NOTICE OF INTENT Workforce Commission Office of Workers' Compensation Pain Medical Treatment Guidelines (LAC 40:2101-2115) The Louisiana Workforce Commission does hereby give notice of its intent to amend certain portions of the Medical Guidelines contained in the Louisiana Administrative Code, Title 40, Labor and Employment, Part I, Workers’ Compensation Administration, Subpart 2, Medical Guidelines, Chapter 21, regarding chronic pain guidelines. This Rule is promulgated by the authority vested in the director of the Office of Workers’ Compensation found in R.S. 23:1291 and R.S. 23:1310.1(C). Title 40 LABOR AND EMPLOYMENT Part I. Workers’ Compensation Administration Subpart 2. Medical Guidelines Chapter 21. Pain Medical Treatment Guidelines Subchapter A. Chronic Pain Disorder Medical Treatment Guidelines Editor’s Note: Form LWC-WC 1009. Disputed Claim for Medical Treatment has been moved to §2328 of this Part. §2101. Introduction A. This document has been prepared by the Louisiana Workforce Commission, Office of Workers' Compensation (OWCA) and should be interpreted within the context of guidelines for physicians/providers treating individuals qualifying under Louisiana Workers' Compensation Act as injured workers with chronic pain. Although the primary purpose of this document is advisory and educational1, the guidelines are enforceable under the Louisiana Workers Compensation Act.1 All medical care, services, and treatment owed by the employer to the employee in accordance with the Louisiana Workers' Compensation Act shall mean care, services, and treatment in accordance with these guidelines. Medical care, services, and treatment that varies from these guidelines shall also be due by the employer when it is demonstrated to the medical director of the office by a preponderance of the scientific medical evidence, that a variance from these guidelines is reasonably required to cure or relieve the injured worker from the effects of the injury or occupational disease given the circumstances. 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. AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1. HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation Administration, LR 37:1681 (June 2011). §2103. General Guideline Principles A. The principles summarized in this section are key to the intended implementation of all Office of Workers' Compensation medical treatment 1 guidelines and critical to the reader's application of the guidelines in this document. 1. Application of Guidelines. The OWCA provides procedures to implement medical treatment guidelines and to foster communication to resolve disputes among the provider, payer, and patient through the Office of4 Workers Compensation Act.2 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 disability1 workers’ compensation injuries.4 Currently, practitioners often think of education last, after medications, manual therapy, and surgery. Practitioners must develop and4 implement an effective strategy and skills4 strategies1 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 and evidence-based1 information to the patient.1 More in-depth education is1 currently exists within 4a component of1 treatment regimens which1 employing functional, restorative, preventive1 and innovative4 rehabilitative1 programs of prevention and rehabilitation1. No treatment plan is complete Page 1 of 137 without addressing issues of individual and/or group patient education as a means of facilitating self-management of symptoms and prevention. Facilitation through language interpretation, when necessary, is a priority and part of the medical care treatment protocol.1 3. Informed Decision Making. Providers should implement informed decision making as a crucial element of a successful treatment plan. Patients, with the assistance of their health care practitioner, should identify their personal and professional functional goals of treatment at the first visit1 when a chronic pain condition allows functional improvement3. Progress towards the individual’s identified functional goals should be addressed by all members of the health care team at subsequent visits and throughout the established treatment plan1 when a chronic pain condition allows attainment of functional goals. Injured workers may not reach functional goals to return to work and therefore they will require a significantly different plan.3 Nurse case managers, physical therapists, and other members of the health care team play an integral role in informed decision-making and achievement of functional goals. Patient education and informed decision-making should facilitate self-management of symptoms and prevention of further injury.1 3. 4 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 adherence1 compliance4, as well as availability of services. Clinical judgment may substantiate the need to accelerate or decelerate the time frames discussed in this document. Such deviation shall be in accordance with La. R.S. 23:1203.1. 4.5. Active Interventions. Active interventions1 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 when chronic pain conditions allow attainment of functional goals because some chronic pain patients require active interventions as well maintenance procedures and medications3. 5.6. 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. 6.7. Positive Patient Response. Positive results are defined primarily as functional gains that can be objectively measured. Standard measurement tools, including outcome measures, should be used 4. a. Objective functional gains include, but are not limited to, positional tolerances, range-of-motion (ROM), strength, and endurance, activities of daily living, ability to function at work1, cognition, psychological behavior, and efficiency/velocity measures that can be quantified. Not all chronic pain patients will reach any functional goals and may only improve ADL's and or pain complaints due to severity of the injury. (American Medical Association Guidelines, 5th Edition) 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. 7.8. Re-Evaluation of Treatment Every Three to Four Weeks. If a given treatment or modality is not producing positive results within three to four weeks or within the time to produce effect in the1 non-chronic pain2 guidelines, the treatment should be either modified or discontinued.4 the physical therapist must consult with the treating physician for consideration for a referral to a pain specialist or surgeon or other appropriate specialist for other treatment options9. Reconsideration of diagnosis should also occur in the event of poor response to a seemingly rational intervention. 8.9. Surgical Interventions. Surgery should be contemplated within the context of expected improvement of 4 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. The decision and recommendation for operative treatment, and the appropriate informed consent should be made by the operating surgeon. Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work activities and the patient should agree to comply with the pre- and post-operative treatment plan and home exercise requirements. The patient should understand the length of partial and full disability expected post-operatively.4 Page 2 of 137 9.10. Pharmacy-Louisiana Law and Regulation. All prescribing will be done in accordance with the laws of the state of Louisiana as they pertain respectively to each individual licensee, including, but not limited to: Louisiana State Board of Medical Examiners regulations governing medications used in the treatment of non-cancer-related chronic or intractable pain; Louisiana Board of Pharmacy Prescription Monitoring Program; Louisiana Department of Health and Hospitals licensing and certification standards for pain management clinics; other laws and regulations affecting the prescribing