La. Admin. Code tit. 40 § I-2109

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-2109 - Initial Evaluation and Diagnostic Procedures

A. The OWCA recommends the following diagnostic procedures be considered, at least initially, the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Standard procedures that should be utilized when initially diagnosing a work-related chronic pain complaint are listed below.

1. History and Physical Examination (Hx and PE). These are generally accepted, well-established, and widely used procedures that establish the foundation/basis for and dictate subsequent stages of diagnostic and therapeutic procedures. When findings of clinical evaluations and those of other diagnostic procedures are not complementing each other, the objective clinical findings should have preference. The medical records should reasonably document the following.

a. Medical history-as in other fields of medicine, a thorough patient history is an important part of the evaluation of chronic pain. In taking such a history, factors influencing a patients current status can be made clear and taken into account when planning diagnostic evaluation and treatment. It may be necessary to acquire previous medical records. One efficient manner in which to obtain historical information and patient reported functional status is by using a questionnaire. The questionnaire may be sent to the patient prior to the initial visit or administered at the time of the office visit. History should ascertain the following elements:

i general information - general items requested are name, sex, age, birth date, etc;

ii. level of education - the level of patient's education may influence response to treatment;

iii. work history/occupation - to include both impact of injury on job duties and impact on ability to perform job duties, work history, job description, mechanical requirements of the job, duration of employment, and job satisfaction;

iv. current employment status;

v. marital status;

vi. family environment - Is the patient living in a nuclear family or with friends? Is there or were there, any family members with chronic illness or pain problems? Responses to such questions reveal the nature of the support system or the possibility of conditioning toward chronicity;

vii. ethnic origin - Ethnicity of the patient, including any existing language barriers, may influence the patient's perception of and response to pain. There is evidence that providers may under-treat patients of certain ethnic backgrounds due to underestimation of their pain;

viii. belief system-Patients should be asked about their value systems, including spiritual and cultural beliefs, in order to determine how these may influence the patients and familys response to illness and treatment recommendations.

ix. functional assessment-Functional ability should be assessed and documented at the beginning of treatment. Periodic assessment should be recorded throughout the course of care to follow the trajectory of recovery. Functional measures are likely to be more reliable over time than pain measures.

(a). Patient-reported outcomes, whether of pain or function, are susceptible to a phenomenon called response shift. This refers to changes in self-evaluation, which may accompany changes in health status. Patient self-reports may not coincide with objective measures of outcome, due to reconceptualization of the impact of pain on daily function and internal recalibration of pain scales. Response shift may obscure treatment effects in clinical trials and clinical practice, and it may lead to apparent discrepancies in patient-reported outcomes following treatment interventions. While methods of measuring and accounting for response shift are not yet fully developed, understanding that the phenomenon exists can help clinicians understand what is happening when some measures of patient progress appear inconsistent with other measures of progress.

x. activities of daily living (ADLs)-Pain has a multidimensional effect on the patient that is reflected in changes in usual daily vocational, social, recreational, and sexual activities;

xi. past and present psychological problems;

xii. history of abuse-physical, emotional, sexual;

xiii. history of disability in the family;

xiv. sleep disturbances: poor sleep has been shown to increase patients self-perceived pain scores. Pre-injury and post-injury sleep should be recorded.

xv. causality-How did this injury occur? Was the problem initiated by a work-related injury or exposure? Patients perception of causality (e.g., was it their fault or the fault of another).

b. Pain History. Characterization of the patient's pain and of the patient's response to pain is one of the key elements in treatment.

i. site of pain - localization and distribution of the pain help determine the type of pain the patient has (i.e., central versus peripheral);

ii. pain diagram drawings to document the distribution of pain.

iii. Visual Analog Scale (VAS)-Current pain, highest pain level, and usual pain level may be recorded. Include a discussion of the range of pain during the day and how activities, use of modalities, and other actions affect the intensity of pain.

iv. duration-including intermittent pain, activity related pain;

v. place of onset-circumstances during which the pain began (e.g., an accident, an illness, a stressful incident, or spontaneous onset);

vi. pain characteristics-such as burning, shooting, stabbing, and aching. Time of pain occurrence, as well as intensity, quality, and radiation, give clues to the diagnosis and potential treatment. Quality of pain can be helpful in identifying neuropathic pain which is normally present most of the day, at night, and is often described as burning;

vii. list of activities which aggravate or exacerbate, ameliorate, decrease, or have no effect on the level of pain;

viii. associated symptoms-Does the patient have numbness or paresthesia, dysesthesia, weakness, bowel or bladder dysfunction, altered temperature, increased sweating, cyanosis or edema? Is there local tenderness, allodynia, hyperesthesia, or hyperalgesia? Does the patient have constitutional symptoms such as fevers, chills, night sweats, unexplained weight loss, or pain that awakes them from a deep sleep at night?

c. Medical management history:

i. prior treatment-chronological review of medical records including previous medical evaluations and response to treatment interventions. In other words, what has been tried and which treatments have helped?;

ii. prior surgery - If the patient has had prior surgery specifically for the pain, he/she is less likely to have a positive outcome;

iii. medications-history of and current use of medications, including opioids,over the counter medications and herbal/dietary supplements, to determine drug usage (or abuse) interactions and efficacy of treatment. Drug allergies and other side effects experienced with previous or current medication therapy and adherence to currently prescribed medications should be documented. Ideally, this includes dosing schedules as reported by the patient or patient representative. Information should be checked against the Louisiana Prescription Monitoring Program (PMP), offered by the Louisiana Pharmacy Board;

iv. review of systems check list - Determine if there is any interplay between the pain complaint and other medical conditions;

v. psychosocial functioning-determine if the following are present: current symptoms of depression or anxiety; evidence of stressors in the workplace or at home, and past history of psychological problems. Other confounding psychosocial issues may be present, including the presence of psychiatric disease. Due to the high incidence of co-morbid problems in populations that develop chronic pain, it is recommended that patients diagnosed with Chronic Pain be referred for a full psychosocial evaluation;

vi. diagnostic tests - All previous radiological and laboratory investigations should be reviewed;

vii. pre-existing conditions - Treatment of these conditions is appropriate when the pre-existing condition affects recovery from chronic pain.

