The most distal body part is the body part farthest away from the central body.

3. In calculating partial loss-of-use benefits, the most distal permanent impairment rating provided by the physician shall be multiplied by the number of weeks corresponding to the scheduled injury for the appropriate entire finger, whole hand, or whole upper extremity, or the appropriate entire toe, whole foot, or whole lower extremity, then multiplied by the amount pursuant to §8-42-107(6).

G. PERMANENT IMPAIRMENT RATINGS FOR CUMULATIVE TRAUMA

1. The Cumulative Trauma Disorder (CTD) rating system is designed for disorders that primarily involve muscular, tendinous, ligamentous and bony structures. It follows the same general principles set forth in section 3.1j of the AMA Guides and has similar relative values for traumatic soft tissue conditions. Disorders that have vascular or neurologic involvement are rated by other sections of the AMA Guides.

2. Impairments secondary to Cumulative Trauma Disorders may be accompanied by impairments that are ratable using existing portions of the AMA Guides. The Level II accredited physician shall first calculate any applicable impairment from range of motion, neurologic and/or vascular findings, or other disorders (section 3.1j) excluding grip strength. If no impairment exists under these sections of the AMA Guides and the physician has determined that the claimant has an impairment of daily living activities with anatomic and physiologic correlation, the physician shall proceed to rate the impairment as follows:

a. Multiple joint and upper extremity sites can be involved in CTD. Limit the impairment determination to areas of primary pathology, with anatomic or physiologic correlation based on objective findings. Do not rate areas of reactive muscular spasm and radiating or referred pain.

b. Determine the stage of cumulative trauma for each joint involved, Stage 1 is 0-10%, Stage 2 is 11-20%, Stage 3 is 21-30%, and Stage 4 is 31-40%. Refer to Rule XVII, Exhibit B.

c. Identify the appropriate joint impairment found on Table 17 of Chapter 3 of the AMA Guides.

d. Multiply the joint impairment from Table 17 by the CTD stage impairment from step B to yield an upper extremity impairment.

e. If there is anatomic and physiologic basis to rate other joints in the same extremity, complete the rating in the manner described and combine the extremity ratings distal to proximal.

f. If extremity impairment is bilateral, convert each upper extremity impairment to whole person rating and then combine whole person ratings for both right and left upper extremities as referenced in the AMA Guides. Complete the upper extremity worksheets, Figure 1 of Chapter 3 of the AMA Guides, for each extremity separately.

3. The CTD rating system is preferred to impairment determined by decrease in grip strength. If grip strength is used, the CTD rating system shall not be used as it would be duplicative. Similarly, care must be taken to avoid duplicative ratings with other associated disorders where there is significant neurovascular involvement or where there is limitation in ranges of motion. For further reference to these cautions, refer to the AMA Guides, section 3.1j.

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers' Compensation

PERMANENT WORK-RELATED MENTAL IMPAIRMENT RATING REPORT WORK SHEET

Since the AMA Guides to the Evaluation of Permanent Impairment, 3 rd Edition (Revised) does not provide a quantified method for assigning permanent impairment percentages under Chapter 14 “Mental and Behavioral Disorders.” the provider shall utilize this form. Patient Name ______Date of Service: ______WC # ______Carrier # ______

SCORINGINSTRUCTIONS:

1. This form should only be used to determine an impairment after the case has been found to meet all of the specific criteria for a DSM – IV diagnosis.

2. The AMA Guides to Permanent Impairment. 3rd Edition (Revised) should be consulted for guidance in determining these ratings. 3. Determination of a rating of permanent mental or behavioral impairment shall be limited to mental or behavioral disorder impairments not likely to remit with further mental health treatment.

4. Impairment ratings based on chronic pain are not applicable within the mental/behavioral domain. but are restricted to physical examination with evidence of anatomic or physiologic correlation and included within a physical impairment rating.

