reglab/statecodes huggingface dataset:
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-2023 - Therapeutic Procedures-Operative

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 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 condition(s). It is imperative to rule out non-physiologic
					 modifiers of pain presentation or non-operative conditions mimicking
					 radiculopathy or instability (e.g., peripheral neuropathy, piriformis syndrome,
					 myofascial pain, scleratogenous or sympathetically mediated pain syndromes,
					 sacroiliac dysfunction, psychological conditions, etc.) prior to consideration
					 of elective surgical intervention.
B. Operative treatment is indicated when the
					 natural history of surgically treated lesions is better than the natural
					 history for non-operatively treated lesions. All patients being considered for
					 surgical intervention should first undergo a comprehensive
					 neuro-musculoskeletal examination to identify mechanical pain generators that
					 may respond to non-surgical techniques or may be refractory to surgical
					 intervention.
C. While sufficient
					 time allowances for non-operative treatment are required to determine the
					 natural cause and response to non-operative treatment of low back pain
					 disorders, timely decision making for operative intervention is critical to
					 avoid de-conditioning and increased disability (exclusive of "emergent" or
					 urgent pathology such as cauda equina syndrome or associated rapidly
					 progressive neurologic loss).
1. In general,
					 if the program of non-operative treatment fails, operative treatment is
					 indicated when:
a. Improvement of the
					 symptoms has plateaued and the residual symptoms of pain and functional
					 disability are unacceptable at the end of 6 to 12 weeks of active treatment, or
					 at the end of longer duration of non-operative programs for debilitated
					 patients with complex problems; and/or
b. Frequent recurrences of symptoms cause
					 serious functional limitations even if a non-operative active treatment program
					 provides satisfactory relief of symptoms, and restoration of function on each
					 recurrence.
c. Mere passage of time
					 with poorly guided treatment is not considered an active treatment
					 program.
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-2101 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. This document
					 has been prepared by the Louisiana Workforce Commission, Office of Workers'
					 Compensation (OWCA) and should be interpreted within the context of guidelines
					 for physicians/providers treating individuals qualifying under Louisiana
					 Workers' Compensation Act as injured workers with chronic pain. Although the
					 primary purpose of this document is advisory and educational, the guidelines
					 are enforceable under the Louisiana Workers Compensation Act. All medical care,
					 services, and treatment owed by the employer to the employee in accordance with
					 the Louisiana Workers' Compensation Act shall mean care, services, and
					 treatment in accordance with these guidelines. Medical care, services, and
					 treatment that varies from these guidelines shall also be due by the employer
					 when it is demonstrated to the medical director of the office by a
					 preponderance of the scientific medical evidence, that a variance from these
					 guidelines is reasonably required to cure or relieve the injured worker from
					 the effects of the injury or occupational disease given the circumstances.
					 Therefore, these guidelines are not relevant as evidence of a provider's legal
					 standard of professional care. To properly utilize this document, the reader
					 should not skip nor overlook any sections.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1203.1.
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-2105 - Introduction to Chronic Pain

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
					 International Association for the Study of Pain (IASP) defines pain as "an
					 unpleasant sensory and emotional experience with actual or potential tissue
					 damage." Pain is a complex experience embracing physical, mental, social, and
					 behavioral processes that often compromises the quality of life of many
					 individuals. Pain is an unpleasant subjective perception usually in the context
					 of tissue damage.
B. Pain is
					 subjective and cannot be measured or indicated objectively. Pain evokes
					 negative emotional reactions such as fear, anxiety, anger, and depression.
					 People usually regard pain as an indicator of physical harm, despite the fact
					 that pain can exist without tissue damage and tissue damage can exist without
					 pain. Many people report pain in the absence of tissue damage or any likely
					 pathophysiologic cause. There is no way to distinguish their experience from
					 that due to actual tissue damage. If they regard their experience as pain and
					 they report it the same way as pain caused by tissue damage, it should be
					 accepted as pain.
C. Pain can
					 generally be classified as:
1. Nociceptive
					 which includes pain from visceral origins or damage to other tissues.
					 Myofascial pain is a nociceptive type of pain characterized by myofascial
					 trigger points limited to a specific muscle or muscles.
2. neuropathic including pain originating
					 from brain, peripheral nerves or both; and
3. psychogenic which originates in mood,
					 characterological, social, or psychophysiological processes.
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-2107 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
A. Aftersensation
					 refers to the abnormal persistence of a sensory perception, provoked by a
					 stimulus even though the stimulus has ceased.
B. Allodynia is pain due to a non-noxious
					 stimulus that does not normally provoke pain.
1. Mechanical Allodynia - refers to the
					 abnormal perception of pain from usually non-painful mechanical
					 stimulation.
2. Static Mechanical
					 Allodynia - refers to pain obtained by applying a single stimulus such as light
					 pressure to a defined area.
3.
					 Dynamic Mechanical Allodynia - obtained by moving the stimulus such as a brush
					 or cotton tip across the abnormal hypersensitive area.
4. Thermal Allodynia - refers to the abnormal
					 sensation of pain from usually non-painful thermal stimulation such as cold or
					 warmth.
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-2111 - Therapeutic Procedures-Non-Operative