viii. family history pertaining to similar disorders.

d. Substance use/abuse:

i. alcohol use;

ii. smoking history and use of nicotine replacements;

iii. history of current and prior prescription and recreational drug use and abuse;

iv. the use of caffeine or caffeine-containing beverages;

v. substance abuse information may be only fully obtainable from multiple sources over time. Patient self-reports may be unreliable. Patient self-reports should always be checked against medical records.

e. Other factors affecting treatment outcome:

i. compensation/disability/litigation;

ii. treatment expectations - what does the patient expect from treatment: complete relief of pain or reduction to a more tolerable level?

iii. Other scales may be used to identify cases which are likely to require more complex care. Examples include:

(a). fear avoidance beliefs questionnaire;

(b). tampa scale of kinesiophobia;

(c). pain catastrophizing scale.

f. Physical examination:

i. neurologic evaluation-includes cranial nerves survey, muscle tone and strength, atrophy, detailed sensory examination (see ii-below), motor evaluation (station, gait, coordination), reflexes (normal tendon reflexes and presence or absence of abnormal reflexes such as frontal lobe release signs or upper motor neuron signs), cerebellar testing, signs suggestive of a sensory ataxia (positive Romberg, impaired proprioception, etc.), and provocative neurological maneuvers.

ii. sensory evaluation-A detailed sensory examination is crucial in evaluating a patient with chronic pain complaints. Quantitative sensory testing, such as Semmes-Weinstein, may be useful tools in determining sensory abnormalities. Ideally, the examination should determine if the following sensory signs are present and consistent on repeated examination:

(a). Hyperalgesia;

(b). Hyperpathia;

(c). Paresthesia;

(d). Dysesthesia;

(e). Mechanical Allodynia - static versus dynamic;

(f). Thermal Allodynia;

(g). Hypoesthesia;

(h). Hyperesthesia;

(i). Summation.

iii. musculoskeletal evaluation-range of motion, segmental mobility, musculoskeletal provocative maneuvers, palpation, observation, and functional activities. All joints, muscles, ligaments, and tendons should be examined for asymmetry, swelling, laxity, and tenderness. A portion of the musculoskeletal evaluation is the myofascial examination. The myofascial examination includes palpating soft tissues for evidence of tightness and trigger points.

iv. evaluation of non-physiologic findings:

(a). Waddells Signs cannot be used to predict or diagnose malingering. It is not an appropriate test for assessing non-physiologic causes of low back pain. The sole purpose of the Waddells signs is to identify low back pain patients who may need further psychosocial assessment prior to surgery. Refer to Personality/Psychological/Psychosocial Evaluation.

(b). Variabilities on formal exam including variable sensory exam, inconsistent tenderness, and/or swelling secondary to extrinsic sources.

(c). Inconsistencies between formal exam and observed abilities of range-of-motion, motor strength, gait and cognitive/emotional state should be noted in the assessment.

(d). Observation of consistencies between pain behavior, affect and verbal pain rating, and affect and physical re-examination.

2. Personality/Psychosocial/ Psychiatric/Psychological Evaluation

a. These are generally accepted and well-established and widely used diagnostic procedures not only with selected use in acute pain problems, but have also with more widespread use in subacute and chronic pain populations.

i. Diagnostic evaluations should distinguish between conditions that are pre-existing, aggravated by the current injury, or work related.

ii. interpersonal relationships-both social and work;

iii. patient activities;

iv. current perception of the medical system;

v. current perception/attitudes toward employer/job;

vi. results of current treatment;

vii. risk factors and psychological comorbidities that may influence outcome and that may require treatment;

viii. childhood history, including history of childhood psychological trauma, abuse and family history of disability.

b. Psychosocial evaluations should determine if further psychosocial or behavioral interventions are indicated for patients diagnosed with chronic pain. The interpretations of the evaluation should provide clinicians with a better understanding of the patient in his or her social environment, thus allowing for more effective rehabilitation. Psychosocial assessment requires consideration of variations in pain experience and expression resulting from affective, cognitive, motivational and coping processes, and other influences such as gender, age, race, ethnicity, national origin, religion, sexual orientation, disability, language, or socioeconomic status.

i. Frequency: one-time visit for the clinical interview. If psychometric testing is indicated as a part of the initial evaluation, time for such testing should not exceed an additional two hours of professional time.

(a). Clinical Evaluation: All chronic pain patients should have a clinical evaluation that addresses the following areas:

(i). History of Injury - The history of the injury should be reported in the patient's words or using similar terminology. Caution must be exercised when using translators.

[a]. nature of injury;

[b]. psychosocial circumstances of the injury;

[c]. current symptomatic complaints;

[d]. extent of medical corroboration;

[e]. treatment received and results;

[f]. compliance with treatment;

[g]. coping strategies used, including perceived locus of control;

[h]. perception of medical system and employer;

[i]. history of response to prescription medications.

