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-2303 - 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 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. 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 workers'
					 compensation injury 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.
a. Treatment of Pre-Existing Conditions The
					 conditions that preexisted the work injury/disease will need to be managed
					 under two circumstances:
i. 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
ii. 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.
b. The focus
					 of treatment should remain on the work injury/disease.