Current through Register Vol. 50, No. 6, June 20, 2024
A. Non-operative therapeutic rehabilitation
					 is applied to patients with chronic and complex problems of de-conditioning and
					 functional disability. Treatment modalities may be utilized sequentially or
					 concomitantly depending on chronicity and complexity of the problem, and
					 anticipated therapeutic effect. Treatment plans should always be based on a
					 diagnosis utilizing appropriate diagnostic procedures.
B. All treatment plans begin with shared
					 decision making with the patient. Before initiation of any therapeutic
					 procedure, an authorized treating physician, employer, and insurer should
					 consider these important issues in the care of the injured worker:
1. Patients undergoing therapeutic
					 procedure(s) should be released or returned to modified or restricted duty
					 during their rehabilitation at the earliest appropriate time. Refer to
					 Return-to-Work in this Section for detailed information.
2. Reassessment of the patients status in
					 terms of functional improvement should be documented after each treatment. If
					 patients are not responding within the recommended time periods, alternative
					 treatment interventions, further diagnostic studies or specialist and/or
					 surgeon consultations should be pursued. Continued treatment should be
					 monitored using objective measures such as:
a.
					 return-to-work or maintaining work status;
b. fewer restrictions at work or performing
					 activities of daily living (ADL);
c. decrease in usage of medications related
					 to the work injury; and
d.
					 measurable functional gains, such as increased range of motion, documented
					 increase in strength, increased ability to stand, sit or lift, or patient
					 completed functional evaluations;
3. Clinicians should provide and document
					 education to the patient. No treatment plan is complete without addressing
					 issues of individual and/or group patient education as a means of facilitating
					 self-management of symptoms.
4.
					 Psychological or psychosocial screening should be performed on all chronic pain
					 patients.
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-2113 - Therapeutic Procedures-Operative

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 When considering operative intervention in chronic pain management, the
					 treating physician must carefully consider the inherent risk and benefit of the
					 procedure. All operative intervention should be based on a positive correlation
					 with clinical findings, the clinical course, and diagnostic tests. A
					 comprehensive assessment of these factors should have led to a specific
					 diagnosis with positive identification of the pathologic condition. Operative
					 treatment is indicated when the natural history of surgically treated lesions
					 is better than the natural history for non-operatively treated lesions.
1. Surgical procedures are seldom meant to be
					 curative and should be employed in conjunction with other treatment modalities
					 for maximum functional benefit. Functional benefit should be objectively
					 measured and includes the following:
a.
					 return-to-work or maintaining work status;
b. fewer restrictions at work or performing
					 activities of daily living (ADLs);
c. decrease in usage of medications
					 prescribed for the work-related injury;
d. measurable functional gains, such as
					 increased range-of-motion or documented increase in strength;
e. education of the patient should include
					 the proposed goals of the surgery, expected gains, risks or complications, and
					 alternative treatment
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-2115 - Maintenance Management