(ii). Health History

[a]. nature of injury;

[b]. medical history;

[c]. psychiatric history;

[d]. history of alcohol or substance abuse;

[e]. activities of daily living;

[f]. mental status exam;

[g]. previous injuries, including disability, impairment, and compensation

(iii). Psychosocial History

[a]. childhood history, including abuse;

[b]. educational history;

[c]. family history, including disability;

[d]. marital history and other significant adulthood activities and events;

[e]. legal history, including criminal and civil litigation;

[f]. employment and military history;

[g]. signs of pre-injury psychological dysfunction;

[h]. current interpersonal relations, support, living situation;

[i]. financial history.

(iv). Psychological test results, if performed

(v). Danger to self or others.

(vi). Current psychiatric diagnosis consistent with the standards of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.

(vii). Pre-existing psychiatric conditions. Treatment of these conditions is appropriate when the pre-existing condition affects recovery from chronic pain.

(viii). Causality (to address medically probable cause and effect, distinguishing pre-existing psychological symptoms, traits and vulnerabilities from current symptoms).

(ix). Treatment recommendations with respect to specific goals, frequency, timeframes, and expected outcomes.

(b). Tests of Psychological Functioning: Psychometric Testing is a valuable component of a consultation to assist the physician in making a more effective treatment plan. Psychometric testing is useful in the assessment of mental conditions, pain conditions, cognitive functioning, treatment planning, vocational planning, and evaluation of treatment effectiveness. There is no general agreement as to which standardized psychometric tests should be specifically recommended for psychological evaluations of chronic pain conditions. It is appropriate for the mental health provider to use their discretion and administer selective psychometric tests within their expertise and within standards of care in the community. Some of these tests are available in Spanish and other languages, and many are written at a sixth grade reading level. Examples of frequently used psychometric tests performed include, but not limited to, the following.

(i). Comprehensive Inventories for Medical Patients

[a]. Battery for Health Improvement, 2nd Edition (BHI-2). What it measures Depression, anxiety and hostility; violent and suicidal ideation; borderline, dependency, chronic maladjustment, substance abuse, conflicts with work, family and physician, pain preoccupation, somatization, perception of functioning and others. Benefits When used as a part of a comprehensive evaluation, can contribute substantially to the understanding of psychosocial factors underlying pain reports, perceived disability, somatic preoccupation, and help to design interventions. Serial administrations can track changes in a broad range of variables during the course of treatment, and assess outcome.

[b]. Millon Behavioral Medical Diagnostic (MBMD). What it Measures Updated version of the Millon Behavioral Health Inventory (MBHI). Provides information on Coping Styles (introversive, inhibited, dejected, cooperative, sociable, etc), Health Habits (smoking, drinking, eating, etc.), Psychiatric Indications (anxiety, depression, etc), stress moderators (Illness Apprehension vs. Illness Tolerance, etc), treatment prognostics (Interventional Fragility vs. Interventional Resilience, Medication Abuse vs. Medication Competence, etc) and other factors. Benefits When used as a part of a comprehensive evaluation, can contribute substantially to the understanding of psychosocial factors affecting medical patients. Understanding risk factors and patient personality type can help to optimize treatment protocols for a particular patient.

[c]. Pain Assessment Battery (PAB). What it measures - collection of four separate measures that are administered together. Emphasis on the assessment of pain, coping strategies, degree and frequency of distress, health-related behaviors, coping success, beliefs about pain, quality of pain experience, stress symptoms analysis, and others. Benefits-When used as a part of a comprehensive evaluation, can contribute substantially to the understanding of patient stress, pain reports and pain coping strategies, and help to design interventions. Serial administrations can track changes in measured variables during the course of treatment, and assess outcome.

ii. Comprehensive Psychological Inventories. These tests are designed for detecting various psychiatric syndromes, but in general are more prone to false positive findings when administered to medical patients.

(a). Millon Clinical Multiaxial Inventory, 3rd Edition (MCMI-III). What it measures - has scales based on DSM diagnostic criteria for affective, personality, and psychotic disorders and somatization. Benefits - when used as a part of a part of a comprehensive evaluation, can screen for a broad range of DSM diagnoses.

(b). Minnesota Multiphasic Personality Inventory, 2nd Edition (MMPI-2). What it measures - original scale constructs, such as hysteria and psychesthenia are archaic but continue to be useful. Newer content scales include depression, anxiety, health concerns, bizarre mentation, social discomfort, low self-esteem, and almost 100 others. Benefits When used as a part of a comprehensive evaluation, measure a number of factors that have been associated with poor treatment outcome.

(c). Personality Assessment Inventory (PAI). What it measures - a good measure of general psychopathology. Measures depression, anxiety, somatic complaints, stress, alcohol and drug use reports, mania, paranoia, schizophrenia, borderline, antisocial, and suicidal ideation and more than 30 others. Benefits When used as a part of a comprehensive evaluation, can contribute substantially to the identification of a wide variety of risk factors that could potentially affect the medical patient.

iii. Brief Multidimensional Screens for Medical Patients. Treating providers, to assess a variety of psychological and medical conditions, including depression, pain, disability and others, may use brief instruments. These instruments may also be employed as repeated measures to track progress in treatment, or as one test in a more comprehensive evaluation. Brief instruments are valuable in that the test may be administered in the office setting and hand scored by the physician. Results of these tests should help providers distinguish which patients should be referred for a specific type of comprehensive evaluation.

(a). Brief Battery for Health Improvement, 2nd Edition (BBHI-2). What it measures Depression, anxiety, somatization, pain, function, and defensiveness. Benefits Can identify patients needing treatment for depression and anxiety, and identify patients prone to somatization, pain magnification and self-perception of disability. Can compare the level of factors above to other pain patients and community members. Serial administrations can track changes in measured variables during the course of treatment, and assess outcome.

