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 treatment plans should always be based on a diagnosis utilizing appropriate diagnostic procedures.
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:
6.4 Psychological or psychosocial screening should be performed on all chronic pain patients. The following procedures are listed in alphabetical order.
6.4.1ACUPUNCTURE is an accepted and widely used procedure for the relief of pain and inflammation, and there is some scientific evidence to support its use. The exact mode of action is only partially understood. Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the brain, promotes deep relaxation, and affects the release of neurotransmitters. Acupuncture is commonly used as an alternative or in addition to traditional Western pharmaceuticals. While it is commonly used when pain medication is reduced or not tolerated, it may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten the return of functional activity. Acupuncture should be performed by MD, DO[,] DC with appropriate training[; or a licensed acupuncturist].6.4.1.1Acupuncture: is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points). Needles may be inserted, manipulated, and retained for a period of time. Acupuncture can be used to reduce pain, reduce inflammation, increase blood flow, increase range of motion, decrease the side effect of medication-induced nausea, promote relaxation in an anxious patient, and reduce muscle spasm. Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain.
6.4.1.2Acupuncture with Electrical Stimulation: is the use of electrical current (micro-amperage or milli-amperage) on the needles at the acupuncture site. It is used to increase effectiveness of the needles by continuous stimulation of the acupoint. Physiological effects (depending on location and settings) can include endorphin release for pain relief, reduction of inflammation, increased blood circulation, analgesia through interruption of pain stimulus, and muscle relaxation. It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.
6.4.1.3Total Time Frames For Acupuncture and Acupuncture with Electrical Stimulation: Time frames are not meant to be applied to each of the above sections separately. The time frames are to be applied to all acupuncture treatments regardless of the type or combination of therapies being provided. Time to produce effect: 3 to 6 treatments
Frequency: 1 to 3 times per week
Maximum course duration: 14 treatments (one course)
Any of the above acupuncture treatments may extend longer if objective functional gains can be documented or when symptomatic benefits facilitate progression in the patient's treatment program. An additional course of treatment beyond 14 treatments may be documented with respect to need and ability to facilitate positive symptomatic or functional gains. Such care should be re-evaluated and documented with each series of treatments.
6.4.1.4Other Acupuncture Modalities: Acupuncture treatment is based on individual patient needs and therefore treatment may include a combination of procedures to enhance treatment effect. Other procedures may include the use of heat, soft tissue manipulation/massage, and exercise. Refer to Active Therapy (Therapeutic Exercise) and Passive Therapy sections (Massage and Superficial Heat and Cold Therapy) for a description of these adjunctive acupuncture modalities and time frames.6.4.2BIOFEEDBACK is a generally well-accepted form of behavioral medicine that helps patients learn self-awareness and self-regulation skills for the purpose of gaining greater control of their physiology. Stress-related psycho physiological reactions may arise as a reaction to organic pain and in some cases may cause pain. Electronic instrumentation is used to monitor the targeted physiology and then displayed or fed back to the patient visually, auditorially, or tactilely with coaching by a biofeedback specialist. Indications for biofeedback include individuals who are suffering from musculoskeletal injury where muscle dysfunction or other physiological indicators of excessive or prolonged stress response affects and/or delays recovery. Other applications include training to improve self-management of pain, anxiety, panic, anger or emotional distress, narcotic withdrawal, insomnia/ sleep disturbance, and other central and autonomic nervous system imbalances. Biofeedback is often utilized for relaxation training. Mental health professionals may also utilize it as a component of psychotherapy, where biofeedback and other behavioral techniques are integrated with psychotherapeutic interventions. Biofeedback is often used in conjunction with physical therapy or medical treatment. Recognized types of biofeedback include the following:
6.4.2.1Electromyogram (EMG): Used for self-management of pain and stress reactions involving muscle tension.6.4.2.2Skin Temperature: Used for self-management of pain and stress reactions, especially vascular headaches.6.4.2.3Respiration Feedback (RFB): Used for self-management of pain and stress reactions via breathing control.6.4.2.4Respiratory Sinus Arrhythmia (RSA): Used for self-management of pain and stress reactions via synchronous control of heart rate and respiration. Respiratory sinus arrhythmia is a benign phenomena which consists of a small rise in heart rate during inhalation, and a corresponding decrease during exhalation. This phenomenon has been observed in meditators and athletes, and is thought to be a psycho physiological indicator of health.6.4.2.5Heart Rate Variability (HRV): Used for self-management of stress via managing cardiac reactivity.6.4.2.6Electrodermal Response (EDR): Used for self-management of stress involving palmar sweating or galvanic skin response.6.4.2.7Electroencephalograph (EEG, QEEG): Used for self-management of various psychological states by controlling brainwaves. The goal in biofeedback treatment is normalizing the physiology to the pre-injury status to the extent possible and involves transfer of learned skills to the workplace and daily life. Candidates for biofeedback therapy or training must be motivated to learn and practice biofeedback and self-regulation techniques. In the course of biofeedback treatment, patient stressors are discussed and self-management strategies are devised. If the patient has not been previously evaluated, a psychological evaluation should be performed prior to beginning biofeedback treatment for chronic pain. The psychological evaluation may reveal cognitive difficulties, belief system conflicts, somatic delusions, secondary gain issues, hypochondriasis, and possible biases in patient self-reports, which can affect biofeedback. Home practice of skills is often helpful for mastery and may be facilitated by the use of home training tapes. Psychologists or psychiatrists, who provide psychophysiological therapy which integrates biofeedback with psychotherapy, should be either Biofeedback Certification Institute of America (BCIA) certified or practicing within the scope of their training. All other providers of Biofeedback for chronic pain patients must be BCIA certified and shall have their biofeedback treatment plan approved by the authorized treating psychologist or psychiatrist. Biofeedback treatment must be done in conjunction with the patient's psychosocial intervention. Biofeedback may also be provided by unlicensed health care providers, who follow a set treatment and educational protocol. Such treatment may utilize standardized material or relaxation tapes.
Time to produce effect: 3 to 4 sessions
Frequency: 1 to 2 times per week
Optimum duration: 6 to 8 sessions
Maximum duration: 10 to 12 sessions.
Treatment beyond 12 sessions must be documented with respect to need, expectation, and ability to facilitate positive symptomatic or functional gains.