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Successful management of chronic pain conditions results in fewer relapses
					 requiring intense medical care. Failure to address long-term management as part
					 of the overall treatment program may lead to higher costs and greater
					 dependence on the health care system. Management of CRPS and CPD continues
					 after the patient has met the definition of maximum medical improvement (MMI).
					 MMI is declared when a patient's condition has plateaued and the authorized
					 treating physician believes no further medical intervention is likely to result
					 in improved function. When the patient has reached MMI, a physician must
					 describe in detail the maintenance treatment.
B. Maintenance care in CRPS and CPD requires
					 a close working relationship between the carrier, the providers, and the
					 patient. Providers and patients have an obligation to design a cost-effective,
					 medically appropriate program that is predictable and allows the carrier to set
					 aside appropriate reserves. Carriers and adjusters have an obligation to assure
					 that medical providers can design medically appropriate programs. Designating a
					 primary physician for maintenance management is strongly recommended.
C. Maintenance care will be based on
					 principles of patient self-management. When developing a maintenance plan of
					 care, the patient, physician and insurer should attempt to meet the following
					 goals:
1. maximal independence will be
					 achieved through the use of home exercise programs or exercise programs
					 requiring special facilities (e.g., pool, health club) and educational
					 programs;
2. modalities will
					 emphasize self-management and self-applied treatment;
3. management of pain or injury exacerbations
					 will emphasize initiation of active therapy techniques and may occasionally
					 require anesthetic injection blocks;
4. dependence on treatment provided by
					 practitioners other than an authorized treating physician will be
					 minimized;
5. reassessment of the
					 patients function must occur regularly to maintain daily living activities and
					 work function;
6. patients will
					 understand that failure to comply with the elements of the self-management
					 program or therapeutic plan of care may affect consideration of other
					 interventions.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 21 - Pain Medical Treatment Guidelines › Subchapter B - Complex Regional Pain Syndrome › Section I-2117 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. This document
					 has been prepared by the Louisiana Workforce Commission, Office of Workers
					 Compensation (OWCA) and should be interpreted within the context of guidelines
					 for physicians/providers treating individuals qualifying under Louisianas
					 Workers Compensation Act as injured workers with cervical spine injuries.
					 Although the primary purpose of this document is advisory and educational,
					 these guidelines are enforceable under the Louisiana Workers Compensation Act.
					 All medical care, services, and treatment owed by the employer to the employee
					 in accordance with the Louisiana Workers Compensation Act shall mean care,
					 services, and treatment in accordance with these guidelines. Medical Care,
					 services, and treatment that varies from these guidelines shall also be due by
					 the employer when it is demonstrated to the medical director of the office by a
					 preponderance of the scientific medical evidence, that a variance from these
					 guidelines is reasonably required to cure or relieve the injured worker from
					 the effects of the injury or occupational disease given the circumstances.
					 Therefore, these guidelines are not relevant as evidence of a providers legal
					 standard of professional care. To properly utilize this document, the reader
					 should not skip nor overlook any sections.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1203.1.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 21 - Pain Medical Treatment Guidelines › Subchapter B - Complex Regional Pain Syndrome › Section I-2121 - Introduction to Complex Regional Pain Syndrome

Current through Register Vol. 50, No. 6, June 20, 2024
A. Complex regional pain syndrome (CRPS types
					 I and II) describes painful syndromes, which were formerly referred to as
					 reflex sympathetic dystrophy (RSD) and causalgia. CRPS conditions usually
					 follow injury that appears regionally and have a distal predominance of
					 abnormal findings, exceeding the expected clinical course of the inciting event
					 in both magnitude and duration and often resulting in significant impairment of
					 limb function.
B. CRPS-I (RSD) is a
					 syndrome that usually develops after an initiating noxious event, is not
					 limited to the distribution of a single peripheral nerve, and is apparently
					 disproportionate to the inciting event. It is associated at some point with
					 evidence of edema, changes in skin, blood flow, abnormal sudomotor activity in
					 the region of the pain, allodynia or hyperalgesia. The site is usually in the
					 distal aspect of an affected extremity or with a distal to proximal gradient.
					 The peripheral nervous system and possibly the central nervous system are
					 involved.
C. CRPS-II (causalgia) is
					 the presence of burning pain, allodynia, and hyperpathia usually in the hand or
					 foot after partial injury to a nerve or one of its major branches. Pain is
					 within the distribution of the damaged nerve but not generally confined to a
					 single nerve.
D. Stages seen in
					 CRPS-I are not absolute and in fact, may not all be observed in any single
					 patient. In some patients, stages may be missed or the patient may remain for
					 long periods of time in one stage.
E. Stage 1 - Acute (Hyperemic)
1. Starts at the time of injury or even weeks
					 later. Associated with spontaneous pain, aching, burning. Typically restricted
					 to the distal extremity. Hyperpathia, allodynia, hypoesthesia or hyperesthesia
					 may be present. Initially, hair and nail growth may be increased but later
					 decrease. Skin may be warm or cold.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 21 - Pain Medical Treatment Guidelines › Subchapter B - Complex Regional Pain Syndrome › Section I-2123 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
A.
After
					 Sensation
- refers to the abnormal persistence of a sensory
					 perception, provoked by a stimulus even though the stimulus has
					 ceased.
B.
Allodynia
- pain due to a non-noxious stimulus that does not
					 normally provoke pain.
1.
Mechanical
					 Allodynia
- refers to the abnormal perception of pain from usually
					 non-painful mechanical stimulation.
2.
Static Mechanical
					 Allodynia
- refers to pain obtained by applying a single stimulus such
					 as light pressure to a defined area.
3.
Dynamic Mechanical
					 Allodynia
- obtained by moving the stimulus such as a brush or cotton
					 tip across the abnormal hypersensitive area.
4.
Thermal Allodynia
-
					 refers to the abnormal sensation of pain from usually non-painful thermal
					 stimulation such as cold or warmth.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 21 - Pain Medical Treatment Guidelines › Subchapter B - Complex Regional Pain Syndrome › Section I-2125 - Initial Evaluation

