RULE 17, EXHIBIT 7 Complex Regional Pain Syndrome/ Reflex Sympathetic Dystrophy Medical Treatment Guideline Revised: 10/6/2017 Effective: 11/30/2017 Adopted: November 4, 1996 Effective: December 30, 1996 Revised: January 8, 1998 Effective: March 15, 1998 Revised: May 27, 2003 Effective: July 30, 2003 Revised: September 29, 2005 Effective: January 1, 2006 Revised: December 27, 2011 Effective: February 14, 2012 Presented by: DIVISION OF WORKERS' COMPENSATION TABLE OF CONTENTS Section Description Page A. INTRODUCTION .............................................................................................................................. 1 B. GENERAL GUIDELINE PRINCIPLES ............................................................................................ 2 1. APPLICATION OF GUIDELINES ....................................................................................... 2 2. EDUCATION ....................................................................................................................... 2 3. INFORMED DECISION MAKING ....................................................................................... 2 4. TREATMENT PARAMETER DURATION ........................................................................... 2 5. ACTIVE INTERVENTIONS ................................................................................................. 2 6. ACTIVE THERAPEUTIC EXERCISE PROGRAM .............................................................. 2 7. POSITIVE PATIENT RESPONSE ...................................................................................... 2 8. RE-EVALUATION OF TREATMENT NO LESS THAN EVERY 3 TO 4 WEEKS ............... 3 9. SURGICAL INTERVENTIONS ........................................................................................... 3 10. SIX-MONTH TIME FRAME ................................................................................................. 3 11. RETURN-TO-WORK........................................................................................................... 3 12. DELAYED RECOVERY ...................................................................................................... 3 13. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE .......... 4 14. TREATMENT OF PRE-EXISTING CONDITIONS .............................................................. 4 C. INTRODUCTION TO COMPLEX REGIONAL PAIN SYNDROME ................................................. 5 D. DEFINITIONS .................................................................................................................................. 6 1. AFTER SENSATION........................................................................................................... 6 2. ALLODYNIA ........................................................................................................................ 6 3. CENTRAL PAIN .................................................................................................................. 6 4. CENTRAL SENSITIZATION ............................................................................................... 6 5. DYSTONIA .......................................................................................................................... 6 6. HYPERALGESIA ................................................................................................................ 6 7. HYPEREMIA ....................................................................................................................... 6 8. HYPERESTHESIA .............................................................................................................. 6 9. HYPERPATHIA ................................................................................................................... 6 10. HYPOESTHESIA ................................................................................................................ 6 11. PAIN BEHAVIOR ................................................................................................................ 6 12. SUDOMOTOR CHANGES ................................................................................................. 6 13. SYMPATHETICALLY MAINTAINED PAIN (SMP) .............................................................. 7 14. TROPHIC CHANGES ......................................................................................................... 7 15. VASOMOTOR CHANGES .................................................................................................. 7 E. INITIAL EVALUATION .................................................................................................................... 8 1. HISTORY TAKING AND PHYSICAL EXAMINATION (HX & PE) ...................................... 8 a. Medical History....................................................................................................... 8 b. Pain History .......................................................................................................... 10 c. Medical Management History .............................................................................. 10 d. Substance Use/Abuse ......................................................................................... 11 e. Other Factors Affecting Treatment Outcome ....................................................... 11 f. Physical Examination ........................................................................................... 11 F. OVERVIEW OF CARE FOR CRPS OR SYMPATHETICALLY MEDIATED PAIN ...................... 13 G. DIAGNOSTIC CRITERIA AND PROCEDURES ........................................................................... 14 1. DIAGNOSIS OF CRPS ..................................................................................................... 14 2. DIAGNOSTIC COMPONENTS OF CLINICAL CRPS ...................................................... 17 3. DIAGNOSTIC COMPONENTS OF CONFIRMED CRPS ................................................. 18 4. SYMPATHETICALLY MAINTAINED PAIN (SMP) ............................................................ 18 5. NOT CRPS OR SMP ........................................................................................................ 18 6. DIAGNOSTIC IMAGING ................................................................................................... 19 a. Plain Film Radiography ........................................................................................ 19 b. Triple Phase Bone Scan ...................................................................................... 19 7. INJECTIONS – DIAGNOSTIC SYMPATHETIC ............................................................... 19 a. Stellate Ganglion Block ........................................................................................ 20 b. Lumbar Sympathetic Block .................................................................................. 21 c. Phentolamine Infusion Test ................................................................................. 21 8. THERMOGRAPHY (INFRARED STRESS THERMOGRAPHY) ...................................... 21 a. Cold Water Stress Test (Cold Pressor Test) ....................................................... 21 b. Warm Water Stress Test ...................................................................................... 21 c. Whole Body Thermal Stress ................................................................................ 22 9. AUTONOMIC TEST BATTERY ........................................................................................ 22 a. Infrared Resting Skin Temperature (RST) ........................................................... 22 b. Resting Sweat Output (RSO) ............................................................................... 22 c. Quantitative Sudomotor Axon Reflex Test (QSART) ........................................... 22 10. OTHER DIAGNOSTIC TESTS NOT SPECIFIC FOR CRPS ........................................... 22 a. Electrodiagnostic Procedures .............................................................................. 23 b. Laboratory Tests .................................................................................................. 23 c. Peripheral Blood Flow (Laser Doppler or Xenon Clearance Techniques) ........... 24 11. PERSONALITY/ PSYCHOLOGICAL/PSYCHOSOCIAL EVALUATIONS FOR PAIN MANAGEMENT ................................................................................................................ 24 12. SPECIAL TESTS .............................................................................................................. 24 H. THERAPEUTIC PROCEDURES – NON-OPERATIVE ................................................................. 25 1. ACUPUNCTURE ............................................................................................................... 25 2. BIOFEEDBACK ................................................................................................................. 26 3. COMPLEMENTARY MEDICINE ....................................................................................... 26 4. DISTURBANCES OF SLEEP ........................................................................................... 26 5. EDUCATION/INFORMED/SHARED DECISION MAKING ............................................... 26 6. INJECTIONS – THERAPEUTIC ....................................................................................... 28 a. Sympathetic Injections ......................................................................................... 28 b.