6.4.3COMPLEMENTARY ALTERNATIVE MEDICINE (CAM) is a term used to describe a broad range of treatment modalities, a number of which are generally accepted and supported by some scientific evidence, and others which still remain outside the generally accepted practice of conventional Western Medicine. In many of these approaches, there is attention given to the relationship between physical, emotional, and spiritual well-being. While CAM may be performed by a myriad of both licensed and non-licensed health practitioners with training in one or more forms of therapy, credentialed practitioners should be used when available or applicable. Although CAM practices are diverse and too numerous to list, they can be generally classified into five domains:
6.4.3.1Alternative Medical Systems: These are defined as medical practices that have developed their own systems of theory, diagnosis and treatment and have evolved independent of and usually prior to conventional Western Medicine. Some examples are Traditional Chinese Medicine, Ayurvedic Medicine, Homeopathy, and Naturopathy.6.4.3.2Mind-Body Interventions: These include practices such as hypnosis, meditation, bioenergetics, and prayer.6.4.3.3Biological-based Practices: These include herbal and dietary therapy as well as the use of nutritional supplements. To avoid potential drug interactions, supplements should be used in consultation with the authorized treating physician.6.4.3.4Body-Based Therapy: Included in this category are the practices of Yoga and Rolfing bodywork.6.4.3.5Energy-Based Practices: Energy-based practices include a wide range of modalities that support physical as well as spiritual and/or emotional healing. Some of the more well-known energy practices include Qi Gong, Tai Chi, Healing Touch and Reiki. Practices such as Qi Gong and Tai Chi are taught to the patient and are based on exercises the patient can practice independently at home. Other energy-based practices such as Healing Touch and Reiki involve a practitioner/patient relationship.6.4.3.6 Methods used to evaluate chronic pain patients for participation in CAM will differ with various approaches and with the training and experience of individual practitioners. A patient may be referred for CAM therapy when the patient's cultural background, religious beliefs, or personal concepts of health suggest that an unconventional medical approach might assist in the patient's recovery or when the physician's experience and clinical judgment support a CAM approach. The patient must demonstrate a high degree of motivation to return to work and improve their functional activity level while participating in therapy. Other more traditional conservative treatments should generally be attempted before referral to CAM. Treatment with CAM requires prior authorization. Frequency: Per CAM therapy selected
Optimum duration: Should be based upon the physician's clinical judgment and demonstration by the patient of positive symptomatic and functional gains. Practitioner provided CAM therapy is generally not recommended on a maintenance basis.
6.4.4DISTURBANCES OF SLEEP are common in chronic pain. Although primary insomnia may accompany pain as an independent co-morbid condition, it more commonly occurs secondary to the pain condition itself. Exacerbations of pain often are accompanied by exacerbations of insomnia; the reverse can also occur. Sleep laboratory studies have shown disturbances of sleep architecture in pain patients. Loss of deep slow-wave sleep and increase in light sleep occur and sleep efficiency, the proportion of time in bed spent asleep, is decreased. These changes are associated with patient reports of non-restorative sleep. Many chronic pain patients develop behavioral habits that exacerbate and maintain sleep disturbances. Excessive time in bed, irregular sleep routine, napping, low activity, and worrying in bed are all maladaptive responses that can arise in the absence of any psychopathology. There is some evidence that behavioral modification, such as patient education and group or individual counseling, can be effective in reversing the effects of insomnia. Behavioral modifications are easily implemented and can include:
6.4.4.1 Maintaining a regular sleep schedule, retiring and rising at approximately the same time on weekdays and weekends.6.4.4.2 Avoiding daytime napping.6.4.4.3 Avoiding caffeinated beverages after lunchtime6.4.4.4 Making the bedroom quiet and comfortable, eliminating disruptive lights, sounds, television sets, and keeping a bedroom temperature of about 65ûF.6.4.4.5 Avoiding alcohol or nicotine within two hours of bedtime.6.4.4.6 Avoiding large meals within two hours of bedtime.6.4.4.7 Exercising vigorously during the day, but not within two hours of bedtime, since this may raise core temperature and activate the nervous system.6.4.4.8 Associating the bed with sleep and sexual activity only, using other parts of the home for television, reading and talking on the telephone.6.4.4.9 Leaving the bedroom when unable to sleep for more than 20 minutes, retuning to the bedroom when ready to sleep again. These modifications should be undertaken before sleeping medication is prescribed for long term use.
6.4.5INJECTIONS-THERAPEUTICWhen considering the use of injections in chronic pain management, the treating physician must carefully consider the inherent risks and benefits. Any continued use of injections should be monitored using objective measures such as:
| . | Return-to-work or maintaining work status. |
| . | Fewer restrictions at work or performing activities of daily living |
| . | Decrease in usage of medications |
Measurable functional gains, such as increased range of motion for documented increase in strength. Reduction of reported pain scores
6.4.5.1Spinal Therapeutic InjectionsGeneral Description - The following injections are considered to be reasonable treatment for patients with chronic pain. Other injections not listed may be beneficial. Therapeutic spinal injections typically may be used after initial conservative treatments, such as physical and occupational therapy, medication, manual therapy, exercise, acupuncture, etc., have been undertaken.
Special Considerations - For all spinal injections (excluding trigger point, botox and occipital or peripheral nerve blocks) multi-planar fluoroscopy, during procedures is required to document technique and needle placement, and should be performed by a physician experienced in the procedure. Permanent images are required to verify needle placement. The subspecialty disciplines of the physicians may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry. The practitioner who performs injections for low back pain should document hands on training through workshops of the type offered by organizations such as the International Spine Intervention Society (ISIS) and/or completed fellowship training with interventional training. Practitioners who perform spinal injections must also be knowledgeable of radiation safety.
6.4.5.1.1Epidural Steroid Spinal Injections:Description - Epidural steroid injections (ESI) deliver corticosteroid into the epidural space. The purpose of ESI is to reduce pain and inflammation, restoring range of motion and thereby facilitating progress in more active treatment programs. ESI uses three approaches: transforaminal, translaminar (midline), and caudal. For ESI in the low back, the transforaminal approach is the preferred method for unilateral, single-level pathology and for post-surgical patients. Also for the low back, there is good evidence that the transforaminal approach can deliver medication to the target tissue with few complications and can be used to identify the specific site of pathology.
Needle Placement - Multi-planar fluoroscipic imaging is required for all transforaminal epidural steroid injections. Contrast epidurograms allow one to verify the flow of medication into the epidural space. Permanent images are required to verify needle placement. Indications - There is some evidence that epidural steroid injections are effective for patients with radicular pain or radiculopathy (sensory or motor loss in a specific dermatome or myotome). Although there is no evidence regarding the effectiveness of ESI for non-radicular pain, it is a generally accepted intervention.
Frequency: Up to 3 treatments (a treatment may be a one or two level injection) over a period of six months, depending upon each patient's response.
Maximum: Two sessions (consisting of up to three injections each) may be done in one year based upon the patient's response.
6.4.5.1.2Zygapophyseal (Facet) Injection:Description - A generally accepted intra-articular or pericapsular injection of local anesthetic and corticosteroid. There is conflicting evidence to support a long-term therapeutic effect using facet injections. Indications patients with pain suspected to be of facet origin - Patients with recurrent pain should be evaluated, to determine the need for a rhizotomy.
Facet injections may be repeated if they result in documented functional benefit and/or at least an 50% initial improvement in pain as measured by accepted pain scales (such as VAS). Maximum Duration: 4 per level per year. Prior authorization must be obtained for injections beyond three levels.