Current through Register Vol. 50, No. 6, June 20, 2024
A. All
					 potential pain generators should be thoroughly investigated by complete
					 neurological and musculoskeletal exam and diagnostic procedures. Because CRPS-I
					 is commonly associated with other injuries, it is essential that all related
					 diagnoses are defined and treated. These disturbances are typically restricted
					 to one extremity, usually distally, but are variable in their expression.
1. History and physical examination (Hx&
					 PE) The history and physical exam establish the basis for subsequent diagnostic
					 and therapeutic procedures. When clinical evaluation findings do not complement
					 the findings of other diagnostic procedures, clinical findings should have
					 preference. Before the diagnosis of CRPS-I or CRPS-II is established, an
					 experienced practitioner must perform a detailed neurological and
					 musculoskeletal exam to exclude other potentially treatable pain generators or
					 neurological lesions.
a. Medical History. As
					 in other fields of medicine, a thorough patient history is an important part of
					 the evaluation of 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. History should ascertain the following
					 elements:
i. Causality: How did this injury
					 occur? Was the problem initiated by a work-related injury or
					 exposure?
ii. Presenting symptoms:
(a). severe, generally unremitting burning
					 and/or aching pain, and/or allodynia;
(b). swelling of the involved area;
(c). changes in skin color;
(d). asymmetry in nail and/or hair
					 growth;
(e). abnormal sweat
					 patterns of the involved extremity;
(f). dystonia; and/or
(g). subjective temperature changes of the
					 affected area.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 21 - Pain Medical Treatment Guidelines › Subchapter B - Complex Regional Pain Syndrome › Section I-2127 - Diagnostic Procedures

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Diagnostic imaging is a generally accepted, well-established, and widely used
					 diagnostic procedure when specific indications, based on history and physical
					 examination, are present. Physicians should refer to individual OWCA guidelines
					 for specific information about specific testing procedures.
1. Plain Film Radiography:
a. Description. A radiological finding in
					 CRPS may be unilateral osteoporosis; however, osteoporosis may be absent in
					 many cases. In CRPS-I, the osteoporosis may be rapid in progression. The
					 disorder typically affects the distal part of an extremity such as a hand or
					 foot, yet intermediate joints such as the knee or elbow may be
					 involved.
b. Results. The
					 radiological appearance of osteoporosis has been characterized as spotty or
					 patchy. Although CRPS-I may exist in the absence of osteoporosis, the diagnosis
					 of CRPS-I cannot be made solely on the basis of radiographic appearance or the
					 osteoporosis alone.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 21 - Pain Medical Treatment Guidelines › Subchapter B - Complex Regional Pain Syndrome › Section I-2129 - Diagnosis of CRPS

Current through Register Vol. 50, No. 6, June 20, 2024
A. Diagnostic
					 Components of CRPS-I (RSD)
1. Subjective
					 Complaints. Complaint of pain, usually burning or aching pain and out of
					 proportion to identified pathology. May be sharp, or lancinating. Frequently is
					 present without provocation or movement.
2. Physical Findings:
a. Swelling, generally unilateral and
					 variable in presentation.
b.
					 Vasomotor signs Unilateral. Initial extremity warming early on, coldness of
					 extremity as condition progresses. Discoloration of skin usually darker blue or
					 purple, may be mottled, may be paler.
c. Sudomotor sign Increased sweating of the
					 involved extremity.
d. Trophic
					 Changes Coarse, thick hair, later may be sparse; nails brittle, ridged, may
					 grow faster initially, later grow more slowly; skin is smooth, shiny; digits
					 tapered (pencil pointing); joints stiff with decreased ROM; muscle wasting;
					 motor disturbances; increased physiological tremor, dystonia.
3. Diagnostic Testing Procedures:
a. x-rays of both extremities;
b. triple phase bone scan;
c. sympathetic blocks;
d. infrared thermogram;
e. autonomic test battery.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 21 - Pain Medical Treatment Guidelines › Subchapter B - Complex Regional Pain Syndrome › Section I-2131 - Therapeutic Procedures-Non-Operative

