Before initiation of any therapeutic procedure, the authorized treating provider, employer and insurer must consider these important issues in the care of the injured worker.
First, 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.
Second, cessation and/or review of treatment modalities should be undertaken when no further significant subjective or objective improvement in the patient's condition is noted. If patients are not responding within the recommended duration periods, alternative treatment interventions, further diagnostic studies or consultations should be pursued.
Third, providers 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.
In cases where a patient is unable to attend an outpatient center, home therapy may be necessary. Home therapy may include active and passive therapeutic procedures as well as other modalities to assist in alleviating pain, swelling, and abnormal muscle tone. Home therapy is usually of short duration and continues until the patient is able to tolerate coming to an outpatient center.
The following procedures are listed in alphabetical order.
6.1ACUPUNCTURE is an accepted and widely used procedure for the relief of pain and inflammation. 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]. 6.1.1Acupuncture: 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 and inflammation, and to increase blood flow to an area and increase range of motion. Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain. | . | Time to produce effect: 3 to 6 treatments |
| . | Frequency: 1 to 3 times per week |
| . | Course duration: 14 treatments |
6.1.2 Acupuncture 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.
| . | Time to produce effect: 3 to 6 treatments |
| . | Frequency: 1 to 3 times per week |
| . | Course duration: 14 treatments |
6.1.3Other 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. | . | Time to produce effect: 3 to 6 treatments |
| . | Frequency: 1 to 3 times per week |
| . | Course duration: 14 treatments |
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. Treatment beyond 14 sessions (1 course) may be documented with respect to need and ability to facilitate positive symptomatic or functional gains.
6.2BIOFEEDBACK is a form of behavioral medicine that helps patients learn self-awareness and self-regulation skills for the purpose of gaining greater control of their physiology, such as muscle activity, brain waves, and measures of autonomic nervous system activity. 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. Biofeedback is provided by clinicians certified in biofeedback and/or who have documented specialized education, advanced training, or direct or supervised experience qualifying them to provide the specialized treatment needed (e.g., surface EMG, EEG, or other). Treatment is individualized to the patient's work-related diagnosis and needs. Home practice of skills is required for mastery and may be facilitated by the use of home training tapes. The ultimate 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.
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 emotional stress/pain responses such as anxiety, depression, anger, sleep disturbance, and other central and autonomic nervous system imbalances. Biofeedback is often utilized along with other treatment modalities.
| . | Time to produce effect: 3 to 4 sessions |
| . | Frequency: 1 to 2 times per week |
| . | 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. |
6.3INJECTIONS - THERAPEUTIC are generally accepted, well-established procedures that may play a significant role in the treatment of patients with upper extremity pain or pathology. Therapeutic injections involve the delivery of anesthetic and/or anti-inflammatory medications to the painful structure. Therapeutic injections have many potential benefits. Ideally, a therapeutic injection will: (a) reduce inflammation in a specific target area; (b) relieve secondary muscle spasm; and (c) diminish pain and support therapy directed to functional recovery. Diagnostic and therapeutic injections should be used early and selectively to establish a diagnosis and support rehabilitation. If injections are overused or used outside the context of a monitored rehabilitation program, they may be of significantly less value. 6.3.1Steroid Injections: may provide both diagnostic and therapeutic value in treating a variety of shoulder disorders. These include biceps tendonitis, bursitis, rotator cuff tendonitis and impingement syndrome. Steroid injections provide a potent anti-inflammatory effect, which is usually short term in duration, lasting weeks or months. Injections should always be used as an adjunctive treatment in the context of a physical exercise and rehabilitation program.
***When performing tendon injections, the risk of tendon rupture should be discussed with the patient and the need for temporary restricted duty emphasized. ****
Contraindications: General contraindications include local or systemic infection, bleeding disorders, and allergy to medications used.