6.4.5.1.3Sacro-iliac Joint Injection:Description - A generally accepted injection of local anesthetic in an intra-articular fashion into the sacro-iliac joint under radiographic guidance. May include the use of corticosteroids. Long-term therapeutic effect has not yet been established.
Indications - Primarily diagnostic to rule out sacroiliac joint dysfunction vs. other pain generators. Intra-articular injection can be of value in diagnosing the pain generator. These injections may be repeated if they result in increased documented functional benefit and/or at least an 50% initial improvement in pain scales as measured by accepted pain scales (such as VAS).
Maximum Duration: 3 injections per year.
6.4.5.2Trigger Point Injections:Description - Trigger point injection consists of dry needling or injection of local anesthetic with or without corticosteroid into highly localized, extremely sensitive bands of skeletal muscle fibers that produce local and referred pain when activated. Medication is injected in the area of maximum tenderness. Injection efficacy can be enhanced if injections are immediately followed by myofascial therapeutic interventions, such as vapo-coolant spray and stretch, ischemic pressure massage (myotherapy), specific soft tissue mobilization and physical modalities.
The effectiveness of trigger point injection is uncertain, in part due to the difficulty of demonstrating advantages of active medication over injection of saline. Needling alone may be responsible for some of the therapeutic response.
Indications - Trigger point injections may be used to relieve myofascial pain and facilitate active therapy and stretching of the affected areas. They are to be used as an adjunctive treatment in combination with other active treatment modalities. Trigger point injections should be utilized primarily for the purpose of facilitating functional progress. Trigger point injections are indicated in those patients where well-circumscribed trigger points have been consistently observed. Generally, these injections are not necessary unless consistently observed trigger points are not responding to specific, noninvasive, myofascial interventions within approximately a 4-week time frame.
Frequency: Weekly. Suggest no more than 4 injection sites per session per week to avoid significant post-injection soreness.
Optimum duration: 4 sessions.
Maximum duration: 8 weeks. Some patients may require 2 to 4 repetitions of trigger point injection series over a 1 to 2 year period.
6.4.5.3Botulinum Toxin (Botox) Injection:Description - Used to temporarily weaken or paralyze muscles. May reduce muscle pain in conditions associated with spasticity, dystonia, or other types of painful muscle spasm. Neutralizing antibodies develop in at least 4% of patients treated with botulinum toxin type A, rendering it ineffective. Several antigenic types of botulinum toxin have been described. Botulinum toxin type B, first approved by the Food and Drug Administration (FDA) in 2001, is similar pharmacologically to botulinum toxin type A, and there is good evidence of its efficacy in improving function in cervical dystonia (torticollis). It appears to be effective in patients who have become resistant to the type A toxin. The immune responses to botulinum toxins type A and B are not cross-reactive, allowing type B toxin to be used when type A action is blocked by antibody. Experimental work with healthy human volunteers suggests that muscle paralysis from type B toxin is not as complete or as long lasting as that resulting from type A. The duration of treatment effect of botulinum toxin type B for cervical dystonia has been estimated to be 12 to 16 weeks. EMG needle guidance may permit more precise delivery of botulinum toxin to the target area.
Indications - To improve range of motion and reduce painful muscle spasm. May be useful in musculoskeletal conditions associated with muscle spasm or headaches. There should be evidence of limited range of motion prior to the injection. May be useful in central neurologic conditions that produce spasticity or dystonia (e.g., brain injury, spinal cord injury, or stroke). Use is recommended according to current FDA guidelines.
Frequency: No less than 3 months between re-administration.
Optimum duration: 3 to 4 months.
Maximum duration: Currently unknown. Repeat injections should be based upon functional improvement and therefore used sparingly in order to avoid development of antibodies that might render future injections ineffective.
6.4.6MEDICATIONSThere is no single formula for pharmacological treatment of patients with chronic nonmalignant pain.
Control of chronic non-malignant pain is expected to involve the use of medication. Strategies for pharmacological control of pain cannot be precisely specified in advance. Rather, drug treatment requires close monitoring of the patient's response to therapy, flexibility on the part of the prescriber and a willingness to change treatment when circumstances change. Many of the drugs discussed in the medication section were licensed for indications other than analgesia, but are effective in the control of many types of chronic pain. Consensus regarding the use of opioids has generally been reached in the field of cancer pain, where nociceptive mechanisms are generally identifiable, expected survival may be short, and symptomatic relief is emphasized more than functional outcomes. In injured workers, by contrast, central and neuropathic mechanisms frequently overshadow nociceptive processes, expected survival is relatively long, and return to a high level of function is a major goal of treatment. Approaches to pain, which were developed in the context of malignant pain, therefore may not be transferable to chronic non-malignant pain.
All medications should be given an appropriate trial in order to test for therapeutic effect. Trials of medication requiring specific therapeutic drug levels may take several months to achieve, depending upon the half-life of the drug. It is recommended that patients with chronic nonmalignant pain be maintained on drugs that have the least serious side effects. For the clinician to interpret the following material, it should be noted that:
(1) drug profiles listed are not complete;(2) dosing of drugs will depend upon the specific drug, especially for off-label use; and(3) not all drugs within each class are listed, and other drugs within the class may be appropriate. Clinicians should refer to informational texts or consult a pharmacist before prescribing unfamiliar medications or when there is a concern for drug interactions. The following drug classes are listed in alphabetical order, not in order of suggested use. The following list is not all inclusive. It is acknowledged that medications not on this list may be appropriate choices for the care of injured workers.6.4.6.1Alpha-Acting Agents: Noradrenergic pain-modulating systems are present in the central nervous system, and the alpha-2 adrenergic receptor may be involved in the functioning of these pathways. Alpha-2 agonists may act by stimulating receptors in the substantia gelatinosa of the dorsal horn of the spinal cord, inhibiting the transmission of nociceptive signals. Spasticity may be reduced by presynaptic inhibition of motor neurons. Given limited experience with their use, they cannot be considered first-line analgesics, but a trial of their use may be warranted in many cases of refractory pain. 6.4.6.1.1 Clonidine (Catapres) 6.4.6.1.1.1 Description - Central alpha 2 agonist6.4.6.1.1.2 Indications - Sympathetically mediated pain, treatment of withdrawal from opioids.6.4.6.1.1.3 Dosing and Time to Therapeutic Effect - Increase dosage weekly to therapeutic effect.6.4.6.1.1.4 Recommended Laboratory Monitoring - Renal function.6.4.6.1.2 Tizanidine (Zanaflex) 6.4.6.1.2.1 Description - Alpha 2 adrenergic agonist.6.4.6.1.2.2 Indications - Spasticity, musculoskeletal disorders.6.4.6.1.2.3 Dosing and Time to Therapeutic Effect - As needed (PRN) or titrate to effective dose.6.4.6.1.2.4 Recommended Laboratory Monitoring - Hepatic and renal function.6.4.6.2Anticonvulsants: Although the mechanism of action of anticonvulsant drugs in neuropathic pain states remains to be fully defined, they appear to act as nonselective sodium channel blocking agents. A large variety of sodium channels are present in nervous tissue, and some of these are important mediators of nociception, as they are found primarily in unmyelinated fibers and their density increases following nerve injury. While the pharmacodynamic effects of the various anticonvulsant drugs are similar, the pharmacokinetic effects differ significantly. Carbamazepine has important effects as an inducer of hepatic enzymes and may influence the metabolism of other drugs enough to present problems in patients taking more than one drug. Gabapentin and oxcarbazepine, by contrast, are relatively non-significant enzyme inducers, creating fewer drug interactions.6.4.6.2.1 Gabapentin (Neurontin)6.4.6.2.1.1 Description - Structurally related to gamma-aminobutyric acid (GABA) but does not interact with GABA receptors.6.4.6.2.1.2 Indications - Neuropathic pain.6.4.6.2.1.3 Dosing and Time to Therapeutic Effect - Dosage may be increased over several days.6.4.6.2.1.4 Recommended Laboratory Monitoring - Renal function.6.4.6.2.2 Oxcarbazepine (Trileptal) 6.4.6.2.2.1 Description - The mechanism of action resembles that of carbamazepine, but has an advantage in being a less potent inducer of hepatic enzymes. Controlled trials of its effectiveness in chronic pain are lacking.