Current through Register Vol. 50, No. 6, June 20, 2024
A. Non-operative therapeutic rehabilitation
					 is applied to patients with CRPS or SMP who experience chronic and complex
					 problems of de-conditioning and functional disability. Treatment modalities may
					 be utilized sequentially or concomitantly depending on chronicity and
					 complexity of the problem, and treatment plans should always be based on a
					 diagnosis utilizing appropriate diagnostic procedures.
B. Before initiation of any therapeutic
					 procedure, the authorized treating physician, employer and insurer must
					 consider these important issues in the care of the injured worker:
1. Patients undergoing therapeutic
					 procedure(s) should be released or returned to modified or restricted duty
					 during their rehabilitation at the earliest appropriate time. Refer to
					 Return-to-Work for detailed information.
2. Reassessment of the patient's status in
					 terms of functional improvement should be documented after each treatment. If
					 patients are not responding within the recommended time periods, alternative
					 treatment interventions, further diagnostic studies or consultations should be
					 pursued. Continued treatment should be monitored using objective measures such
					 as:
a. Return to work or maintaining work
					 status.
b. Fewer restrictions at
					 work or performing or limitations in activities of daily living
					 (ADL).
c. Decrease in usage of
					 medications.
d. Measurable
					 functional gains, such as increased range of motion or documented increase in
					 strength.
3. Clinicians
					 should provide and document education to the patient. No treatment plan is
					 complete without addressing issues of individual and/or group patient education
					 as a means of facilitating self-management of symptoms.
4. Psychological or psychosocial screening
					 should be performed on all chronic pain patients.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 21 - Pain Medical Treatment Guidelines › Subchapter B - Complex Regional Pain Syndrome › Section I-2133 - Therapeutic Procedures-Operative

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 When considering operative intervention in chronic pain management, the
					 treating physician must carefully consider the inherent risk and benefit of the
					 procedure. All operative intervention should be based on a positive correlation
					 with clinical findings, the clinical course, and diagnostic tests. A
					 comprehensive assessment of these factors should have led to a specific
					 diagnosis with positive identification of the pathologic
					 conditions(s).
B. Surgical
					 procedures are seldom meant to be curative and would be employed in conjunction
					 with other treatment modalities for maximum functional benefit. Functional
					 benefit should be objectively measured and includes the following:
1. Return to work or maintaining work
					 status.
2. Fewer restrictions at
					 work or performing activities of daily living (ADL).
3. Decrease in usage of
					 medications.
4. Measurable
					 functional gains, such as increased range of motion or documented increase in
					 strength.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 21 - Pain Medical Treatment Guidelines › Subchapter B - Complex Regional Pain Syndrome › Section I-2135 - Maintenance Management

