RULE 17, EXHIBIT 9 Chronic Pain Disorder Medical Treatment Guidelines Revised: April 26, 2007 Effective: July 1, 2007 Adopted: January 8, 1998 Effective: March 15, 1998 Revised: May 27, 2003 Effective: July 30, 2003 Revised: September 29, 2005 Effective: January 1, 2006 Presented by: State of Colorado Department of Labor and Employment 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. TREATMENT PARAMETER DURATION...................................................................................... 2 4. ACTIVE INTERVENTIONS............................................................................................................ 2 5. ACTIVE THERAPEUTIC EXERCISE PROGRAM......................................................................... 2 6. POSITIVE PATIENT RESPONSE................................................................................................. 2 7. RE-EVALUATION TREATMENT EVERY 3 TO 4 WEEKS............................................................ 2 8. SURGICAL INTERVENTIONS ...................................................................................................... 3 9. SIX-MONTH TIME FRAME ........................................................................................................... 3 10. RETURN-TO-WORK ..................................................................................................................... 3 11. DELAYED RECOVERY................................................................................................................. 3 12. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE ...................... 3 13. TREATMENT OF PRE-EXISTING CONDITIONSS....................................................................... 4 C. INTRODUCTION TO CHRONIC PAIN.........................................................................................5 D. DEFINITIONS...............................................................................................................................7 1. AFTERSENSATION ...................................................................................................................... 7 2. ALLODYNIA .................................................................................................................................. 7 3. ANALGESIA .................................................................................................................................. 7 4. BIOPSYCHOSOCIAL .................................................................................................................... 7 5. CENTRAL PAIN ............................................................................................................................ 7 6. CENTRAL SENSITIZATION.......................................................................................................... 7 7. DYSESTHSIA................................................................................................................................7 8. HYPERALGESIA........................................................................................................................... 7 9. HYPERALGESIA (POSITIVE SENSORY PHENOMENA) ............................................................ 7 10. HYPERPATHIA ............................................................................................................................. 7 11. HYPOALGESIA............................................................................................................................. 7 12. HYPOESTHESIA (NEGATIVE SENSORY PHENOMENA)........................................................... 7 13. MALINGERING ............................................................................................................................. 8 14. MYOFASCIAL PAIN ...................................................................................................................... 8 15. MYOFASCIAL TRIGGER POINT .................................................................................................. 8 16. NEURALGIA.................................................................................................................................. 8 17. NEURITIS...................................................................................................................................... 8 18. NEUROGENIC PAIN..................................................................................................................... 8 19. NEUROPATHIC PAIN ................................................................................................................... 8 20. NEUROPATHY.............................................................................................................................. 8 21. NOCICEPTOR............................................................................................................................... 8 22. PAIN BEHAVIOR........................................................................................................................... 8 23. PAIN THRESHOLD ....................................................................................................................... 8 24. PARESTHESIA ............................................................................................................................. 8 25. PERIPHERAL NEUROGENIC PAIN ............................................................................................. 8 26. PERIPHERAL NEUROPATHIC PAIN ........................................................................................... 8 27. SUMMATION................................................................................................................................. 8 28. SYMPATHETICALLY MAINTAINED PAIN (SMP)......................................................................... 9 29. TENDER POINTS ......................................................................................................................... 9 E. INITIAL EVALUATION & DIAGNOSTIC PROCEDURES...............................................................10 1. HISTORY AND PHYSICAL EXAMINATION (HX & PE)................................... .............................10 a. Medical History 10 b. Pain History................................................................................................................... 11 c. Medical Management History........................................................................................ 11 d. Substance Use/Abuse................................................................................................... 12 e. Other Factors Affecting Treatment Outcome................................................................. 12 f. Physical Examination .................................................................................................... 12 2. PERSONALITY/PSYCHOSOCIAL/PSYCHOLOGICAL EVALUATION....................................... 13 a. Qualifications................................................................................................................. 13 b. Clinical Evaluation......................................................................................................... 14 c. Tests of Psychological Functioning ............................................................................... 15 3. DIAGNOSTIC STUDIES.............................................................................................................. 21 4. LABORATORY TESTING ........................................................................................................... 21 5. INJECTIONS - DIAGNOSTIC...................................................................................................... 22 a. Spinal Diagnostic Injections .......................................................................................... 22 i. Medial Branch Blocks......................................................................................... 23 ii. Transforaminal Injections ................................................................................... 24 iii. Zygapophyseal (Facet) blocks........................................................................... 24 iv. Atlanto-Axial and Atlanto-Occipital Injections .................................................... 24 v. Sacroiliac Joint Injection.................................................................................... 25 b. Other Diagnostic Injections ........................................................................................... 25 i. Sympathetic Injections............................................................................................... 26 ii. Peripheral Nerve Blocks ............................................................................................ 26 6. SPECIAL TESTS......................................................................................................................... 26 a. Computer-Enhanced Evaluations.................................................................................