6.4.6.2.2.2 Indications - Neuropathic pain.6.4.6.2.2.3 Dosing and Time to Therapeutic Effect - Dosage may be increased weekly.6.4.6.2.2.4 Recommended Laboratory Monitoring - Drug levels, renal and hepatic function.6.4.6.2.3 Carbamazepine (Tegretol) 6.4.6.2.3.1 Description - Anticonvulsant structurally related to tricyclic antidepressants.6.4.6.2.3.2 Indications - Trigeminal neuralgia and other neuropathic pain.6.4.6.2.3.3 Dosing and Time to Therapeutic Effect - Dosage levels typically exceed those utilized for seizure prophylaxis. Titrate to desired effect.6.4.6.2.3.4 Recommended Laboratory Monitoring - Drug levels, renal and hepatic function, complete blood count.6.4.6.3Antidepressants: are classified into a number of categories based on their chemical structure and their effects on neurotransmitter systems. Their effects on depression are attributed to their actions on disposition of norepinephrine and serotonin at the level of the synapse; although these synaptic actions are immediate, the symptomatic response in depression is delayed by several weeks. When used for chronic pain, the effects may in part arise from treatment of underlying depression, but may also involve additional neuromodulatory effects on endogenous opioid systems, raising pain thresholds at the level of the spinal cord. Pain responses may occur at lower drug doses with shorter times to symptomatic response than are observed when the same compounds are used in the treatment of mood disorders. Neuropathic pain, diabetic neuropathy, post-herpetic neuralgia, and cancer-related pain may respond to antidepressant doses low enough to avoid adverse effects that often complicate the treatment of depression.
6.4.6.3.1 Tricyclics (e.g., amitriptyline [Elavil], nortriptyline [Pamelor, Aventyl], doxepin [Sinequan, Adapin])6.4.6.3.1.1 Description - Serotonergics, typically tricyclic antidepressants (TCAs), are utilized for their serotonergic properties as increasing CNS serotonergic tone can help decrease pain perception in non-antidepressant dosages. Amitriptyline is known for its ability to repair Stage 4 sleep architecture, a frequent problem found in chronic pain patients and to treat depression, frequently associated with chronic pain.6.4.6.3.1.2 Indications - Chronic musculoskeletal and/or neuropathic pain, insomnia. Second line drug treatment for depression.6.4.6.3.1.3 Dosing and Time to Therapeutic Effect - Varies by specific tricyclic. Low dosages are commonly used for chronic pain and/or insomnia.6.4.6.3.1.4 Recommended Laboratory Monitoring - Renal and hepatic function. EKG for those on high dosages or with cardiac risk.6.4.6.3.2 Selective serotonin reuptake inhibitors (SSRIs) (e.g., citalopram [Celexa], fluoxetine [Prozac], paroxetine [Paxil], sertraline [Zoloft]). 6.4.6.3.2.1 Description - SSRIs are characterized by the predominance of inhibition of serotonin reuptake at the pre-synaptic nerve terminal.6.4.6.3.2.2 Indications - Depression, chronic pain with depression and/or anxiety.6.4.6.3.2.3 Time to Produce Therapeutic Effect - 3 to 4 weeks.6.4.6.3.2.4 Recommended Laboratory Monitoring - Renal and hepatic function.6.4.6.3.3 Atypical Antidepressants/Other Agents6.4.6.3.3.1 Description - Venlafaxine, (Effexor), nefazadone (Serzone), trazodone (Deseryl), and mirtazapine (Remeron) share adjuvant analgesic effects with tricyclic antidepressants. They differ in their side effect and drug interaction profiles.6.4.6.3.3.2 Indications - Venlafaxine is approved for generalized anxiety disorder, bupropion for smoking cessation.6.4.6.3.3.3 Recommended Laboratory Monitoring - Drug specific.6.4.6.4Hypnotics and Sedatives: Sedative and hypnotic drugs decrease activity, induce drowsiness, and moderate agitation. Many drugs produce these effects incidental to their usual intended effects, similar to the side effects of many antihistamines and antidepressants.6.4.6.4.1 Zaleplon (Sonata) 6.4.6.4.1.1 Description - A nonbenzodiazepine hypnotic.6.4.6.4.1.2 Indications - Insomnia.6.4.6.4.1.3 Dosing and Time to Therapeutic Effect - Time of onset is 30 to 60 minutes. Due to rapid elimination, may be taken as little as 4 hours before awakening.6.4.6.4.1.4 Recommended Laboratory Monitoring - Hepatic function.6.4.6.4.2 Zolpidem (Ambien) 6.4.6.4.2.1 Description - A nonbenzodiazepine hypnotic, which does not appear to cause rebound insomnia. It has little respiratory depression and insignificant anxiolytic or muscle relaxant activity.6.4.6.4.2.2 Indications - Short-term use for insomnia6.4.6.4.2.3 Time to Therapeutic Effect - Onset of action is 30 to 60 minutes6.4.6.4.2.4 Recommended Laboratory Monitoring - Hepatic function.6.4.6.5Skeletal Muscle Relaxants: are most useful for acute musculoskeletal injury or exacerbation of injury.6.4.6.5.1 Cyclobenzaprine (Flexeril)6.4.6.5.1.1 Description - Structurally related to tricyclics.6.4.6.5.1.2 Indications - Chronic pain associated with muscle spasm.6.4.6.5.1.3 Dosing and Time to Therapeutic Effect - Variable, onset of action is 1 hour.6.4.6.5.1.4 Recommended Laboratory Monitoring - Hepatic and renal function.6.4.6.5.2 Carisoprodol (Soma) 6.4.6.5.2.1 Description - Mode of action may be central; meprobamate is an active metabolite.6.4.6.5.2.2 Indications - Chronic pain associated with muscle spasm.6.4.6.5.2.3 Recommended Laboratory Monitoring - Renal and hepatic function.6.4.6.5.3 Metazalone (Skelaxin) 6.4.6.5.3.1 Description - Central acting muscle relaxant.6.4.6.5.3.2 Indications - Muscle spasm.6.4.6.5.3.3 Dosing and Time to Therapeutic Effect - Onset of action 1 hour.6.4.6.5.3.4 Recommended Laboratory Monitoring - Hepatic function.6.4.6.6Opioids: are the most powerful analgesics. Opioids include some of the oldest and most effective drugs used in the control of severe pain. The discovery of opioids receptors and their endogenous peptide ligands has led to an understanding of effects at the binding sites of these naturally occurring substances. Most of their analgesic effects have been attributed to their modification of activity in pain pathways within the central nervous system; however, it has become evident that they also are active in the peripheral nervous system. Activation of receptors on the peripheral terminals of primary afferent nerves can mediate antinociceptive effects, including inhibition of neuronal excitability and release of inflammatory peptides. Some of their undesirable effects on inhibiting gastrointestinal motility are peripherally mediated by receptors in the bowel wall. The central nervous system actions of these drugs account for much of their analgesic effect. Consultation or referral to a pain specialist should be considered when the pain persists but the underlying tissue pathology is minimal or absent and correlation between the original injury and the severity of impairment is not clear. Consider consultation if suffering and pain behaviors are present and the patient continues to request medication, or when standard treatment measures have not been successful or are not indicated.