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Successful management of chronic pain conditions results in fewer relapses
					 requiring intense medical care. Failure to address long-term management as part
					 of the overall treatment program may lead to higher costs and greater
					 dependence on the health care system. Management of CRPS and SMP continues
					 after the patient has met the definition of maximum medical improvement (MMI).
					 MMI is declared when a patient's condition has plateaued and the authorized
					 treating physician believes no further medical intervention is likely to result
					 in improved function. When the patient has reached MMI, a physician must
					 describe in detail the maintenance treatment.
B. Maintenance care in CRPS and SMP requires
					 a close working relationship between the carrier, the providers, and the
					 patient. Providers and patients have an obligation to design a cost effective,
					 medically appropriate program that is predictable and allows the carrier to set
					 aside appropriate reserves. Carriers and adjusters have an obligation to assure
					 that medical providers can plan medically appropriate programs. A designated
					 primary physician for maintenance team management is recommended.
C. Maintenance Care will be based on
					 principles of patient self-management. When developing a maintenance plan of
					 care, the patient, physician and insurer should attempt to meet the following
					 goals:
1. Maximal independence will be
					 achieved through the use of home exercise programs or exercise programs
					 requiring special facilities (e.g., pool, health club) and educational
					 programs;
2. Modalities will
					 emphasize self management and self-applied treatment;
3. Management of pain or injury exacerbations
					 will emphasize initiation of active therapy techniques and may occasionally
					 require anesthetic injection blocks.
4. Dependence on treatment provided by
					 practitioners other than the authorized treating physician will be
					 minimized;
5. Periodic reassessment
					 of the patient's condition will occur as appropriate.
6. Patients will understand that failure to
					 comply with the elements of the self-management program or therapeutic plan of
					 care may affect consideration of other interventions.
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 A - Carpal Tunnel Syndrome (CTS) Medical Treatment Guidelines › Section I-2201 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. This document
					 has been prepared by the Louisiana Workforce Commission, Office of Workers'
					 Compensation (OWCA) and should be interpreted within the context of guidelines
					 for physicians/providers treating individuals qualifying under Louisiana's
					 Workers' Compensation Act as injured workers with CTS. Although the primary
					 purpose of this document is advisory and educational, these guidelines are
					 enforceable under the Louisiana Workers Compensation Act. All medical care,
					 services, and treatment owed by the employer to the employee in accordance with
					 the Louisiana Workers' Compensation Act shall mean care, services, and
					 treatment in accordance with these guidelines. Medical care, services, and
					 treatment that varies from these guidelines shall also be due by the employer
					 when it is evidence, that a variance from these guidelines is reasonably
					 required to cure or relieve the injured worker from the effects of the injury
					 or occupational disease given the circumstances. Therefore, these guidelines
					 are not relevant as evidence of a provider's legal standard of professional
					 care. To properly utilize this document, the reader should not skip nor
					 overlook any sections.
AUTHORITY
						NOTE: Promulgated in accordance with
						R.S.
						23:1203.1.
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 A - Carpal Tunnel Syndrome (CTS) Medical Treatment Guidelines › Section I-2205 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
A. Carpal tunnel
					 syndrome (CTS) is one of the most common mononeuropathies (a disorder involving
					 only a single nerve). The median nerve is extremely vulnerable to compression
					 and injury in the region of the wrist and palm. In this area, the nerve is
					 bounded by the wrist bones and the transverse carpal ligament. The most common
					 site of compression is at the proximal edge of the flexor retinaculum (an area
					 near the crease of the wrist). There is often a myofascial component in the
					 patient's presentation. This should be considered when proceeding with the
					 diagnostic workup and therapeutic intervention.
B. Studies have repeatedly confirmed that the
					 diagnosis cannot be made based on any single historical factor or physical
					 examination finding. Electrodiagnostic tests may be negative in surgically
					 confirmed cases. Conversely, electrodiagnostic testing may be positive in
					 asymptomatic individuals. The diagnosis of CTS, therefore, remains a clinical
					 diagnosis based on a preponderance of supportive findings.
C. Classic findings of CTS include subjective
					 numbness or dysesthesias confined to the median nerve distribution, worsening
					 of symptoms at night, and positive exam findings. When the diagnosis is in
					 question, steroid injection into the carpal tunnel is a strongly supportive
					 test if it is followed by significant relief of symptoms.
1. Please refer to other appropriate upper
					 extremity guidelines as necessary.
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 A - Carpal Tunnel Syndrome (CTS) Medical Treatment Guidelines › Section I-2207 - Initial Diagnostic Procedures

Current through Register Vol. 50, No. 6, June 20, 2024
A. Introduction. The two standard procedures
					 that are to be utilized when initially evaluating a work-related carpal tunnel
					 complaint are History Taking, and Physical Examination. History-taking and
					 Physical Examination are generally accepted, well-established, and widely used
					 procedures which establish the foundation/basis for and dictate all ensuing
					 stages of diagnostic and therapeutic procedures. When findings of clinical
					 evaluation and those of other diagnostic procedures do not complement each
					 other, the objective clinical findings should have preference.
B. History
1. Description of symptoms should address at
					 least the following .
a. numbness, tingling,
					 and/or burning of the hand involving the distal median nerve distribution;
					 however, distribution of the sensory symptoms may vary considerably between
					 individuals. Although the classic median nerve distribution is to the palmar
					 aspect of the thumb, the index finger, the middle finger and radial half of the
					 ring finger, patients may report symptoms in any or all of the fingers. The
					 Katz Hand diagram (see Fig. 1) may be useful in documenting the distribution of
					 symptoms; the classic pattern of carpal tunnel affects at least two of the
					 first three digits and does not involve dorsal and palmar aspects of the hand.
					 A probable pattern involves the palmar but not dorsal aspect of the hand
					 (excluding digits).
b. nocturnal
					 symptoms frequently disrupt sleep and consist of paresthesias and/or pain in
					 the hand and/or arm.
c. pain in the
					 wrist occurs frequently and may even occur in the forearm, elbow or shoulder.
					 While proximal pain is not uncommon, its presence warrants evaluation for other
					 pathology in the cervical spine, shoulder and upper extremity.
d. the "flick sign," or shaking the
					 symptomatic hand to relieve symptoms may be reported.
e. clumsiness of the hand or dropping objects
					 is often reported, but may not be present early in the course.
Figure 1. Katz Hand Diagram
Click Here To View
						Image
Used with permission. JAMA 2000; 283 (23): 3110-17.
						Copyrighted 2000, American Medical Association.
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 A - Carpal Tunnel Syndrome (CTS) Medical Treatment Guidelines › Section I-2213 - Therapeutic Procedures-Operative