(b). Multidimensional Pain Inventory (MPI). What it measures - interference, support, pain severity, life-control, affective distress, response of significant other to pain, and self-perception of disability at home and work, and in social and other activities of daily living. Benefits Can identify patients with high levels of disability perceptions, affective distress, or those prone to pain magnification. Serial administrations can track changes in measured variables during the course of treatment, and assess outcome.

(c). Pain Patient Profile (P3). What it measures Assesses depression, anxiety, and somatization. Benefits Can identify patients needing treatment for depression and anxiety, as well as identify patients prone to somatization. Can compare the level of depression, anxiety and somatization to other pain patients and community members. Serial administrations can track changes in measured variables during the course of treatment, and assess outcome.

(d). SF-36 a. What it measures - a survey of general health well-being and functional states. Benefits - assesses a broad spectrum of patient disability reports. Serial administrations could be used to track patient perceived functional changes during the course of treatment, and assess outcome.

(e). Sickness Impact Profile (SIP). What it measures - perceived disability in the areas of sleep, eating, home management, recreation, mobility, body care, social interaction, emotional behavior, and communication. Benefits - assesses a broad spectrum of patient disability reports. Serial administrations could be used to track patient perceived functional changes during the course of treatment, and assess outcome.

(f). McGill Pain Questionnaire (MPQ). What it measures - cognitive, emotional and sensory aspects of pain. Benefits - can identify patients prone to pain magnification. Repeated administrations can track progress in treatment for pain.

(g). McGill Pain Questionnaire - Short Form (MPQ-SF). What it measures - emotional and sensory aspects of pain. Benefits - can identify patients prone to pain magnification. Repeated administrations can track progress in treatment for pain.

(h). Oswestry Disability Questionnaire. What it measures - disability secondary to low back pain. Benefits - can measure patients' self-perceptions of disability. Serial administrations could be used to track changes in self-perceptions of functional ability during the course of treatment, and assess outcome.

(i). Visual Analog Scales (VAS). What it measures - graphical measure of patient's pain report. Benefits - quantifies the patients' pain report. Serial administrations could be used to track changes in pain reports during the course of treatment and assess outcome.

iv. Brief Multidimensional Screens for Psychiatric Patients. These tests are designed for detecting various psychiatric syndromes, but in general are more prone to false positive findings when administered to medical patients.

(a). Brief Symptom Inventory. What it measures: Somatization, obsessive-compulsive, depression, anxiety, phobic anxiety, hostility, paranoia, psychoticism, and interpersonal sensitivity. Benefits: Can identify patients needing treatment for depression and anxiety, as well as identify patients prone to somatization. Can compare the level of depression, anxiety, and somatization to community members. Serial administrations could be used to track changes in measured variables during the course of treatment, and assess outcome.

(b). Brief Symptom Inventory - 18 (BSI-18). What it Measures: Depression, anxiety, somatization. Benefits: Can identify patients needing treatment for depression and anxiety, as well as identify patients prone to somatization. Can compare the level of depression, anxiety, and somatization to community members. Serial administrations could be used to track patient perceived functional changes during the course of treatment, and assess outcome.

(c). Symptom Check List 90 (SCL 90). What it measures: Somatization, obsessive-compulsive, depression, anxiety, phobic anxiety, hostility, paranoia, psychoticism, and interpersonal sensitivity. Benefits: Can identify patients needing treatment for depression and anxiety, as well as identify patients prone to somatization. Can compare the level of depression, anxiety and somatization to community members. Serial administrations could be used to track changes in measured variables during the course of treatment, and assess outcome.

v. Brief Specialized Psychiatric Screening Measures

(a). Beck Depression Inventory (BDI). What it measures: Depression. Benefits: Can identify patients needing referral for further assessment and treatment for depression and anxiety, as well as identify patients prone to somatization. Repeated administrations can track progress in treatment for depression, anxiety, and somatic preoccupation.

(b). Post Traumatic Stress Diagnostic Scale (PDS). What it Measures: Post Traumatic Stress Disorder (PTSD). Benefits: Helps confirm suspected PTSD diagnosis. Repeated administrations can track treatment progress of PTSD patients.

(c). Center of Epidemiologic Studies - Depression Questionnaire. What it measures: Depression. Benefits: Brief self-administered screening test. Requires professional evaluation to verify diagnosis.

(d). Brief Patient Health Questionnaire from PRIME - MD. What it measures: Depression, panic disorder. Benefits: Brief self-administered screening test. Requires professional evaluation to verify diagnosis.

(e). Zung Questionnaire. What it measures: Depression. Benefits: Brief self-administered screening test. Requires professional evaluation to verify diagnosis.

(f). Diagnostic Studies. Imaging of the spine and/or extremities is a generally accepted, well-established, and widely used diagnostic procedure when specific indications, based on history and physical examination, are present. Physicians should refer to individual OWCA guidelines for specific information about specific testing procedures.

(g). Radiographic Imaging, MRI, CT, bone scan, radiography, SPECT and other special imaging studies may provide useful information for many musculoskeletal disorders causing chronic pain. Single Photon Emission Computerized Tomography (SPECT): A scanning technique which may be helpful to localize facet joint pathology and is useful in determining which patients are likely to have a response to facet injection. SPECT combines bone scans & CT Scans in looking for facet joint pathology.