6.4.6.6.1 On-Going, Long-Term Management - Actions may include: 6.4.6.6.1.1 Prescriptions from a single practitioner,6.4.6.6.1.2 Ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects,6.4.6.6.1.3 Ongoing effort to gain improvement of social and physical function as a result of pain relief,6.4.6.6.1.4 Contract detailing reasons for termination of supply, with appropriate tapering of dose,6.4.6.6.1.5 Use of random drug screening as deemed appropriate by the prescribing physician,6.4.6.6.1.6 Use of more than two opioids: a long acting opioid for maintenance of pain relief and a short acting opioid for limited rescue use when pain exceeds the routine level. If more than two opioids are prescribed for long-term use, a second opinion from specialist who is Board Certified in Neurology, Physical Medicine and Rehabilitation, or Anesthesiology with recognized training and/or certification in pharmacological pain management is strongly recommended.6.4.6.6.1.7 Use of acetaminophen-containing medications in patients with liver disease should be limited; and6.4.6.6.1.8 Continuing review of overall situation with regard to nonopioid means of pain control.6.4.6.7Nonsteroidal Anti-Inflammatory Drugs: Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are useful for pain and inflammation. In mild cases, they may be the only drugs required for analgesia. There are several classes of NSAIDs and the response of the individual injured worker to a specific medication is unpredictable. For this reason a range of NSAIDs may be tried in each case with the most effective preparation being continued.
6.4.6.7.1 Non-selective Nonsteroidal Anti-Inflammatory Drugs6.4.6.7.2 Selective Cyclo-oxygenase-2 (COX-2) Inhibitors COX-2 inhibitors are more recent NSAIDs and differ in adverse side effect profiles from the traditional NSAIDs. The major advantages of selective COX-2 inhibitors over traditional NSAIDs are that they have less gastrointestinal toxicity and no platelet effects. COX-2 inhibitors can worsen renal function in patients with renal insufficiency; thus, renal function may need monitoring.
6.4.6.8Topical Drug Delivery:6.4.6.8.1 Description - Topical medications may be an alternative treatment for localized musculoskeletal disorders and is an acceptable form of treatment in selected.6.4.6.8.2 Indications - Generalized musculoskeletal or joint pain. Patient selection must be rigorous to select those patients with the highest probability of compliance.6.4.6.8.3 Dosing and Time to Therapeutic Effect - It is necessary that all topical agents be used with strict instructions for application as well as maximum number of applications per day to obtain the desired benefit and avoid potential toxicity.6.4.6.9Other Agents:6.4.6.9.1 Tramadol (Ultram) 6.4.6.9.1.1 Description - An opioid partial agonist that is generally well tolerated, does not cause GI ulceration, or exacerbate hypertension or congestive heart failure.6.4.6.9.1.2 Indications - Mild to moderate pain relief. This drug has been shown to provide pain relief equivalent to that of commonly prescribed NSAIDs.6.4.6.9.2 Baclofen (Lioresal) 6.4.6.9.2.1 Description - May be effective due to stimulation of Gamma Aminobutyric Acid (GABA) receptors.6.4.6.9.2.2 Indications - Pain from muscle rigidity.6.4.6.9.2.3 Recommended Laboratory Monitoring - Renal function.6.4.6.9.3 Mexilitene (Mexitil) 6.4.6.9.3.1 Description - An antiarrhythmic drug, which, like some anticonvulsive agents, may act on ion channels in neuronal tissue and reduce its pathological activity to a more stable level. Low concentrations may suffice to abolish impulses in damaged nerves, and mexilitene has been used successfully to treat neuropathic pain.6.4.6.9.3.2 Indications - Neuropathic pain.6.4.6.9.3.3 Recommended Laboratory Monitoring - Hepatic function, CBC. Plasma levels may also be necessary.6.4.7ORTHOTICS/PROSTHETICS/EQUIPMENT Devices and adaptive equipment may be necessary in order to reduce impairment and disability, to facilitate medical recovery, to avoid re-aggravation of the injury, and to maintain maximum medical improvement. Indications would be to provide relief of the industrial injury or prevent further injury and include the need to control neurological and orthopedic injuries for reduced stress during functional activities. In addition, they may be used to modify tasks through instruction in the use of a device or physical modification of a device. Equipment needs may need to be reassessed periodically. Equipment may include high and low technology assistive devices, computer interface or seating, crutch or walker training, and self-care aids. It should improve safety and reduce risk of re-injury. Standard equipment to alleviate the effects of the injury on the performance of activities of daily living may vary from simple to complex adaptive devices to enhance independence and safety. Certain equipment related to cognitive impairments may also be required.
Ergonomic modifications may be necessary to facilitate medical recovery, to avoid re-aggravation of the injury, and to maintain maximum medical improvement. Ergonomic evaluations with subsequent recommendations may assist with the patients' return-to-work.
For chronic pain disorders, equipment such as foot orthoses or lumbar support devices may be helpful. The injured worker should be educated as to the potential harm from using a lumbar support for a period of time greater than which is prescribed. Special cervical orthosis and/or equipment may have a role in the rehabilitation of a cervical injury such as those injuries to a cervical nerve root resulting in upper extremity weakness or a spinal cord injury with some degree of paraparesis or tetraparesis. Fabrication/modification of orthotics, including splints, would be used when there is need to normalize weight-bearing, facilitate better motion response, stabilize a joint with insufficient muscle or proprioceptive/reflex competencies, to protect subacute conditions as needed during movement, and correct biomechanical problems.