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Surgical Decompression is well-established, generally accepted, and widely used
					 and includes open and endoscopic techniques. There is good evidence that
					 surgery is more effective than splinting in producing long-term symptom relief
					 and normalization of median nerve conduction velocity.
1. Endoscopic and open techniques can be used
					 based on the experience and discretion of the surgeon.
2. Indications for Surgery include positive
					 history, abnormal electrodiagnostic studies, and/or failure of conservative
					 management. Job modification should be considered prior to surgery. Please
					 refer to the "Job Site Alteration" section for additional information on job
					 modification.
3. Surgery as an
					 Initial Therapy. Surgery should be considered as an initial therapy in
					 situations where:
a. Median nerve trauma has
					 occurred; "acute carpal tunnel syndrome", or
b. Electrodiagnostic evidence of moderate to
					 severe neuropathy. EMG findings showing evidence of acute or chronic motor
					 denervation suggest the possibility that irreversible damage may be
					 occurring.
4. Surgery
					 may be considered in cases where electrodiagnostic testing is normal. A second
					 opinion from a hand surgeon is strongly recommended. The following criteria
					 should be considered in deciding whether to proceed with surgery:
a. the patient experiences significant
					 temporary relief following steroid injection into the carpal tunnel;
					 or
b. the patient has failed 3 to 6
					 months of conservative treatment including work site change; and
c. psychosocial factors have been addressed
					 through psychological screening requirements as defined "Adjunctive Testing" in
					 this Section; and
d. the patient's
					 signs and symptoms are specific for carpal tunnel syndrome
5. Suggested parameters for return-to-work
					 are:
Time Frame
Activity Level
2 Days
Return to Work with Restrictions on utilizing the
								  affected extremity
2-3 Weeks
Sedentary and non-repetitive work
4-6 Weeks
Case-by-case basis
6-12 Weeks
Heavy Labor, forceful and repetitive
NOTE: All return-to-work decisions are based upon
						clinical outcome.
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-2215 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. This document
					 has been prepared by the Louisiana Workforce Commission, Office of Workers'
					 Compensation (OWCA) and should be interpreted within the context of guidelines
					 for physicians/providers treating individuals qualifying under Louisiana's
					 Workers' Compensation Act as injured workers with upper extremity involvement.
					 Although the primary purpose of this document is advisory and educational,
					 these guidelines are enforceable under the Louisiana Workers Compensation Act.
					 All medical care, services, and treatment owed by the employer to the employee
					 in accordance with the Louisiana Workers' Compensation Act shall mean care,
					 services, and treatment in accordance with these guidelines. Medical Care,
					 services, and treatment that varies from these guidelines shall also be due by
					 the employer when it is demonstrated to the medical director of the office by a
					 preponderance of the scientific medical evidence, that a variance from these
					 guidelines is reasonably required to cure or relieve the injured worker from
					 the effects of the injury or occupational disease given the circumstances.
					 Therefore, these guidelines are not relevant as evidence of a provider's legal
					 standard of professional care. To properly utilize this document, the reader
					 should not skip nor overlook any sections.
AUTHORITY
						NOTE: Promulgated in accordance with
						R.S.
						23:1203.1.
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-2219 - Definition of Thoracic Outlet Syndrome

