RULE 17, EXHIBIT 3 Thoracic Outlet Syndrome Medical Treatment Guidelines Adopted: December 8, 2014 Effective: February 1, 2015 Adopted: January 9, 1995 Effective: March 2, 1995 Revised: January 8, 1998 Effective: March 15, 1998 Revised: September 29, 2005 Effective: January 1, 2006 Revised: September 12, 2008 Effective: November 1, 2008 Presented by: DIVISION OF WORKERS' COMPENSATION TABLE OF CONTENTS SECTION DESCRIPTION PAGE A. INTRODUCTION .............................................................................................................................. 1 B. GENERAL GUIDELINES 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 .............................................................. 3 7. POSITIVE PATIENT RESPONSE ...................................................................................... 3 8. RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS ..................................................... 3 9. SURGICAL INTERVENTIONS ........................................................................................... 3 10. SIX-MONTH TIME FRAME ................................................................................................. 3 11. RETURN-TO-WORK........................................................................................................... 3 12. DELAYED RECOVERY ...................................................................................................... 4 13. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE .......... 4 14. CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI) ........................................ 4 C. DEFINITION OF THORACIC OUTLET SYNDROME ..................................................................... 6 D. INITIAL DIAGNOSTIC PROCEDURES .......................................................................................... 7 1. HISTORY TAKING AND PHYSICAL EXAMINATION (HX & PE) ...................................... 7 a. History Taking ........................................................................................................ 7 b. Occupational Relationship for Neurogenic and Vascular TOS .............................. 9 c. Physical Findings ................................................................................................... 9 d. Cervical Spine X-ray ............................................................................................ 12 e. Vascular Studies .................................................................................................. 12 E. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES ..................................... 13 1. CERVICAL COMPUTED AXIAL TOMOGRAPHY OR MAGNETIC RESONANCE IMAGING (CT/MRI) ........................................................................................................... 13 2. ELECTRODIAGNOSTIC STUDIES .................................................................................. 13 a. Electromyography/Nerve Conduction Velocities (EMG/NCV) ............................. 13 b. Portable Automated Electrodiagnostic Device ..................................................... 14 c. Quantitative Sensory Testing (QST) .................................................................... 14 3. VASCULAR STUDIES ...................................................................................................... 15 4. THERMOGRAPHY ........................................................................................................... 15 5. ANTERIOR SCALENE OR PECTORALIS MUSCLE BLOCKS ....................................... 15 6. BOTULINUM INJECTIONS .............................................................................................. 15 7. PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL EVALUATIONS ......................... 15 8. SPECIAL TESTS .............................................................................................................. 16 a. Computer-Enhanced Evaluations ........................................................................ 16 b. Functional Capacity Evaluation (FCE) ................................................................. 16 c. Jobsite Evaluation ................................................................................................ 17 d. Vocational Assessment ........................................................................................ 18 e. Work Tolerance Screening .................................................................................. 18 F. THERAPEUTIC PROCEDURES – NON-OPERATIVE ................................................................. 20 1. ACUPUNCTURE ............................................................................................................... 20 a. Acupuncture ......................................................................................................... 21 b. Acupuncture with Electrical Stimulation ............................................................... 22 c. Total Time Frames for Acupuncture and Acupuncture with Electrical Stimulation ............................................................................................................................. 22 d. Other Acupuncture Modalities .............................................................................. 22 2. BIOFEEDBACK ................................................................................................................. 22 a. Electromyogram (EMG) ....................................................................................... 23 b. Skin Temperature................................................................................................. 23 c. Respiration Feedback (RFB) ............................................................................... 23 d. Respiratory Sinus Arrhythmia (RSA) ................................................................... 23 e. Heart Rate Variability (HRV) ................................................................................ 23 f. Electrodermal Response (EDR) ........................................................................... 23 g. Electroencephalograph (EEG, QEEG) ................................................................ 23 3. INJECTIONS - THERAPEUTIC ........................................................................................ 24 a. Scalene Blocks..................................................................................................... 24 b. Botulinum Toxin ................................................................................................... 24 c. Trigger Point Injections and Dry Needling Treatment .......................................... 24 4. INTERDISCIPLINARY REHABILITATION PROGRAMS: ................................................ 25 a. Formal Interdisciplinary Rehabilitation Programs ................................................ 28 b. Informal Interdisciplinary Rehabilitation Program ................................................ 29 5. MEDICATIONS ................................................................................................................. 30 a. Acetaminophen .................................................................................................... 30 b. Anticonvulsants .................................................................................................... 31 c. Antidepressants ................................................................................................... 33 d. Muscle Relaxants ................................................................................................. 36 e. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) ................................................. 36 f. Opioids ................................................................................................................. 37 6. EDUCATION/INFORMED DECISION MAKING ............................................................... 38 7. PERSONALITY/PSYCHOSOCIAL/PSYCHOLOGICAL INTERVENTION ....................... 39 a. Cognitive Behavioral Therapy (CBT) or Similar Treatment ................................. 41 b. Other Psychological/Psychiatric Interventions ..................................................... 41 8. RESTRICTION OF ACTIVITIES ....................................................................................... 41 9. RETURN-TO-WORK......................................................................................................... 41 a. Job History Interview ............................................................................................ 42 b. Coordination of Care ............................................................................................ 42 c. Communication .................................................................................................... 42 d. Establishment of Return-to-Work Status ............................................................