Orthotic/prosthetic training is the skilled instruction (preferably by qualified providers) in the proper use of orthotic devices and/or prosthetic limbs.
For information regarding specific types of orthotics/prosthetics/equipment, refer to individual medical treatment guidelines.
6.4.8PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION Psychosocial treatment is a generally accepted, well-established therapeutic and diagnostic procedure with selected use in acute pain problems, but with more widespread use in sub-acute and chronic pain populations. Psychosocial treatment may be important component in the total management of a patient with chronic pain and should be implemented as soon as the problem is identified.Once a diagnosis consistent with the standards of the American Psychiatric Association Diagnostic Statistical Manual of Mental Disorders has been determined, the patient should be evaluated for the potential need for psychiatric medications. Use of any medication to treat a diagnosed condition may be ordered by the authorized treating physician or by the consulting psychiatrist. Visits for management of psychiatric medications are medical in nature and are not a component of psychosocial treatment. Therefore, separate visits for medication management may be necessary, depending upon the patient and medications selected.
The screening or diagnostic workup should have clarified and distinguished between pre-existing, aggravated, and/or purely causative psychological conditions. Therapeutic and diagnostic modalities include, but are not limited to, individual counseling, and group therapy. Treatment can occur within an individualized model, a multi-disciplinary model, or within a structured pain management program.
A psychologist with a Ph.D., PsyD, EdD credentials, or a Psychiatric MD/DO may perform psychosocial treatments. Other licensed mental health providers working in consultation with a Ph.D., PsyD, EdD, or Psychiatric MD/DO, and with experience in treating chronic pain disorders in injured workers may also perform treatment.
Frequency: 1 to 5 times weekly for the first 4 weeks (excluding hospitalization, if required), decreasing to 1 to 2 times per week for the second month. Thereafter, 2 to 4 times monthly with the exception of exacerbations which may require increased frequency of visits. Not to include visits for medication management.
Maximum duration: 6 to 12 months, not to include visits for medication management. For select patients, longer supervised treatment may be required.
6.4.9RESTRICTION OF ACTIVITIES Continuation of normal daily activities is the goal for chronic pain patients since immobility will negatively affect rehabilitation. Prolonged immobility results in a wide range of deleterious effects, such as a reduction in aerobic capacity and conditioning, loss of muscle strength and flexibility, increased segmental stiffness, promotion of bone demineralization, impaired disc nutrition, and the facilitation of the illness role.6.4.10RETURN-TO-WORK is one of the major components in chronic pain management.REHABILITATION - It is understood Individuals with Chronic Pain may require additional visits due to acute exacerbations. The practitioner is required to document the rationale for care and may be subject to Utilization Review. All visit limits pertain to an annual amount. It is also understood that practitioners should only provide treatment that is consistent with impairments and dysfunctions identified by a comprehensive physical assessment.
6.4.11THERAPY-ACTIVE therapies are based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion, and alleviating discomfort. Active therapy requires an internal effort by the individual to complete a specific exercise or task, and thus assists in developing skills promoting independence to allow self-care after discharge. This form of therapy requires supervision from a therapist or medical provider such as verbal, visual, and/or tactile instructions. At times a provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is predominately executed by the patient. Patients should be instructed to continue active therapies at home as an extension of the treatment process in order to maintain improvement levels. Home exercise can include exercise with or without mechanical assistance or resistance and functional activities with assistive devices. Interventions are selected based on the complexity of the presenting dysfunction with ongoing examination, evaluation and modification of the plan of care as improvement or lack thereof occurs. Change and/or discontinuation of an intervention should occur if there is attainment of expected goals/outcome, lack of progress, lack of tolerance and/or lack of motivation. Passive interventions/modalities may only be used as adjuncts to the active program.
6.4.11.1Activities of Daily Living: Supervised instruction, active-assisted training, and/or adaptation of activities or equipment to improve a person's capacity in normal daily living activities such as self-are, work re-integration training, homemaking, and driving.6.4.11.2Functional Activities: are the use of therapeutic activity to enhance mobility, body mechanics, employability, coordination, and sensory motor integration.6.4.11.3Nerve Gliding: exercises consist of a series of flexion and extension movements of the hand, wrist, elbow, shoulder, and neck that produce tension and longitudinal movement along the length of the median and other nerves of the upper extremity. These exercises are based on the principle that the tissues of the peripheral nervous system are designed for movement, and that tension and glide (excursion) of nerves may have an effect on neurophysiology through alterations in vascular and axoplasmic flow. Biomechanical principles have been more thoroughly studied than clinical outcomes.6.4.11.4Neuromuscular Re-education: is the skilled application of exercise with manual, mechanical, or electrical facilitation to enhance strength, movement patterns, neuromuscular response, proprioception, kinesthetic sense, coordination education of movement, balance, and posture. Indications include the need to promote neuromuscular responses through carefully timed proprioceptive stimuli, to elicit and improve motor activity in patterns similar to normal neurologically developed sequences, and improve neuromotor response with independent control. Maximum number of visits 24
6.4.11.5Proper Work Techniques: Please refer to the "Job Site Evaluation" and "Job Site Alteration" sections of these guidelines.6.4.11.6Therapeutic Exercise: with or without mechanical assistance or resistance may include isoinertial, isotonic, isometric and isokinetic types of exercises. Indications include the need for cardiovascular fitness, reduced edema, improved muscle strength, improved connective tissue strength and integrity, increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle recruitment, increased range of motion, and are used to promote normal movement patterns. Can also include complementary/alternative exercise movement therapy. Time to produce effect: 2 to 6 treatments
Frequency: 3 to 5 times per week
Optimum duration: 4 to 8 weeks
Maximum duration: 24 visits, and maximum of 24 in combination with functional activities
6.4.12THERAPY - PASSIVE Most of the following passive therapies and modalities are generally accepted methods of care for a variety of work-related injuries. Passive therapy includes those treatment modalities that do not require energy expenditure on the part of the patient. They are principally effective during the early phases of treatment and are directed at controlling symptoms such as pain, inflammation and swelling and to improve the rate of healing soft tissue injuries. They should be used adjunctively with active therapies such as postural stabilization and exercise programs to help control swelling, pain, and inflammation during the active rehabilitation process. Please refer to Section B. 4. General Guideline Principles, Active Interventions. Passive therapies may be used intermittently as a provider deems appropriate or regularly if there are specific goals with objectively measured functional improvements during treatment. On occasion, specific diagnoses and post-surgical conditions may warrant durations of treatment beyond those listed as "maximum." factors such as exacerbation of symptoms, re-injury, interrupted continuity of care, and comorbidities may also extend durations of care. Specific goals with objectively measured functional improvement during treatment must be cited to justify extended durations of care. It is recommended that, if no functional gain is observed after the number of treatments under "time to produce effect" have been completed, alternative treatment interventions, further diagnostic studies, or further consultations should be pursued.