5. To obtain the final overall impairment rating:

a. The elements to be rated are divided into four Areas of Function: Activities of Daily Living: Social Functioning; Thinking, Concentration and Judgment; and Adaptation to Stress.

b. Assign a rating (0-6) to each subcategory of the areas of function based on patient self-report, other sources of information. and the physician's clinical assessment. Given the heavy reliance on the patient's subjective report for information in some of the ratings, the physician should give careful consideration to any corroborating evidence that might be available.

c. Average the two highest subcategory ratings within each Area of Function to obtain the overall category rating. For example, if the two highest scores are 2 and 5. the category score is 3.5.

d. To calculate the overall impairment rating, average the two highest category ratings and then. if appropriate in the case, use clinical judgment to add or subtract up to 0.5 point from the result. If the score is modified in this fashion due to clinical judgment, justification for doing so must be documented. Factors influencing the physician's discretion may include the following:

i. Factors influencing the patient's believability, such as the presence of symptom magnification. or the presence or absence of corroborating information from psychological or neuropsychological testing;

ii. The extent to which medication ameliorates the effects of the condition;

e. Use the Category Conversion Table in these instructions to convert the final number to a percentage.

6. Include the DSM-IV diagnosis at the top of the worksheet.

The final determination must include ratings for all of the elements in each area of function, the category averages reached in each area of function. the overall average. the final assigned overall permanent impairment rating. and documentation for any divergence (=0.5) from the calculated score. CATEGORY CONVERSION TABLE Final Score Percentage 0 0 0.25 0 0.5 1 0.75 1 1 1 1.25 2 1.5 3 to 4 1.75 5 2 6 to 7 2.25 8 to 9 2.5 10 to 12 2.75 13 to 15 3 16 to 18 3.25 19 to 21 3.5 22 to 23 3.75 24 to 25 4 26 to 32 4.25 33 to 38 4.5 39 to 44 4.75 45 to 50 5 51 to 56 5.25 57 to 62 5.5 63 to 68 5.75 69 to 75 6 76 to 83 6.25 84 to 91 6.5 92 to 100

7. If apportionment is applicable, complete a separate form calculating the pre-injury rating to be subtracted from the total current rating.

8. If there is a finding of no impairment, refer to Part V on the worksheet, if appropriate.

APPENDIX

1. Activities of Daily Living

Sexual Function: Scoring categories 5 and 6 are not available because the maximum impairment allowed per the AMA Guides for total loss of sexual function is 30% for a male less than 40 years of age: 20% for a male 40 or older.

Sleep: Scoring categories 5 and 6 are not available because the AMA Guides allow a maximum of 50% impairment for sleep or arousal disorders. To reach a 20% rating the activities of daily living must be affected to the extent that supervision is required in some areas. To reach a 50% rating, supervision by caretakers is required.

2. Social Functioning

Soctal functioning refers to an individual's capacity to interact appropriately and communicate effectively with other individuals. Social functioning includes the ability to get along with others, such as with family members, fmends. neighbors. grocery clerks. landlords or bus drivers. Impaired social functioning may be demonstrated by a history of altercations, evictions. firings. fear of strangers. avoidance of interpersonal relationships, social isolation. etc. Strength in social functioning may be documented by an individual's ability to initiate social contacts with others, communicate clearly with others, mteract and participate in group activities. etc. Cooperative behaviors. consideration for others. awareness of others' feelings, and social maturity also need to be considered. Social functioning in work situations may involve interactions with the public. responding appropriately to persons in authority, such as supervisors. or cooperative behaviors involving co-workers.