(h). Electrodiagnostic studies may be useful in the evaluation of patients with suspected myopathic or neuropathic disease and may include Nerve Conduction Studies (NCS), Standard Needle Electromyography, or Somatosensory Evoked Potential (SSEP). The evaluation of electrical studies is difficult and should be relegated to specialists who are well trained in the use of this diagnostic procedure.

(i). Special Testing Procedures may be considered when attempting to confirm the current diagnosis or reveal alternative diagnosis. In doing so, other special tests may be performed at the discretion of the physician.

(j). Testing for complex regional pain syndrome (CRPS-I) or sympathetically maintained pain (SMP) is described in the Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy Medical Treatment Guidelines.

c. While there is some agreement about which psychological factors need to be assessed in patients with chronic pain, a comprehensive psychological evaluation should attempt to identify both primary psychiatric risk factors or "red flags" (e.g., psychosis, active suicidality) as well as secondary risk factors or "yellow flags" (e.g., moderate depression, job dissatisfaction). Significant personality disorders must be taken into account when considering a patient for spinal cord stimulation and other major procedures.

d. Psychometric testing is a valuable component of a consultation to assist the physician in making a more effective treatment plan. There is good evidence that psychometric testing can have significant ability to predict medical treatment outcome. For example, one study found that psychometric testing exceeded the ability of discography to predict disability in patients with low back pain. Pre-procedure psychiatric/psychological evaluation must be done prior to diagnostic confirmatory testing for a number of procedures. Examples include discography for fusion, spinal cord stimulation, or intrathecal drug delivery systems, and a psychologist employed by the physician planning to perform the procedure should not do them and they should not be done by a psychologist employed by the physician planning to perform the procedure.

e. In many instances, psychological testing has validity comparable to that of commonly used medical tests; for example, the correlation between high trait anger and blood pressure is equal to the correlation between reduced blood flow and the failure of a synthetic hemodialysis graft. Thus, psychometric testing may be of comparable validity to medical tests and may provide unique and useful diagnostic information.

f. All patients who are diagnosed as having chronic pain should be referred for a psychosocial evaluation, as well as concomitant interdisciplinary rehabilitation treatment. This referral should be performed in a way so as to not imply that the patients claims are invalid or that the patient is malingering or mentally ill. Even in cases where no diagnosable mental condition is present, these evaluations can identify social, cultural, coping, and other variables that may be influencing the patients recovery process and may be amenable to various treatments including behavioral therapy. As pain is understood to be a biopsychosocial phenomenon, these evaluations should be regarded as an integral part of the assessment of chronic pain conditions.

i. Qualifications

(a). A psychologist with a PhD, PsyD, or EdD credentials or a physician with Psychiatric MD/DO credentials may perform the initial comprehensive evaluations. It is preferable that these professionals have experience in diagnosing and treating chronic pain disorders and/or working with patients with physical impairments.

(b). Psychometric tests should be administered by psychologists with a PhD, PsyD, or EdD or health professionals working under the supervision of a doctorate level psychologist. Physicians with appropriate training may also administer such testing, but interpretation of the tests should be done by properly credentialed mental health professionals.

ii. Clinical Evaluation. Special note to health care providers: most providers are required to adhere to the federal regulations under the Health Insurance Portability and Accountability Act (HIPAA). Unlike general health insurers, workers compensation insurers are not required to adhere to HIPAA standards. Thus, providers should assume that sensitive information included in a report sent to the insurer could be forwarded to the employer. It is recommended that the health care provider either obtain a full release from the patient regarding information that may go to the employer or not include sensitive health information not directly related to the work related conditions in reports sent to the insurer.

(a). All chronic pain patients should have a clinical evaluation that addresses the following areas recalling that not all details should be included in the report sent to the insurer due to the HIPAA issue noted above:

(i). history of injury-The history of the injury should be reported in the patients words or using similar terminology. Caution must be exercised when using translators.

[a]. nature of injury;

[b]. psychosocial circumstances of the injury;

[c]. current symptomatic complaints;

[d]. extent of medical corroboration;

[e]. treatment received and results;

[f]. adherence with treatment;

[g]. coping strategies used, including perceived locus of control, catastrophizing, and risk aversion;

[h]. perception of medical system and employer;

[i]. history of response to prescription medications.

(ii). health history

[a]. nature of injury;

[b]. medical history;

[c]. psychiatric history: to include past diagnoses, counseling, medications, and response to treatment;

[d]. history of substance related and addictive disorders to include: alcohol, opioids, medications (sedative, hypnotic, and anxiolytic), stimulants, prescriptions drug abuse, nicotine use and other substances of abuse/dependence;

[e]. activities of daily living;

[f]. past, recent, and concurrent stressors.

[g]. previous injuries, including disability, impairment, and compensation

(iii). psychosocial history

[a]. childhood history, including abuse/neglect;

[b]. educational history;

[c]. family history, including disability;

[d]. marital history and other significant adulthood activities and events;

[e]. legal history, including but not limited to substance use related, domestic violence, criminal and civil litigation;

[f]. employment history;

[g]. military duty: Because post-traumatic stress disorder (PTSD) might be an unacceptable condition for many military personnel to acknowledge, it may be prudent to screen initially for signs of depression or anxiety-both of which may be present in PTSD;

[h]. signs of pre-injury psychological dysfunction;

[i]. financial history.

[j]. current living situation including roommates, family, intimate partners, and financial support;

[k]. prior level of function including self-care, community, recreational, and employment activities.

(iv). Psychological test results, if performed

(v). assessment of any danger posed to self or others.

(vi). Current psychiatric diagnosis consistent with the standards of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.

