Complex Regional Pain Syndrome Montana Utilization and Treatment Guidelines Effective July 1, 2014 Presented by: State of Montana Department of Labor and Industry EMPLOYMENT RELATIONS DIVISION A. Table of Contents B. General Guideline Principles ..................................................................................................... 5 C. Introduction to Complex Regional Pain Syndrome ................................................................... 8 D. Definitions .................................................................................................................................. 9 E. Initial Evaluation ..................................................................................................................... 11 E.1 History and Physical Examination ..................................................................................... 11 E.1.a Medical History .......................................................................................................... 11 E.1.b Pain History ................................................................................................................. 12 E.1.c Medical Management History ..................................................................................... 13 E.1.d Substance Use/Abuse .................................................................................................. 14 E.1.e Other Factors Affecting Treatment Outcome .............................................................. 14 E.1.f Physical Examination ................................................................................................... 14 F. Diagnostic Criteria and Procedures .......................................................................................... 16 F.1 Diagnosis of CRPS ............................................................................................................. 16 F.2 Diagnostic Components of Clinical CRPS ......................................................................... 18 F.3 Diagnostic Components of Confirmed CRPS .................................................................... 19 F.4. Sympathetically Maintained Pain (SMP) .......................................................................... 19 F.5. Not CRPS or SMP ............................................................................................................. 20 F.6 Diagnostic Imaging ............................................................................................................. 20 F.7 Injections - Diagnostic Sympathetic ................................................................................... 21 F.8 Thermography (Infrared Stress Thermography) ................................................................. 22 F.9 Autonomic Test Battery ...................................................................................................... 23 F.10 Other Diagnostic Tests not Specific for CRPS ................................................................. 24 F.11 Personality/Psychosocial/Psychological Evaluations for Pain Management ................... 25 F.11.a Qualifications ............................................................................................................. 26 F.11.b Clinical Evaluation .................................................................................................... 26 F.11.c Tests of Psychological Functioning ........................................................................... 28 F.12 Special Tests ..................................................................................................................... 34 F.12.a Computer-Enhanced Evaluations............................................................................... 34 F.12.b Functional Capacity Evaluation (FCE) ...................................................................... 34 F.12.c Job Site Evaluation .................................................................................................... 35 F.12.d Vocational Assessment .............................................................................................. 36 F.12.e Work Tolerance Screening (Fitness for Duty) ........................................................... 36 MT CRPS 2014.docx 1 G. Therapeutic Procedures – Non-Operative ............................................................................. 37 G.1 Acupuncture ....................................................................................................................... 37 G.1.a. Acupuncture ............................................................................................................... 39 G.1.b Acupuncture with Electrical Stimulation .................................................................... 39 G.1.c Other Acupuncture Modalities .................................................................................... 39 G.1.d Total Time Frames for Acupuncture and Acupuncture with Electrical Stimulation .. 40 G.2 Biofeedback ....................................................................................................................... 40 G.3 Complimentary Alternative Medicine (CAM) ................................................................... 42 G.4 Disturbances of Sleep......................................................................................................... 43 G.5 Injections — Therapeutic ................................................................................................... 44 G.5.a Sympathetic Injections ................................................................................................ 45 G.5.b Trigger Point Injections .............................................................................................. 46 G.5.c Peripheral Nerve Blocks.............................................................................................. 46 G.5.d Other Intravenous Medications and Regional Blocks................................................. 46 G.5.e Continuous Brachial Plexus Infusions ........................................................................ 46 G.5.f Epidural Infusions ........................................................................................................ 46 G.5.g. Ketamine .................................................................................................................... 47 G.6 Interdisciplinary Rehabilitation Programs ......................................................................... 47 G.6.a Formal Rehabilitation Programs ................................................................................. 49 G.6.b Informal Rehabilitation Program ................................................................................ 51 G.6.c Opioid/Chemical Treatment Programs........................................................................ 51 G.7 Medications and Medical Management ............................................................................. 53 G.7.a CRPS-Specific Medications ........................................................................................ 55 G.7.b Acetaminophen .......................................................................................................... 56 G.7.c Alpha-Acting Agents................................................................................................... 57 G.7.d Anticonvulsants ........................................................................................................... 57 G.7.e Antidepressants ........................................................................................................... 59 G.7.f Herbal/Dietary Supplements ........................................................................................ 61 G.7.g Hypnotics and Sedatives ............................................................................................. 63 G.7.h NMDA Receptor Antagonists .................................................................................... 63 G.7.i Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) ..................................................... 64 G.7.j Opioids ......................................................................................................................... 65 G.7.k Skeletal Muscle Relaxants .......................................................................................... 76 G.7.l Topical Drug Delivery ................................................................................................. 77 MT CRPS 2014.docx 2 G.7.m Tramadol .................................................................................................................... 79 G.7.n Other Agents ............................................................................................................... 80 G.8 Orthotics/Prosthetics/Equipment ...................................................................................... 80 G.9 Patient Education .............................................................................................................. 81 G.10 Personality/Psychological/Psychosocial Intervention ..................................................... 82 G.11 Restriction of Activities .................................................................................................. 85 G.12 Return to Work................................................................................................................. 86 G.12.a Job History Interview ...............................................................................................