The following passive therapies are listed below:
6.4.12.1Electrical Stimulation (Unattended and Attended): is an accepted treatment. Once applied, unattended electrical stimulation requires minimal on-site supervision by the provider. Indications include pain, inflammation, muscle spasm, atrophy, decreased circulation, and the need for osteogenic stimulation. A home unit should be purchased if treatment is effective and frequent use is recommended. Time to produce effect: 2 to 4 treatments Maximum duration: 14 visits
6.4.12.2Iontophoresis: is an accepted treatment which consists of the transfer of medication, including, but not limited to, steroidal anti-inflammatories and anesthetics, through the use of electrical stimulation. Indications include pain (Lidocaine), inflammation (hydrocortisone, salicylate), edema (mecholyl, hyaluronidase, salicylate), ischemia (magnesium, mecholyl, iodine), muscle spasm (magnesium, calcium), calcific deposits (acetate), scars, and keloids (sodium chloride, iodine, acetate). There is no proven benefit for this therapy in the low back Time to produce effect: 1 to 4 treatments Frequency: 3 times per week with at least 48 hours between treatments
Maximum duration: 8 visits per body region
6.4.12.3Manipulation: is generally accepted, well-established and widely used therapeutic intervention for low back pain. Manipulative Treatment (not therapy) is defined as the therapeutic application of manually guided forces by an operator to improve physiologic function and/or support homeostasis that has been altered by the injury or occupational disease, and has associated clinical significance. High velocity, low amplitude (HVLA) technique, chiropractic manipulation, osteopathic manipulation, muscle energy techniques, counter strain, and non-force techniques are all types of manipulative treatment. This may be applied by osteopathic physicians (D.O.), chiropractors (D.C.), properly trained physical therapists (P.T.), or properly trained medical physicians. Under these different types of manipulation exist many subsets of different techniques that can be described as a) direct- a forceful engagement of a restrictive/pathologic barrier, b) indirect- a gentle/non-forceful disengagement of a restrictive/pathologic barrier, c) the patient actively assists in the treatment and d) the patient relaxing, allowing the practitioner to move the body tissues. When the proper diagnosis is made and coupled with the appropriate technique, manipulation has no contraindications and can be applied to all tissues of the body. Pre-treatment assessment should be performed as part of each manipulative treatment visit to ensure that the correct diagnosis and correct treatment is employed.
High velocity, low amplitude (HVLA) manipulation is performed by taking a joint to its end range of motion and moving the articulation into the zone of accessory joint movement, well within the limits of anatomical integrity. There is good scientific evidence to suggest that HVLA manipulation can be helpful for patients with acute low back pain problems without radiculopathy when used within the first 4 to 6 weeks of symptoms. Although the evidence for sub-acute and chronic low back pain and low back pain with radiculopathy is less convincing, it is a generally accepted and well-established intervention for these conditions. Indications for manipulation include joint pain, decreased joint motion, and joint adhesions. Contraindications to HVLA manipulation include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthritides, aortic aneurysm, and signs of progressive neurologic deficits.
Time to produce effect for all types of manipulative treatment: 1 to 6 treatments.
Frequency: Up to 3 times per week for the first 4 weeks as indicated by the severity of involvement and the desired effect, then up to 2 treatments per week for the next 4 weeks. For further treatments, twice per week or less to maintain function.
Maximum duration: 26 visits.
The combination of 97140 plus either CMT or OMT code is equal to one visit when performed on the same day. Any combination of manual therapeutic intervention exceeding 26 visits (not units) need to go to UR.
6.4.12.4Massage - Manual or Mechanical: Massage is manipulation of soft tissue with broad ranging relaxation and circulatory benefits. This may include techniques that include pressing, lifting, rubbing, pinching of soft tissues by, or with, the practitioner's hands. Indications include edema (peripheral or hard and non-pliable edema), muscle spasm, adhesions, the need to improve peripheral circulation and range of motion, or to increase muscle relaxation and flexibility prior to exercise. In sub-acute low back pain populations there is good evidence that massage can increase function when combined with exercise and patient education. Some studies have demonstrated a decrease in provider visits and pain medication use with combined therapy. One study indicated improved results with acupressure massage. It is recommended that all massage be performed by trained, experienced therapists and be accompanied by an active exercise program and patient education. In contrast to the sub-acute population, massage is a generally accepted treatment for the acute low back pain population, although no studies have demonstrated its efficacy for this set of patients.
Time to produce effect: Immediate
Frequency: 1 to 3 times per week
Maximum duration: 12 visits (CPT codes 97124 and 97140 can not exceed 26 visits in combination).
6.4.12.5Mobilization (Joint): is a generally well-accepted treatment. Mobilization is passive movement involving oscillatory motions to the vertebral segment(s). The passive mobility is performed in a graded manner (I, II, III, IV, or V), which depicts the speed and depth of joint motion during the maneuver. For further discussion on Level V joint mobilization please see section on HVLA manipulation [Refer to section 12. d.]. It may include skilled manual joint tissue stretching. Indications include the need to improve joint play, segmental alignment, improve intracapsular arthrokinematics, or reduce pain associated with tissue impingement. Mobilization should be accompanied by active therapy. For Level V mobilization contraindications include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthritides, aortic aneurysm, and signs of progressive neurologic deficits. Time to produce effect for all types of manipulative treatment: 1 to 6 treatments.
Frequency: Up to 3 times per week for the first 4 weeks as indicated by the severity of involvement and the desired effect, then up to 2 treatments per week for the next 4 weeks. For further treatments, twice per week or less to maintain function.
Maximum duration: 26 visits. CPT codes 97124 and 97140 can not exceed 48 visits in combination
6.4.12.6Mobilization (Soft Tissue): is a generally well-accepted treatment. Mobilization of soft tissue is the skilled application of muscle energy, strain/counter strain, myofascial release, manual trigger point release, and manual therapy techniques designed to improve or normalize movement patterns through the reduction of soft tissue pain and restrictions. These can be interactive with the patient participating or can be with the patient relaxing and letting the practitioner move the body tissues. Indications include muscle spasm around a joint, trigger points, adhesions, and neural compression. Mobilization should be accompanied by active therapy. Maximum duration: 26 visits CPT codes 97124 and 97140 can not exceed 48 visits in combination.