(vii). Pre-existing psychiatric conditions. Treatment of these conditions is appropriate when the pre-existing condition affects recovery from chronic pain.

(viii). causality-to address medically probable cause and effect, and to distinguish pre-existing psychological symptoms, traits, and vulnerabilities from current symptoms.

(ix). Treatment recommendations with respect to specific goals, frequency, timeframes, and expected outcomes.

(x). mental status exam including orientation, cognition, activity, speech, thinking, affect, mood, and perception. May include screening tests such as the mini mental status exam or frontal assessment battery if appropriate.

iii. Tests of Psychological Functioning. Psychometric Testing is a valuable component of a consultation to assist the physician in making a more effective treatment plan. Psychometric testing is useful in the assessment of mental conditions, pain conditions, cognitive functioning, treatment planning, vocational planning, and evaluation of treatment effectiveness. While there is no general agreement as to which psychometric tests should be specifically recommended for psychological evaluations of chronic pain conditions, standardized tests are preferred over those which are not for assessing diagnosis. Generally, it is helpful if tests consider the following issues: validity, physical symptoms, affective disorders, character disorders and traits, and psychosocial history. Character strengths that support the healing/rehabilitative process should also be evaluated and considered with any dysfunctional behavior patterns or pathology to more accurately assess the patients prognosis and likely response to a proposed intervention. In contrast, non-standardized tests can be useful for "ipsative" outcome assessment, in which a test is administered more than once and a patients current and past reports are compared. It is appropriate for the mental health provider to use their discretion and administer selective psychometric tests within their expertise and within standards of care in the community Use of screening psychometrics by non-mental health providers is encouraged, but mental health provider consultation should always be utilized for chronic pain patients in which invasive palliative pain procedures or chronic opiate treatment is being contemplated. Some of these tests are available in Spanish and other languages, and many are written at a sixth grade reading level. Examples of frequently used psychometric tests performed include, but not limited to, the following.

(a). Comprehensive Inventories for Medical Patients

(i). Battery for Health Improvement, 2nd Edition (BHI-2);

(ii). Millon Behavioral Medical Diagnostic (MBMD);

(b). Comprehensive Psychological Inventories.

(i). Millon Clinical Multiaxial Inventory;

(ii). Minnesota Multiphasic Personality Inventory, 2nd Edition (MMPI-2).

(iii). Personality Assessment Inventory (PAI).

(c). Brief Multidimensional Screens for Medical Patients. Treating providers, to assess a variety of psychological and medical conditions, including depression, pain, disability and others, may use brief instruments. These instruments may also be employed as repeated measures to track progress in treatment, or as one test in a more comprehensive evaluation. Brief instruments are valuable in that the test may be administered in the office setting and hand scored by the physician. Results of these tests should help providers distinguish which patients should be referred for a specific type of comprehensive evaluation.

(i). Brief Battery for Health Improvement, 2nd Edition (BBHI-2);

(ii). Pain Patient Profile (P-3);

(iii). SF-36;

(iv). Sickness Impact Profile (SIP);

(v). McGill Pain Questionnaire (MPQ);

(vi). McGill Pain Questionnaire-Short Form (MPQ-SF);

(vii). Oswestry Disability Questionnaire.;

(viii). Visual Analog Scales (VAS).;

(ix). Numerical Rating Scale (NRS);

(x). Chronic Pain Grade Scale (CPGS);

(xi). Pain Catastrophizing Scale (PCS).

(d). Brief Multidimensional Screens for Psychiatric Patients. These tests are designed for detecting various psychiatric syndromes, but in general are more prone to false positive findings when administered to medical patients.

(i). Brief Symptom Inventory (BSI);

(ii). Brief Symptom Inventory-18 (BSI-18);

(iii). Symptom Check List -90 Revised (SCL 90 R).

(e). Brief Specialized Psychiatric Screening Measures:

(i). Beck Depression Inventory (BDI);

(ii). Center of Epidemiologic Studies-Depression Questionnaire (CES-D);

NOTE: Designed for assessment of psychiatric patients, not pain patients, which can bias results, and this should be a consideration when using.

(iii). Brief Patient Health Questionnaire from PRIME - MD. (The PHQ-9 may also be used as a depression screen.);

(iv). Zung Depression Questionnaire;

NOTE: The Zung Depression Scale must be distinguished from the Modified Zung Depression scale used by the DRAM (a QPOP measure). The Zung Depression Scale has different items and a different scoring system than the Modified Zung Depression scale, making the cutoff scores markedly different. The cutoff scores for one measure cannot be used for the other.

(v). General Anxiety Disorder 7-item scale (GAD-7).

3. Diagnostic Studies. Imaging of the spine and/or extremities is a generally accepted, well-established, and widely used diagnostic procedure when specific indications, based on history and physical examination, are present. Practitioners should be aware of the radiation doses associated with various procedures and provide appropriate warnings to patients. Unnecessary CT scans or X-rays increase the lifetime risk of cancer death. Physicians should refer to individual OWCA guidelines for specific information about specific testing procedures. Tests should be performed to rule in or out specific diagnoses especially cases that are difficult to diagnose or fail to progress.

a. Radiographic Imaging, MRI, CT, bone scan, radiography, and other special imaging studies may provide useful information for many musculoskeletal disorders causing chronic pain. It is probably most helpful in ruling out rare, significant diagnoses that may present with pain, such as metastatic cancer Most imaging is likely to demonstrate aging changes which are usually not pathologic. However, it is good to remember every medical condition can be exacerbated. Refer to specific OWCA Medical Treatment Guidelines for details. Before the test is performed, patients should be informed of the purpose of the exam (e.g., to rule out unsuspected cancer) and the likelihood of finding non-pathologic changes that are part of the normal aging process.

b. Electrodiagnostic studies may be useful in the evaluation of patients with suspected myopathic or neuropathic disease and may include Nerve Conduction Studies (NCS), Standard Needle Electromyography, or Somatosensory Evoked Potential (SSEP). The evaluation of electrical studies is complex and should be performed by specialists who are well trained in the use of this diagnostic procedure.

c. Special testing procedures may be considered when attempting to confirm the current diagnosis or reveal alternative diagnosis. Additional special tests may be performed at the discretion of the physician.

d. Testing for Complex Regional Pain Syndrome (CRPS-I) or Sympathetically Maintained Pain (SMP) is described in the OWCAs Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy Medical Treatment Guidelines.

