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-2103 - 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 chronic pain and disability.
					 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 employing 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 individuals 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
					 R.S.
					 23:1203.1.
5. Active Interventions. 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 when chronic pain
					 conditions allow attainment of functional goals because some chronic pain
					 patients require active interventions as well maintenance procedures and
					 medications.
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. 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. 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 or within the time to produce effect in the
					 non-chronic pain guidelines, 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 options.
					 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 workers 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 patients job position before returning the patient to
					 full duty and should request clarification of the patients 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, or 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.