Local Steroid Injections:
| . | Time to produce effect: 3 days |
| . | Maximum duration: 3 injections |
6.3.2Trigger Point Injections: are generally accepted, although used infrequently in uncomplicated cases. They may, however, be used to relieve myofascial pain and facilitate active therapy and stretching of the affected areas, and as an adjunctive treatment in combination with other treatment modalities, such as functional restoration programs, including stretching therapeutic exercise. Trigger point injections should be utilized primarily for the purpose of facilitating functional progress. The Division does not recommend their routine use in the treatment of upper extremity injuries. | . | Time to produce effect: Local anesthetic 30 minutes; 24 to 48 hours for no anesthesia. |
| . | Frequency: Weekly. Suggest no more than 4 injection sites per session per week to avoid significant post-injection soreness. |
| . | Maximum duration: 8 weeks. Occasional patients may require 2 to 4 repetitions of trigger point injection series over a 1 to 2 year period. |
6.4JOB SITE ALTERATION Early evaluation and training of body mechanics and other ergonomic factors are essential for every injured worker and should be done by a qualified individual. In some cases, this requires a job site evaluation. Some evidence supports alteration of the work site in the early treatment of non-traumatic Shoulder Disorders. There is no single factor or combination of factors that is proven to prevent or ameliorate Shoulder Disorders, but a combination of ergonomic are generally considered to be important. Physical factors that may be considered include use of force, repetition, awkward positions, upper extremity vibration, cold environment, and contact pressure on the nerve. The job analysis and modification should include input from the employee, employer, and ergonomist or other professional familiar with work place evaluation. The employee must be observed performing all job functions in order for the job site analysis to be valid. Periodic follow-up is recommended to evaluate effectiveness of the intervention and need for additional ergonomic changes.
6.5MEDICATIONSFor shoulder disorders, medications play a secondary role and should never be the sole modality of treatment. If a patient's symptoms resolve quickly with medications or any other passive modality, the practitioner should still consider prescribing a brief course in shoulder and upper extremity education and safety. When required, a wide range of medication is available. Modalities in this group are generally accepted, established and widely used. All narcotics and habituating medications should be prescribed with strict time, quantity and duration guidelines with a definite cessation parameter. Prescribing these drugs on an as-needed basis (PRN) should almost always be avoided.
6.5.1NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs) are probably the most useful medications in acute and chronic shoulder injury. In mild cases, they may be the only drug required for analgesia. There are several classes of NSAIDs and the response of the individual patient to a specific medication is unpredictable. For this reason, a range of anti-inflammatory medications may be tried in each case with the most effective preparation being continued. For prolonged use of NSAIDs greater than 1-3 months, patients should be monitored for adverse reactions. Appropriate intervals for metabolic screening are dependent upon the patient's age, general health status and should be within parameters listed for each specific medication.
6.5.2ANALGESICS (acetaminophen and aspirin are the common choice for non-narcotic analgesia.6.5.3PSYCHOTROPIC MEDICATION may be used in patients with a high level of anxiety or depression. A variety of psychotropic drugs may be used. In acute or subacute shoulder injury, these medications are generally unnecessary except for the use of tricyclic antidepressants as substitutes for hypnotics and/or analgesics. In most cases, major tranquilizers, anxiolytics and antidepressants are reserved for chronic pain disorders. Patients, whose chief complaint is shoulder injury, but require use of major tranquilizers or anxiolytics for greater than two weeks. In particular, benzodiazepams are almost always contraindicated in patients with shoulder injury unless a severe anxiety state exist requiring psychiatric supervision or in cases of extremely severe, objectively visualized acute muscle spasm. In this type of acute scenario, the maximum duration for benzodiazepam administration should be limited to less than five days.6.5.4HYPNOTICS may be given to shoulder injury sufferers because of a chief complaint of "inability to sleep." Such medication must be used with caution because of their dependence-producing capabilities. The Division recommends consideration of sedating tricyclic antidepressants as an alternative when necessary. Physical methods of restoring a normal sleep pattern can usually be employed as an alternative to medication.6.5.5NARCOTICS should be primarily reserved for the treatment of acute shoulder injury or the treatment of patients with objectively documented acute exacerbations. The action of these drugs is central, affecting the patient's perception of pain rather than the pain process itself. Narcotics are rarely indicated in the treatment of patients with pure shoulder injury without fracture. In mild to moderate cases of upper extremity pain, narcotic medication should not be used at all. Adverse effects include respiratory depression and the development of physical and psychological dependence.