Again, it is not the number of areas in which social functioning is impaired, but the overall degree of interference with a particular functional area or combination of such areas of functioning. For example. a person who is highly antagonistic. uncooperative, or hostile. but is tolerated by local storekeepers may nevertheless have marked restrictions in social functioning because that behavior is not acceptable in other social contexts, such as work. (AMA Guides. 3rd Edition (revised). p. 237)

3. Thinking, Concentration and Judgment

Thinking. concentration, and judgment refer to the ability to sustain focused attention sufficiently long to permit the timely completion of tasks and to make reasoned or logical decisions as to alternative courses of action. Deficiencies in concentration and judgment are best observed in work and work-like settings. Major impairment in this area can often be assessed through direct psychiatric examination and or psychological testing. although mental status examination or psychological test data alone should not be used to accurately describe concentration and sustained ability to perform work-like tasks. On mental status examinations, concentration is assessed by tasks requiring short-term memory or through tasks such as having the individual subtract serial sevens from 100. In psychological tests of intelligence or memory. concentration can be assessed through tasks requiring short-term memory or through tasks that must be completed within established time limits. Strengths and weaknesses in areas of concentration can be discussed in terms of frequency of errors. time it takes to complete the task. and extent to which assistance is required to complete the task. (Disability Evaluation Under Social Security, p.88, Social Security Administration Pub. No. 64-039)

4. Adaptation to Stress

The individual should be able to set realistic and appropriate goals. Given that the work-related injury may have induced various limitations, the individual should demonstrate realistic adaptations to the medical/physical situation. He/she should be able to accommodate changes from pre-injury status to the current status. Adapting to performance standards requires that the individual can adequately cope with job performance and time expectations. Further. the individual should demonstrate the capacity to follow rules and policies, respond appropriately to changes in the work setting. and utilize resources available within the community, medical and family areas.

PERMANENT WORK-RELATED MENTAL IMPAIRMENT RATING REPORT WORK SHEET

CATEGORY DEFINITION GUIDELINES CATEGORY 0: 0%-No Permanent Impairment.

Mental symptoms arising from the work-related psychiatric diagnosis have been absent for the past month. ADLs are not affected. Functioning is at pre-mjury baseline in social and work activities in all areas; no more than everyday problems.

CATEGORY 1: 1-5%-Minimal Category of Permanent Impairment.

Mental symptoms. arising from the work-related psychiatric diagnosis and not likely to remit despite medical treatment. minimally impair functioning.

CATEGORY 2: 6-15%-Mild Category of Permanent Impairment.

Mental symptions, arising from the work-related psychiatric diagnosis are not likely to remit despite medical treatment. and are mildly impairing. ADLs are mildly disrupted. Functioning shows mild permanent impairment in social or work activities.

CATEGORY 3: 16-25%-Moderate Category of Permanent Impairment.

Mental symptoms, arising from the work-related psychiatric diagnosis and not likely to remit despite medical treatment, are moderately impairing. ADLs are moderately disrupted. Functioning shows moderate permanent impairment. Activities sometimes need direction or supervision.

CATEGORY 4: 26-50%-Marked Category of Permanent Impairment.

Mental symptoms. arising from the work-related psychiatric diagnosis and not likely to remit despite medical treatment, are seriously impairing. ADLs are seriously disrupted. Functioning shows serious difficulties in social or work activities.

CATEGORY 5: 51-75%-Extreme Category of Permanent Impairment.

Mental symptoms. arising from the work-related psychiatric diagnosis and not likely to remit despite medical treatment. are incapacitating. At times. ADLs require structuring. Functioning is quite poor. unsafe in work settings, at times requires hospitalization or full-time supervision. Most activities require directed care.

CATEGORY 6: 76-100%-Maximum Category of Permanent Impairment.

This impairment level precludes useful functioning in all areas. These individuals are generally appropriate for institutionalized settings. if available. All activities require directed care.

