Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 22 - Neurological and Neuromuscular Disorder Medical Treatment Guidelines › Subchapter B - Thoracic Outlet Syndrome › Section I-2217 - General Guidelines 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 Office of Worker's' 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 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 when a chronic
					 pain condition allows functional improvement. 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
					 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. 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.
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 Every Three to Four Weeks. If a given treatment or
					 modality is not producing positive results within three to four weeks, the
					 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
					 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.
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 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 may 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. Guidelines are
					 recommendations based on available evidence and/or consensus recommendations.
					 When possible, guideline recommendations will note the level of evidence
					 supporting the treatment recommendation. 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.