6.5.6MINOR TRANQUILIZERS/MUSCLE RELAXANTS should be primarily reserved for the treatment of acute shoulder with muscle spasm or the treatment of patients with objectively documented acute exacerbations. Muscle relaxants may have a significant effect on the early phases of acute shoulder disorders. Their action is central and with no effect on the neuromuscular junction of the muscles themselves. Purported peripheral effects are difficult to separate from the anxiolytic central action.6.6OCCUPATIONAL REHABILITATION PROGRAMS6.6.1 Non-Interdisciplinary: These programs are work-related, outcome-focused, individualized treatment programs. Objectives of the program include, but are not limited to, improvement of cardiopulmonary and neuromusculoskeletal functions (strength, endurance, movement, flexibility, stability, and motor control functions), patient education, and symptom relief. The goal is for patients to gain full or optimal function and return-to-work. The service may include the time-limited use of passive modalities with progression to achieve treatment and/or simulated/real work.6.6.1.1WORK CONDITIONING/SIMULATIONThis program may begin once a patient is out of the acute phase of injury and will be able to tolerate this program.
These programs are usually initiated after the acute phase has been completed and offered at any time throughout the recovery phase. Work conditioning should be initiated when imminent return of a patient to modified or full duty is not an option, but the prognosis for returning the patient to work at completion of the program is at least fair to good.
The need for work place simulation should be based upon the results of a Functional Capacity Evaluation and/or Jobsite Analysis.
| . | Length of visit: 1 to 4 hours per day. |
| . | Frequency: 2 to 5 visits per week |
| . | Maximum Duration: 8 WEEKS. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains. |
Work Hardening is an interdisciplinary program addressing a patient's employability and return to work. It includes a progressive increase in the number of hours per day that a patient completes work simulation tasks until the patient can tolerate a full workday. This is accomplished by addressing the medical, behavioral, physical, functional, and vocational components of employability and return-to-work.
This can include a highly structured program involving a team approach or can involve any of the components thereof. The interdisciplinary team should, at a minimum, be comprised of a qualified medical director who is board certified with documented training in occupational rehabilitation; team physicians having experience in occupational rehabilitation; occupational therapist; physical therapist; case manager; and psychologist. As appropriate, the team may also include: chiropractor, RN, vocational specialist or Certified Biofeedback Therapist.
| . | Length of visit: up to 8 hours/day |
| . | Frequency: 2 to 5 visits per week |
| . | Maximum duration: 8 weeks. Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains. |
6.7PATIENT EDUCATION No treatment plan is complete without addressing issues of individual patient and/or group education as a means of prolonging the beneficial effects of treatment, as well as facilitating self-management of symptoms and injury prevention. The patient should take an active role in the establishment of functional outcome goals, and should be educated on his or her specific injury, assessment findings, and plan of treatment. Education and instruction in proper body mechanics and posture, positions to avoid task/tool adaptation, self-care for exacerbation of symptoms, and home exercise/task adaptation should also be addressed. | . | Time to produce effect: Varies with individual patient. |
| . | Frequency: Should occur at every visit. |
6.8RETURN-TO-WORK is therapeutic, assuming the work is not likely to aggravate the basic problem or increase long-term pain. The practitioner must provide specific physical limitations per the Physician's Form. 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 receive clarification of the patient's job duties.
6.9 SLEEP DISTURBANCES are a common secondary symptom of CTD. 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 affected 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:
6.9.1 Maintaining a regular sleep schedule, retiring and rising at approximately the same time on weekdays and weekends.6.9.2 Avoiding daytime napping.6.9.3 Avoiding caffeinated beverages after lunchtime6.9.4 Making the bedroom quiet and comfortable, eliminating disruptive lights, sounds, television sets, and keeping a bedroom temperature of about 65°F.6.9.5 Avoiding alcohol or nicotine within two hours of bedtime.6.9.6 Avoiding large meals within two hours of bedtime.6.9.7 Exercising vigorously during the day, but not within two hours of bedtime, since this may raise core temperature and activate the nervous system.6.9.8 Associating the bed with sleep and sexual activity only, using other parts of the home for television, reading and talking on the telephone.6.9.9 Leaving the bedroom when unable to sleep for more than 20 minutes, returning to the bedroom when ready to sleep again. These modifications should be undertaken before sleeping medication is prescribed for long term use.
