Louisiana Administrative Code › 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 › Section I-2109 - Initial Evaluation and Diagnostic Procedures

Current through Register Vol. 50, No. 6, June 20, 2024
A. The OWCA recommends the following
					 diagnostic procedures be considered, at least initially, the responsibility of
					 the workers' compensation carrier to ensure that an accurate diagnosis and
					 treatment plan can be established. Standard procedures that should be utilized
					 when initially diagnosing a work-related chronic pain complaint are listed
					 below.
1. History and Physical Examination
					 (Hx and PE). These are generally accepted, well-established, and widely used
					 procedures that establish the foundation/basis for and dictate subsequent
					 stages of diagnostic and therapeutic procedures. When findings of clinical
					 evaluations and those of other diagnostic procedures are not complementing each
					 other, the objective clinical findings should have preference. The medical
					 records should reasonably document the following.
a. Medical history-as in other fields of
					 medicine, a thorough patient history is an important part of the evaluation of
					 chronic pain. In taking such a history, factors influencing a patients current
					 status can be made clear and taken into account when planning diagnostic
					 evaluation and treatment. It may be necessary to acquire previous medical
					 records. One efficient manner in which to obtain historical information and
					 patient reported functional status is by using a questionnaire. The
					 questionnaire may be sent to the patient prior to the initial visit or
					 administered at the time of the office visit. History should ascertain the
					 following elements:
i general information -
					 general items requested are name, sex, age, birth date, etc;
ii. level of education - the level of
					 patient's education may influence response to treatment;
iii. work history/occupation - to include
					 both impact of injury on job duties and impact on ability to perform job
					 duties, work history, job description, mechanical requirements of the job,
					 duration of employment, and job satisfaction;
iv. current employment status;
v. marital status;
vi. family environment - Is the patient
					 living in a nuclear family or with friends? Is there or were there, any family
					 members with chronic illness or pain problems? Responses to such questions
					 reveal the nature of the support system or the possibility of conditioning
					 toward chronicity;
vii. ethnic
					 origin - Ethnicity of the patient, including any existing language barriers,
					 may influence the patient's perception of and response to pain. There is
					 evidence that providers may under-treat patients of certain ethnic backgrounds
					 due to underestimation of their pain;
viii. belief system-Patients should be asked
					 about their value systems, including spiritual and cultural beliefs, in order
					 to determine how these may influence the patients and familys response to
					 illness and treatment recommendations.
ix. functional assessment-Functional ability
					 should be assessed and documented at the beginning of treatment. Periodic
					 assessment should be recorded throughout the course of care to follow the
					 trajectory of recovery. Functional measures are likely to be more reliable over
					 time than pain measures.
(a). Patient-reported
					 outcomes, whether of pain or function, are susceptible to a phenomenon called
					 response shift. This refers to changes in self-evaluation, which may accompany
					 changes in health status. Patient self-reports may not coincide with objective
					 measures of outcome, due to reconceptualization of the impact of pain on daily
					 function and internal recalibration of pain scales. Response shift may obscure
					 treatment effects in clinical trials and clinical practice, and it may lead to
					 apparent discrepancies in patient-reported outcomes following treatment
					 interventions. While methods of measuring and accounting for response shift are
					 not yet fully developed, understanding that the phenomenon exists can help
					 clinicians understand what is happening when some measures of patient progress
					 appear inconsistent with other measures of progress.
x. activities of daily living (ADLs)-Pain has
					 a multidimensional effect on the patient that is reflected in changes in usual
					 daily vocational, social, recreational, and sexual activities;
xi. past and present psychological
					 problems;
xii. history of
					 abuse-physical, emotional, sexual;
xiii. history of disability in the
					 family;
xiv. sleep disturbances:
					 poor sleep has been shown to increase patients self-perceived pain scores.
					 Pre-injury and post-injury sleep should be recorded.
xv. causality-How did this injury occur? Was
					 the problem initiated by a work-related injury or exposure? Patients perception
					 of causality (e.g., was it their fault or the fault of another).