6.4.12.7Short-Wave Diathermy: is an accepted treatment which involves the use of equipment that exposes soft tissue to a magnetic or electrical field. Indications include enhanced collagen extensibility before stretching, reduced muscle guarding, reduced inflammatory response, and enhanced re-absorption of hemorrhage/hematoma or edema. It is an accepted modality as an adjunct to acupuncture or situation where other forms of contact superficial heat is contraindicated.6.4.12.8Superficial Heat and Cold Therapy (excluding Infrared Therapy): is a generally accepted treatment. Superficial heat and cold are thermal agents applied in various manners that lower or raise the body tissue temperature for the reduction of pain, inflammation, and/or effusion resulting from injury or induced by exercise. Includes application of heat just above the surface of the skin at acupuncture points. Indications include acute pain, edema and hemorrhage, need to increase pain threshold, reduce muscle spasm, and promote stretching/flexibility. Cold and heat packs can be used at home as an extension of therapy in the clinic setting. Time to produce effect: Immediate
Frequency: 2 to 5 times per week
Maximum duration: 12 visits, with a maximum of 1 unit per day
6.4.12.9Traction-Mechanical: Traction modalities are contraindicated in patients with tumor, infections, fracture, or fracture dislocation. Non-oscillating inversion traction methods are contraindicated in patients with glaucoma or hypertension. Motorized traction devices are included (i.e. VAX-D, DRX9000, etc.) Time to produce effect: 1 to 3 sessions up to 30 minutes. If response is negative after 3 treatments, discontinue this modality.
Frequency: 2 to 3 times per week. A home traction unit can be purchased if therapy proves effective. Maximum duration: 16 visits
6.4.12.10Transcutaneous Electrical Nerve Stimulation (TENS): is a generally accepted treatment. TENS should include at least one instructional session for proper application and use. Indications include muscle spasm, atrophy, and decreased circulation and pain control. Minimal TENS unit parameters should include pulse rate, pulse width and amplitude modulation. Consistent, measurable functional improvement should be documented prior to the purchase of a home unit. Time to produce effect: Immediate Frequency: Variable Duration: 3 visits
6.4.12.11Ultrasound (Including Phonophoresis): is an accepted treatment. Ultrasound uses sonic generators to deliver acoustic energy for therapeutic thermal and/or non-thermal soft tissue effects. Indications include scar tissue, adhesions, collagen fiber and muscle spasm, and the need to extend muscle tissue or accelerate the soft tissue healing. Ultrasound with electrical stimulation is concurrent delivery of electrical energy that involves dispersive electrode placement. Indications include muscle spasm, scar tissue, pain modulation, and muscle facilitation.Phonophoresis is the transfer of medication to the target tissue to control inflammation and pain through the use of sonic generators. These topical medications include, but are not limited to, steroidal anti-inflammatory and anesthetics. Phonopheresis is not recommended for Low Back Pain.
Time to produce effect: 6 to 15 treatments
Frequency: 3 times per week
Maximum duration: 18 visits
6.4.13THERAPY-ACTIVE The following active therapies are widely used and accepted methods of care for a variety of work-related injuries. They are based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion, and can alleviate discomfort. Active therapy requires an internal effort by the individual to complete a specific exercise or task. This form of therapy requires supervision from a provider such as verbal, visual, and/or tactile instruction(s). At times, the provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is predominately executed by the patient. Patients should be instructed to continue active therapies at home as an extension of the treatment process in order to maintain improvement levels. Follow-up visits to reinforce and monitor progress and proper technique are recommended. Home exercise can include exercise with or without mechanical assistance or resistance and functional activities with assistive devices. The following active therapies are listed in alphabetical order:
6.4.13.1Activities of Daily Living (ADL) are well-established interventions which involve instruction, active-assisted training, and/or adaptation of activities or equipment to improve a person's capacity in normal daily activities such as self-care, work re-integration training, homemaking, and driving. Time to produce effect: 4 to 5 treatments Maximum duration: 10 visits
6.4.13.2Aquatic Therapy: is a well-accepted treatment which consists of the therapeutic use of aquatic immersion for therapeutic exercise to promote strengthening, core stabilization, endurance, range of motion, flexibility, body mechanics, and pain management. Aquatic therapy includes the implementation of active therapeutic procedures in a swimming or therapeutic pool. The water provides a buoyancy force that lessens the amount of force gravity applies to the body. The decreased gravity effect allows the patient to have a mechanical advantage and more likely have a successful trial of therapeutic exercise. The therapy may be indicated for individuals who: Cannot tolerate active land-based or full-weight bearing therapeutic procedures require increased support in the presence of proprioceptive deficit;
Are at risk of compression fracture due to decreased bone density; have symptoms that are exacerbated in a dry environment;
Would have a higher probability of meeting active therapeutic goals than in a land-based environment.
The pool should be large enough to allow full extremity range of motion and fully erect posture. Aquatic vests, belts and other devices can be used to provide stability, balance, buoyancy, and resistance.
Time to produce effect: 4 to 5 treatments Frequency: 3 to 5 times per week Maximum duration: 16 visits
A self-directed program is recommended after the supervised aquatics program has been established, or, alternatively a transition to a land-based environment exercise program.
6.4.13.3 Functional Activities: are well-established interventions which involve the use of therapeutic activity to enhance mobility, body mechanics, employability, coordination, balance, and sensory motor integration. Time to produce effect: 4 to 5 treatments
Frequency: 3 to 5 times per week
Maximum duration: 26 visits
Total number of visit 97110 and 97530 should not exceed 40 visits without pre-authorization.
6.4.13.4 Functional Electrical Stimulation: is an accepted treatment in which the application of electrical current to elicit involuntary or assisted contractions of atrophied and/or impaired muscles. It may be indicated for impaired muscle function to radiculopathy. (Foot drop) Time to produce effect: 2 to 6 treatments
Frequency: 3 times per week
Maximum duration: 14 visits inclusive of electrical stimulation codes. If beneficial, provide with home unit.
6.4.13.5 Neuromuscular Re-education: is a generally accepted treatment. It is the skilled application of exercise with manual, mechanical, or electrical facilitation to enhance strength; movement patterns; neuromuscular response; proprioception, kinesthetic sense, coordination; education of movement, balance, and posture. Indications include the need to promote neuromuscular responses through carefully timed proprioceptive stimuli, to elicit and improve motor activity in patterns similar to normal neurologically developed sequences, and improve neuromotor response with independent control. Time to produce effect: 2 to 6 treatments
Frequency: 3-5 times per week
Maximum duration: 24 visits
6.4.13.6 Therapeutic Exercise: is a generally well-accepted treatment. Therapeutic exercise, with or without mechanical assistance or resistance, may include isoinertial, isotonic, isometric and isokinetic types of exercises. Indications include the need for cardiovascular fitness, reduced edema, improved muscle strength, improved connective tissue strength and integrity, increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle recruitment, improved proprioception, and coordination, increased range of motion. Therapeutic exercises are used to promote normal movement patterns, and can also include complementary/alternative exercise movement therapy (with oversight of a physician or appropriate healthcare professional).6.4.13.7 Spinal Stabilization: is a generally well-accepted treatment. The goal of this therapeutic program is to strengthen the spine in its neural and anatomic position. The stabilization is dynamic which allows whole body movements while maintaining a stabilized spine. It is the ability to move and function normally through postures and activities without creating undue vertebral stress Time to produce effect: 2 to 6 treatments
Frequency: 3 to 5 times per week
Maximum duration: 26 visits
Total number of visits of 97110 & 97530 may not exceed 40 visits without pre-authorization.