6.10THERAPY-PASSIVE 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 in adjunct with active therapies to help control swelling, pain and inflammation during the rehabilitation process. They may be used intermittently as a therapist deems appropriate or regularly if there are specific goals with objectively measured functional improvements during treatment.6.10.1Electrical Stimulation (Unattended and Attended): once applied, requires minimal on-site supervision by the physician or non-physician provider. Indications include pain, inflammation, muscle spasm, atrophy, and decreased circulation. | . | Time to produce effect: 2 to 4 treatments |
| . | Frequency: Varies, depending upon indication, between 2 to 3 times/day to 1 time/week. Provide home unit if frequent use. |
| . | Maximum duration: 24 visits |
6.10.2Extracorporeal shock wave treatment: Consists of the application of pulses of high pressure sound to soft tissues, similar to lithotriptors. It has been investigated for its effectiveness in the treatment of Calcific Tendonitis. It has not been shown to have an advantage over other conservative treatments and remains investigational. It is not recommended.6.10.3Iontophoresis: is 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 (chlorine, iodine, acetate). | . | Time to produce effect: 1 to 4 treatments |
| . | Frequency: 2-3 times per week with at least 48 hours between treatments. |
| . | Maximum duration: 8 treatments per region |
6.10.4Laser irradiation: Consists of the external application of an array of visible and infrared wavelengths to soft tissues. Frequency and duration are dependent on severity and chronicity of problem.6.10.5Manual Therapy Techniques: are passive interventions in which the providers use his or her hands to administer skilled movements designed to modulate pain; increase joint range of motion; reduce/eliminate soft tissue swelling, inflammation, or restriction; induce relaxation; and improve contractile and non-contractile tissue extensibility. These techniques are applied only after a thorough examination is performed to identify those for whom manual therapy would be contraindicated or for whom manual therapy must be applied with caution. 6.10.5.1MANIPULATION: 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. 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: 30 visits. Extended durations of care beyond what is considered "maximum" may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with comorbidities. Refer to the Chronic Pain Guidelines for care beyond 6 months. |
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 30 visits (not units) needs to go to UR.
6.10.5.2MOBILIZATION (Joint) /ManipulationMobilization is passive movement involving oscillatory motions to the involved joints. The passive mobility is performed in a graded manner (I, II, III, IV, or V), which depicts the speed of the maneuver. It may include skilled manual joint tissue stretching. Indications include the need to improve joint play, improve intracapsular arthrokinematics, or reduce pain associated with tissue impingement.
| . | Time to produce effect: 4 to 6 treatments |
| . | Frequency: 2 to 3 times per week |
| . | Maximum duration: 30 visits (CPT codes 97124 and 97140 cannot exceed 30 visits in combination). |
6.10.5.3MOBILIZATION (Soft Tissue) Mobilization of soft tissue is the skilled application of manual techniques designed to normalize movement patterns through the reduction of soft tissue pain and restrictions. Indications include muscle spasm around a joint, trigger points, adhesions, and neural compression.
Nerve Gliding: 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. Nerve gliding performed on a patient by the clinician should be reinforced by patient performance of similar techniques as part of a home exercise program at least twice per day.