Current through Register Vol. 50, No. 6, June 20, 2024
A. Thoracic Outlet Syndrome (TOS) may be
					 described as a neurovascular disorder affecting the upper extremity which, on
					 rare occasions, is caused by workplace factors, such as jobs that require
					 repetitive activities of the upper extremities with forward head and shoulder
					 postures. It should be emphasized that occupational TOS is a relatively
					 uncommon disorder and other disorders with similar symptomatology need to be
					 ruled out.
B. There are four types
					 of thoracic outlet syndrome. The two vascular types, comprised of subclavian
					 vein or artery pathology, are diagnosed with imaging. True or classic
					 neurogenic TOS consists of a chronic lower trunk brachial plexopathy diagnosed
					 by positive electrodiagnostic testing. It is usually unilateral, predominantly
					 affects women, and results in classic electrophysiologic and physical exam
					 findings such as hand atrophy. The two vascular types of TOS and true
					 neurogenic are relatively rare and easily diagnosed. The most common type of
					 TOS is non-specific neurogenic (also called disputed) TOS, which is diagnosed
					 based on upper or lower trunk brachial plexus symptoms.
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						23:1203.1.
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-2227 - Therapeutic Procedures-Operative

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Operative treatment is indicated when the natural history of surgically treated
					 lesions is better than the natural history for non-operatively treated lesions.
					 All patients being considered for surgical intervention should first undergo a
					 comprehensive neuro-musculoskeletal examination to identify mechanical pain
					 generators that may respond to non-surgical techniques or may be refractory to
					 surgical intervention.
1. Non-vascular
					 Diagnostic Criteria for Surgical Procedures
a.
					 True or Classic Neurogenic TOS
i. Clinical-at
					 least two consistent clinical sign plus symptoms consistent with TOS (refer to
					 initial diagnostic procedures).
ii.
					 Neurophysiologic-meets criteria for neurogenic TOS (refer to follow-up
					 diagnostic imaging and testing procedures).
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 23 - Upper and Lower Extremities Medical Treatment Guidelines › Subchapter A - Lower Extremities › Section I-2301 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. This document
					 has been prepared by the Louisiana Workforce Commission, Office of Workers'
					 Compensation (OWCA) and should be interpreted within the context of guidelines
					 for physicians/providers treating individuals qualifying under Louisiana's
					 Workers' Compensation Act as injured workers with lower extremity injuries.
					 Although the primary purpose of this document is advisory and educational,
					 these guidelines are enforceable under the Louisiana Workers Compensation Act.
					 All medical care, services, and treatment owed by the employer to the employee
					 in accordance with the Louisiana Workers' Compensation Act shall mean care,
					 services, and treatment in accordance with these guidelines. Medical Care,
					 services, and treatment that varies from these guidelines shall also be due by
					 the employer when it is demonstrated to the medical director of the office by a
					 preponderance of the scientific medical evidence, that a variance from these
					 guidelines is reasonably required to cure or relieve the injured worker from
					 the effects of the injury or occupational disease given the circumstances.
					 Therefore, these guidelines are not relevant as evidence of a provider's legal
					 standard of professional care. To properly utilize this document, the reader
					 should not skip nor overlook any sections.
AUTHORITY
						NOTE: Promulgated in accordance with
						R.S.
						23:1203.1.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 23 - Upper and Lower Extremities Medical Treatment Guidelines › Subchapter B - Shoulder Injury Medical Treatment Guidelines › Section I-2315 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. This document
					 has been prepared by the Louisiana Workforce Commission, Office of Workers'
					 Compensation and should be interpreted within the context of guidelines for
					 physicians/providers treating individuals qualifying under Louisiana's Workers'
					 Compensation Act as injured workers with shoulder injuries. Although the
					 primary purpose of this document is advisory and educational, these guidelines
					 are enforceable under the Louisiana Workers Compensation Act. All medical care,
					 services, and treatment owed by the employer to the employee in accordance with
					 the Louisiana Workers' Compensation Act shall mean care, services, and
					 treatment in accordance with these guidelines. Medical Care, services, and
					 treatment that varies from these guidelines shall also be due by the employer
					 when it is demonstrated to the medical director of the office by a
					 preponderance of the scientific medical evidence, that a variance from these
					 guidelines is reasonably required to cure or relieve the injured worker from
					 the effects of the injury or occupational disease given the circumstances.
					 Therefore, these guidelines are not relevant as evidence of a provider's legal
					 standard of professional care. To properly utilize this document, the reader
					 should not skip nor overlook any sections.
AUTHORITY
						NOTE: Promulgated in accordance with
						R.S.
						23:1203.1.