4. Laboratory testing is a generally accepted, well-established and widely used procedure.

a. Patients should be carefully screened at the initial exam for signs or symptoms of diabetes, hypothyroidism, arthritis, and related inflammatory diseases. For patients at risk for sleep apnea, testing may be appropriate depending on medication use and issues with insomnia. The presence of concurrent disease does not refute work-relatedness of any specific case. This frequently requires laboratory testing. When a patient's history and physical examination suggest infection, metabolic or endocrinologic disorders, tumorous conditions, systemic musculoskeletal disorders (e.g., rheumatoid arthritis or ankylosing spondylitis), or problems potentially related to medication (e.g., renal disease and non-steroidal anti-inflammatory medications), then laboratory tests, including, but not limited to the following can provide useful diagnostic information:

i. thyroid stimulating hormone (TSH) for hypothyroidism;

ii. diabetic screening: recommended for men and women with a BMI over 30, patients with a family history of diabetes, those from high risk ethnic groups, and patients with a previous history of impaired glucose tolerance. There is some evidence that diabetic patients with upper extremity disorders have sub-optimal control of their diabetes;

iii. serum protein electrophoresis;

iv. sedimentation rate and C-reactive protein (CRP) are nonspecific but elevated in infection, neoplastic conditions, and rheumatoid arthritis. Other screening tests to rule out inflammatory or autoimmune disease may be added when appropriate;

v. serum calcium, phosphorus, uric acid, alkaline, and acid phosphatase for metabolic, endocrine and neo-plastic conditions;

vi. complete blood count (CBC), liver, and kidney function profiles for metabolic or endocrine disorders or for adverse effects of various medications;

vii. bacteriological (microorganism) work-up for wound, blood, and tissue;

viii. vitamin B12 levels may be appropriate for some patients.

b. The OWCA recommends that the workers compensation carrier cover initial lab diagnostic procedures to ensure that an accurate diagnosis and treatment plan is established. When an authorized treating provider has justification for the test, insurers should cover the costs. Laboratory testing may be required periodically to monitor patients on chronic medications.

5. Injections-Diagnostic

a. Spinal Diagnostic Injections. Diagnostic spinal injections are commonly used in chronic pain patients and they usually have been performed previously in the acute or subacute stage. They may rarely be necessary for aggravations of low back pain. Refer to the OWCA Low Back Pain Medical Treatment Guideline for indications.

b. Diagnostic Peripheral nerve blocks such as Genicular Nerves, 3rd Occipital, nerves, Greater and Lesser Occipital nerves, intercostal nerves, Ilioinguinal nerves, iliohypogastric nerves, lateral femoral cutaneous nerves, medial branch facet nerves (cervical, thoracic and lumbar), sacral lateral branches of Sacroiliac joints, Selective nerve root blocks and transforaminal epidural injections and other pure sensory nerves suspected of causing pain. Also include diagnostic facet joint injection as a diagnostic block.

c. Medial Branch Facet Blocks (Cervical, Thoracic and Lumbar) and Sacral Lateral Branch Blocks. If provide 80 percent or more pain reduction as measured by a numerical pain index scale within one hour of the medial branch blocks up to three levels per side, then rhizotomy of the medial branch nerves, up to four nerves per side, may be done without confirmation block. If the initial set of medial branch blocks provides less than 80 percent but at least 50 percent pain reduction as measured by a numerical pain index scale or documented functional improvement, the medial branch block should be repeated for confirmation before a rhizotomy is performed. If 50 percent or greater pain reduction is achieved as measured by the NPIS with two sets of medial branch blocks for facet joint pain, then rhizotomy may be performed.

d. In general, relief should last for at least the duration of the local anesthetic used and should significantly result in functional improvement and relief of pain. Refer to Injections- Spinal Therapeutic for information on other specific therapeutic injections.

6. Special tests are generally well-accepted tests and are performed as part of a skilled assessment of the patients capacity to return to work, his/her strength capacities, and/or physical work demand classifications and tolerance. The procedures in this Subsection are listed in alphabetical order.

a. Computer-enhanced evaluations. These may include isotonic, isometric, isokinetic and/or isoinertial measurement of movement, range of motion (ROM), endurance, or strength. Values obtained can include degrees of motion, torque forces, pressures, or resistance. Indications include determining validity of effort, effectiveness of treatment and demonstrated motivation. These evaluations should not be used alone to determine return to work restrictions.

i. Frequency. One time for evaluation, one for mid-treatment assessment, and one at final evaluation.

b. Functional Capacity Evaluation (FCE): This is a comprehensive or modified evaluation of the various aspects of function as they relate to the workers ability to return-to-work. FCEs should not be used as the sole criteria to diagnose malingering. Areas such as endurance, lifting (dynamic and static), postural tolerance, specific range of motion (ROM), coordination and strength, worker habits, employability as well as psychosocial aspects of competitive employment may be evaluated. Reliability of patient reports and overall effort during testing is also reported.