| . | Time to produce effect: 4 to 6 treatments |
| . | Frequency: 2 to 3 times per week |
| . | Maximum duration: 30 visits (CPT codes 97124 and 97140 cannot exceed 30 visits in combination). |
6.10.6Massage: Manual or Mechanical - Massage is manipulation of soft tissue with broad ranging relaxation and circulatory benefits. This may include stimulation of acupuncture points and acupuncture channels (acupressure), application of suction cups and techniques that include pressing, lifting, rubbing, pinching of soft tissues by or with the practitioner's hands. Indications include edema, muscle spasm, adhesions, the need to improve peripheral circulation and range of motion, or to increase muscle relaxation and flexibility prior to exercise. | . | Time to produce effect: Immediate. |
| . | Frequency: 1 to 3 times per week |
| . | Maximum duration: 12 visits (CPT codes 97124 and 97140 cannot exceed 30 visits in combination). |
6.10.7Orthotics/Immobilization with Splinting: is a generally accepted, well-established and widely used therapeutic procedure. Splints may be effective when worn at night or during portions of the day, depending on activities. Splints should be loose and soft enough to maintain comfort while supporting the involved joint in a relatively neutral position. Splint comfort is critical and may affect compliance. Although off-the-shelf splints are usually sufficient, custom thermoplastic splints may provide better fit for certain patients.Splints may be effective when worn at night or during portions of the day, depending on activities; however, splint use is rarely mandatory. Providers should be aware that over-usage is counterproductive, and counsel patients to minimize daytime splint use in order avoid detrimental effects, such as, stiffness and dependency over time.
| . | Time to produce effect: 1-4 weeks |
| . | Frequency: Daytime intermittent or night use, depending on symptoms and activities. |
| . | Maximum duration: 2 to 4 months. If symptoms persist, consideration should be given to further diagnostic studies or to other treatment options. |
6.10.8Superficial Heat and Cold Therapy: are thermal agents applied in various manners that lowers or raises 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 (clinic). Home treatment as needed. |
| . | Maximum duration: 12 visits, with maximum visits 1 per day. If symptoms persist, consideration should be given to further diagnostic studies or other treatment options. |
6.10.9Ultrasound: uses sonic generators to deliver acoustic energy for therapeutic thermal and/or nonthermal soft tissue effects. Indications include scar tissue, adhesions, collagen fiber and muscle spasm, and to improve muscle tissue extensibility and 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. | . | Time to produce effect: 4 to 8 treatments |
| . | Frequency: 2-3 times per week |
| . | Maximum duration: 18 visits |
6.11THERAPY-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.
6.11.1Activities 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-care, work re-integration training, homemaking, and driving. | . | Time to produce effect: 4 to 5 treatments |
6.11.2Aquatic 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: 24 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.
6.11.3Functional Activities: are the use of therapeutic activity to enhance mobility, body mechanics, employability, coordination, and sensory motor integration. | . | Time to produce effect: 4 to 5 treatments |
| . | Frequency: 3 to 5 times per week |
| . | Maximum duration: 24 visits |
Total number of visit 97110 and 97530 should not exceed 36 visits without pre-authorization
6.11.4Neuromuscular 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. | . | Time to produce effect: 2 to 6 treatments |
| . | Frequency: 3-5 times per week |
| . | Maximum duration: 24 visits |
6.11.5Proper Work Techniques: Please refer to the "Job Site Evaluation" and "Job Site Alteration" sections of these guidelines.6.11.6Therapeutic 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 complimentary/alternative exercise movement therapy. | . | Time to produce effect: 2 to 6 treatments |
| . | Frequency: 3 to 5 times per week |
| . | Maximum duration: 36 visits |
Total number of visit 97110 and 97530 should not exceed 36 visits without pre authorization
6.12RESTRICTION OF ACTIVITIES Continuation of normal daily activities is the recommendation for most Shoulder Disorders with or without neurologic symptoms. Complete work cessation should be avoided, if possible, since it often further aggravates the pain presentation. Modified return-to-work is almost always more efficacious and rarely contraindicated in the vast majority of injured workers with Shoulder Disorders.6.13VOCATIONAL REHABILITATION is a generally accepted intervention. Initiation of vocational rehabilitation requires adequate evaluation of patients for quantification of highest functional level, motivation, and achievement of maximum medical improvement. Vocational rehabilitation may be as simple as returning to the original job or as complicated as being retrained for a new occupation.19 Del. Admin. Code § 1342-E-6.0
11 DE Reg. 1661 (06/01/08)
12 DE Reg. 67 (07/01/08)
17 DE Reg. 322 (9/1/2013) (Final)