Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 20 - Spine Medical Treatment Guidelines › Subchapter B - Low Back Pain › Section I-2015 - General Guideline Principles

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 The principles summarized in this section are key to the intended
					 implementation of all Office of Workers' Compensation medical treatment
					 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 Workers Compensation Act.
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 workers' compensation
					 injuries. Currently, practitioners often think of education last, after
					 medications, manual therapy, and surgery. Practitioners must develop and
					 implement strategies 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-based
					 information to the patient. More in-depth education is currently a component of
					 treatment regimens which employ functional, restorative, preventive and
					 rehabilitative programs. No treatment plan is complete 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.
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 visit. 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 plan. 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 decisionmaking
					 should facilitate self-management of symptoms and prevention of further
					 injury.
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 adherence, 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.
5. Active interventions 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.
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.
7. Positive Patient Response. Positive
					 results are defined primarily as functional gains that can be objectively
					 measured.
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
					 work, cognition, psychological behavior, and efficiency/velocity measures that
					 can be quantified. 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.
8.
					 Re-Evaluation of Treatment within Four Weeks. If a given treatment or modality
					 is not producing positive results within four weeks, treatment should be either
					 modified or discontinued. Reconsideration of diagnosis should also occur in the
					 event of poor response to a seemingly rational intervention.
9. Surgical Interventions. Surgery should be
					 contemplated within the context of expected improvement of 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 postoperatively.
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 and dispensing of medications in the state of Louisiana.
11. Six Month Time Frame. Injuries resulting
					 in temporary total disability may require maintenance treatment and may not
					 attain return to work in six months.
12. Return to Work. Return to work is
					 therapeutic, assuming the work is not likely to aggravate the basic problem or
					 increase long-term pain. An injured worker's return-to-work status shall not be
					 the sole cause to deny reasonable and medically necessary treatment under these
					 guidelines. Two good practices are: early contact with injured workers and
					 provide modified work positions for short-term injuries. The practitioner must
					 provide specific physical limitations and the patient should never be released
					 to non-specific and vague descriptions such as "sedentary" or "light duty." The
					 following physical limitations should be considered and modified as
					 recommended: lifting, pushing, pulling, crouching, walking, using stairs,
					 bending at the waist, awkward and/or sustained postures, tolerance for sitting
					 or standing, hot and cold environments, data entry and other repetitive motion
					 tasks, sustained grip, tool usage and vibration factors. Even if there is
					 residual chronic pain, return-to-work is not necessarily contraindicated. The
					 practitioner should understand all of the physical demands of the patient's job
					 position before returning the patient to full duty and should request
					 clarification of the patient's job duties. Clarification should be obtained
					 from the employer or, if necessary, from including, but not limited to,
					 occupational health nurse, physical therapist, occupational therapist,
					 vocational rehabilitation specialist, an industrial hygienist, chiropractor or
					 another professional. American Medical Association clarifies "disability" as
					 "activity limitations and/or participation restrictions in an individual with a
					 health condition, disorder or disease" versus "impairment" as "a significant
					 deviation, loss, or loss of use of any body structure or body function in an
					 individual with a health condition, disorder or disease".
13. Delayed Recovery. Within the discretion
					 of the treating physician, strongly consider a psychological evaluation, if not
					 previously provided, as well as initiating interdisciplinary rehabilitation
					 treatment and vocational goal setting, for those patients who are failing to
					 make expected progress 6 to 12 weeks after initiation of treatment of an
					 injury. The OWCA recognizes that 3 to 10 percent of all industrially injured
					 patients will not recover within the timelines outlined in this document
					 despite optimal care. Such individuals may require treatments beyond the limits
					 discussed within this document, but such treatment requires clear documentation
					 by the authorized treating practitioner focusing on objective functional gains
					 afforded by further treatment and impact upon prognosis.
14. Guideline Recommendations and Inclusion
					 of Medical Evidence. All recommendations are based on available evidence and/or
					 consensus judgment. It is generally recognized that early reports of a positive
					 treatment effect are frequently weakened or overturned by subsequent research.
					 Per R.S. 1203.1, when interpreting medical evidence statements in the
					 guideline, the following apply to the strength of recommendation.
Strong
Level 1 Evidence
We Recommend
Moderate
Level 2 and Level 3 Evidence
We Suggest
Weak
Level 4 Evidence
Treatment is an Option
Inconclusive
Evidence is Either Insufficient of
								  Conflicting
a. Consensus
					 guidelines are generated by a professional organization that the guidelines are
					 intended to serve. A committee of specialists and experts are selected by the
					 organization to create an unbiased, vetted recommendation for the treatment of
					 specific issues within the realm of their expertise. All recommendations in the
					 guideline are considered to represent reasonable care in appropriately selected
					 cases, regardless of the level of evidence or consensus statement attached to
					 it. Those procedures considered inappropriate, unreasonable, or unnecessary are
					 designated in the guideline as "not recommended."
15. Treatment of Pre-Existing Conditions The
					 conditions that preexisted the work injury/disease will need to be managed
					 under two circumstances:
(a) A pre-existing
					 condition exacerbated by a work injury/disease should be treated until the
					 patient has returned to their objectively verified prior level of functioning
					 or Maximum Medical Improvement (MMI); and
(b) A pre-existing condition not directly
					 caused by a work injury/disease but which may prevent recovery from that injury
					 should be treated until its objectively verified negative impact has been
					 controlled. The focus of treatment should remain on the work
					 injury/disease.