Components of this evaluation may include: musculoskeletal screen; cardiovascular profile/aerobic capacity; coordination; lift/carrying analysis; job-specific activity tolerance; maximum voluntary effort; pain assessment/psychological screening; non-material and material handling activities. Standardized national guidelines (such as National Institute for Occupational Safety and Health (NIOSH)) should be used as the basis for FCE recommendations.

i. Frequency: Once when the patient is unable to return to the pre-injury position and further information is desired to determine permanent work restrictions. Prior authorization is required for repeat FCEs.

ii. Most studies of FCEs were performed on chronic low back cases. There is some evidence that an FCE fails to predict which injured workers with chronic low back pain will have sustained return to work. Another cohort study concluded that there was a significant relation between FCE information and return to work, but the predictive efficiency was poor. There is some evidence that time off work and gender are important predictors for return to work, and floor-to-waist lifting may also help predict return to work; however, the strength of that relationship has not been determined.

iii. A full review of the literature reveals no evidence to support the use of FCEs to prevent future injuries. There is some evidence in chronic low back pain patients that FCE task performance is weakly related to time on disability and time for claim closure, and even claimants who fail on numerous physical performance FCE tasks may be able to return to work. These same issues may exist for lower extremity issues.

iv. Depth and breadth of FCE should be assessed on a case-by-case basis and should be determined by tester and/or referring medical professional. In many cases, a work tolerance screening or return to work performance will identify the ability to perform the necessary job tasks. There is some evidence that a short form FCE reduced to a few tests produces a similar predictive quality compared to the longer two-day version of the FCE regarding length of disability and recurrence of a claim after return to work.

v. When an FCE is being used to determine return to a specific jobsite, the provider is responsible for fully understanding the physical demands and the duties of the job that the worker is attempting to perform. A jobsite evaluation is usually necessary. A job description should be reviewed by the provider and FCE evaluator prior to this evaluation. FCEs cannot be used in isolation to determine work restrictions. It is expected that the FCE may differ from both self-report of abilities and pure clinical exam findings in chronic pain patients. The length of a return to work evaluation should be based on the judgment of the referring physician and the provider performing the evaluation. Since return to work is a complicated multidimensional issue, multiple factors beyond functional ability and work demands should be considered and measured when attempting determination of readiness or fitness to return to work. FCEs should not be used as the sole criteria to diagnose malingering.

c. Job site evaluation is a comprehensive analysis of the physical, mental, and sensory components of a specific job. The goal of the Job Site evaluation is to identify any job modification needed to ensure the safety of the employee upon return to work. These components may include, but are not limited to: postural tolerance (static and dynamic); aerobic requirements; range of motion; torque/force; lifting/carrying; cognitive demands; social interactions; visual perceptual; environmental requirements of a job; repetitiveness; essential functions of a job; and ergonomic set up. Job descriptions provided by the employer are helpful but should not be used as a substitute for direct observation.

i. Frequency: One time with additional visits as needed for follow-up per Job Site.

ii. Jobsite evaluation and alteration should include input from a health care professional with experience in ergonomics or a certified ergonomist, the employee, and the employer. The employee must be observed performing all job functions in order for the jobsite evaluation to be a valid representation of a typical workday. If the employee is unable to perform the job function for observation, a co-worker in an identical job position may be observed instead. Periodic follow-up is recommended to assess the effectiveness of the intervention and need for additional ergonomic changes.

iii. A jobsite evaluation may include observation and instruction of how work is done, what material changes (desk, chair) should be made, and determination of readiness to return to work.

iv. Requests for a jobsite evaluation should describe the expected goals for the evaluation. Goals may include but are not limited to the following:

(a). to determine if there are potential contributing factors to the persons condition and/or for the physician to assess causality;

(b). to make recommendations for and to assess the potential for ergonomic changes;

(c). to provide a detailed description of the physical and cognitive job requirements;

(d). to assist patients in their return to work by educating them on how they may be able to do their job more safely in a bio-mechanically appropriate manner;

(e). to give detailed work/activity restrictions.

d. Vocational Assessment. Once an authorized practitioner has reasonably determined and objectively documented that a patient will not be able to return to his/her former employment and can reasonably prognosticate final restrictions, implementation of a timely vocational assessment can be performed. The vocational assessment should provide valuable guidance in the determination of future rehabilitation program goals. It should clarify rehabilitation goals, which optimize both patient motivation and utilization of rehabilitation resources. If prognosis for return to former occupation is determined to be poor, except in the most extenuating circumstances, vocational assessment should be implemented within 3 to 12 months post-injury. Declaration of Maximum Medical Improvement (MMI) should not be delayed solely due to lack of attainment of a vocational assessment.

i. Frequency: One time with additional visits as needed for follow-up

e. Work tolerance screening (Fitness for Duty) is a determination of an individual's tolerance for performing a specific job based on a job activity or task. It may include a test or procedure to specifically identify and quantify work-relevant cardiovascular, physical fitness and postural tolerance. It may also address ergonomic issues affecting the patients return-to-work potential. May be used when a full FCE is not indicated. In order for a work tolerance to be performed in place of a FCE, an updated job description must be provided to the tester.

i. Frequency. One time for initial screen. May monitor improvements in strength every three to four weeks up to a total of six visits.

La. Admin. Code tit. 40, § I-2109

Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation Administration, LR 37:1685 (June 2011), Amended LR 46199 (2/1/2020).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.