RULE XX ACCREDITATION OF PHYSICIANS

A. STATEMENT OF BASIS AND PURPOSE

1. This rule is promulgated to implement and establish procedures for the physicians accreditation program as set forth in § 8-42-101 (3.5 and 3.6) C.R.S., to provide physicians with an understanding of their administrative, legal and medical roles in the workers' compensation system. Accreditation requirements established herein shall apply to:

(a) Physicians who seek Level I accreditation under the Act; and

(b) Physicians providing permanent impairment evaluation of claimants; and

1. To obtain Level I or Level II Accreditation a physician qualified under the Act shall:

a. complete an application form prescribed by the Division and in Level II cases, indicate if full accreditation or limited accreditation is sought;

b. attend a Division seminar and/or review the Division materials on the worker's compensation system; for Level II accreditation, this must include the American Medical Association Guides to the Evaluation of Permanent Impairment, Third Edition (Revised), in effect as of July 1, 1991 (“AMA Guides”), and demonstrate an understanding of such materials by passing an examination administered by the Division; and

c. certify agreement to comply with all Division rules, including but not limited to the medical treatment guidelines, permanent impairment rating guidelines and utilization standards adopted by the Director, and all relevant statutes.

2. After paying the accreditation registration fee, a physician shall have three opportunities to pass the examination administered by the Division. If the physician does not pass the examination on the third attempt, he or she shall be required to wait six months and pay a second registration fee before taking the examination again.

3. Accreditation begins on the date the physician successfully passes the accreditation examination.

4. Accreditation expires three years subsequent to the date the physician successfully passes the accreditation examination.

5. For Level II Accreditation only:

a. Full Accreditation: A qualified physician who passes the complete Level II Accreditation examination as determined and administered by the Division shall be fully accredited to determine permanent impairment ratings on any work-related injury or illness.

b. Limited Accreditation: A qualified physician who seeks Level II Accreditation in order to rate impairment only in connection with an area of medical specialty and who passes specified portions of the Level II examination as determined and administered by the Division shall receive limited accreditation to determine permanent impairment ratings on the corresponding sections of the AMA Guides.

C. RENEWAL OF ACCREDITATION

1. The Division shall provide accredited physicians not less than sixty (60) days written notice of impending expiration of their accreditation. The procedures for registration and additional training for renewal of accreditation shall be determined by the Director pursuant to this Rule XX and described in such written notification.

2. A physician who does not renew their accreditation before their accreditation expiration date may reapply and complete the process for initial accreditation under section B of this Rule XX.

3. To renew accreditation, a qualified physician shall:

a. complete an application form prescribed by the Division and, for Level II accreditation, indicate if full accreditation or limited accreditation is sought;

b. attend a Division seminar and/or review the Division materials on the worker's compensation system; for Level II accreditation, this shall include the curriculum for permanent impairment ratings;

c. attend a Division seminar and/or review the Division instructional materials on each Medical Treatment Guideline under Rule XVII;

d. certify agreement to comply with all Division rules, including but not limited to the medical treatment guidelines, permanent impairment rating guidelines, and utilization standards adopted by the Director, and all relevant statutes.

D. REVOCATION OF ACCREDITATION

1. The director, with input from the medical director, may revoke a Level I or Level II Accreditation on any of the following grounds:

a. refusal to comply, substantial failure to comply, or two or more incidents of failure to comply with the provisions of these Workers' Compensation Rules of Procedure and all relevant statutes,

b. refusal to comply, substantial failure to comply, or two or more incidents of failure to follow the AMA Guides to the Evaluation of Permanent Impairment, with applicable additions by the Division, the medical treatment guidelines and utilization standards adopted by the Division,

c. a misrepresentation on the application for accreditation, or

d. by final order of the director in a proceeding held pursuant to section 8-43-501, C.R.S., where the reviewing panel has unanimously recommended that accreditation be revoked.

e. A combination of two or more incidents as set forth in subsections (a) and (b) of this Part (D) (1).

2. The severity of any sanctions taken under these rules shall reflect the character of the failure and the attendant circumstances.

3. A proceeding to revoke a Level I or Level II Accreditation may be initiated by the director, with input from the medical director.

4. Following a hearing before an administrative law judge to revoke a physician's accreditation, the administrative law judge shall render findings of fact and conclusions of law, and then make recommendations to the director, who shall enter an order in the case.