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-2119 - 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 readers 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 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. 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.
4. 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.
5. 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.
6. 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.
7.
					 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
					 patient should be re-evaluated by the treating physician that referred him to
					 PT and consideration should be given 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.
8. 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.
9. 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.
10. Six
					 Month-Time Frame. Injuries resulting in temporary total disability require
					 maintenance treatment and may not attain return to work in six
					 months.
11. 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".
12. 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.
13. 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. 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."
14.
					 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.