Imported - Colorado Secretary of State

STATEMENT OF EMERGENCY BASIS AND PURPOSE FOR AMENDMENT OF RULE XIV. L. OF THE
WORKERS' COMPENSATION RULES OF PROCEDURE, 7 C.C.R. 1101-3
BASIS: The Director of the Division of Workers' Compensation is responsible for administering the
workers' compensation system in Colorado. Sections 8-47-107 and 24-4-103(6), C.R.S. provide the
Director of the Division of Workers' Compensation with authority to adopt rules and regulations to govern
proceedings and hearings of the Division on an emergency basis. In certain situation obtaining a Division
Independent Medical Examination (DIME) is a necessary prerequisite before a party may proceed to
hearing.
SB 03-240 becomes effective on or about August 6, 2003. SB 240 amends portions of the statutes
involving the DIME process, including section 24-42-107(8)(b.5) and (c), as well as section 8-42-107.2(3)
(a) and (5). Pursuant to SB 03-240 the Director is required to promulgate rules regarding the selection
process of a panel of three physicians from which the parties are to select the physician to conduct the
DIME. Factors to be considered in the selection process, as well as the general process by which the
parties will select the physician to perform the DIME, are also spelled out. In addition, SB 03-240 gives
the Director specific statutory authority to promulgate rules to determine when a claimant is indigent, as
well as setting forth the process for the parties to submit medical records prior to the DIME.
PURPOSE: Amendment to Rule XIV.L are needed to conform with the new statutory mandates. The
proposed rule:
● Establishes a process whereby the Division selects three physicians from which the parties
can choose one to perform the DIME. The three physicians are selected on a revolving basis
from a pool of physicians who are qualified to perform the examination based on the condition or
injury at issue. The rule also specifies the obligations of the parties when selecting the physician
to perform the DIME;
● Updates the guidelines for determining indigence, clarifies how fees are paid when a claimant
is determined to be indigent;
● Sets forth guidelines to apply in the determination of when a DIME physician has a conflict of
interest in individual cases.
Pursuant to section 24-4-103(4)(b), C.R.S. (2002), the director also finds that:
Immediate adoption of the amendments is imperatively necessary to comply with SB 03-240 and
compliance with the notice requirements of the Colorado Administrative Procedure Act would be
contrary to the public interest.
This emergency rule shall be effective August 6, 2003 and will continue in effect until October 31, 2003.
Dated this 5th day of August, 2003
MaryAnn Whiteside Director Division of Workers' Compensation
STATEMENT OF BASIS AND PURPOSE FOR AMENDMENT OF RULE XIV. L. OF THE WORKERS'
COMPENSATION RULES OF PROCEDURE, 7 C.C.R. 1101-3
BASIS: The Director of the Division of Workers' Compensation is responsible for administering the
workers' compensation system in Colorado. Section 8-47-107, C.R.S. provides the Director of the Division
of Workers' Compensation with authority to adopt proper rules and regulations to govern proceedings and
hearings of the Division, and the discretion to amend said rules from time to time. In certain situation
obtaining a Division Independent Medical Examination (DIME) is a necessary prerequisite before a party
may proceed to hearing.
SB 03-240 becomes effective on or about August 6, 2003. SB 240 amends portions of the statutes
involving the DIME process, including section 24-42-107(8)(b.5) and (c), as well as section 8-42-107.2(3)
(a) and (5). Pursuant to SB 03-240 the Director is required to promulgate rules regarding the selection
process of a panel of three physicians from which the parties are to select the physician to conduct the
DIME. Factors to be considered in the selection process, as well as the general process by which the
parties will select the physician to perform the DIME, are also spelled out. In addition, SB 03-240 gives
the Director specific statutory authority to promulgate rules to determine when a claimant is indigent, as
well as setting forth the process for the parties to submit medical records prior to the DIME.
PURPOSE: Amendment to Rule XIV.L are needed to conform with the new statutory mandates, as well as
to clarify other sections of the current rule. The proposed rule:
● Establishes a process whereby the Division selects three physicians from which the parties
can choose one to perform the DIME. The three physicians are selected on a revolving basis
from a pool of physicians who are qualified to perform the examination based on the condition or
injury at issue. The rule also specifies the obligations of the parties when selecting the physician
to perform the DIME;
● Updates the guidelines for determining indigence, clarifies how fees are paid when a claimant
is determined to be indigent;
● Sets forth guidelines to apply in the determination of when a DIME physician has a conflict of
interest in individual cases.
Other non-substantive changes in the rule are included for purposes of clarification, typographical
correction, or to make the text more readable.
Pursuant to section 24-4-103(4)(b), C.R.S. (2002), the director also finds that:
(1) there is a demonstrated need for these rules amendments; (2) the proper statutory authority exists for
this regulation; (3) to the extent practicable, the rule is clearly stated so that its meaning will be
understood by any party required to comply with the regulation;
(4) the rule does not conflict with other provisions of the law; and
(5) the duplicating or overlapping of regulations is explained by the agency proposing the rule.
This rule shall be effective November 1, 2003.
Dated this 5th day of August, 2003
MaryAnn Whiteside Director Division of Workers' Compensation
STATEMENT OF BASIS AND PURPOSE FOR AMENDMENT TO RULE XVIII, MEDICAL FEE
SCHEDULE, OF THE WORKERS' COMPENSATION RULES OF PROCEDURE 7 CCR 1101-3
BASIS: Section 8-47-107, C.R.S. (2002), provides the Director of the Division of Workers' Compensation
with authority to adopt and amend proper rules and regulations to govern the proceedings and hearings of
the Division. This rule amendment is promulgated pursuant to Section 8-42-101 (3) (a) (I), C.R.S., which
requires the Director to annually review the medical fee schedules established by the Division.
PURPOSE: The purpose of this amendment to Rule XVIII is to:
● repeal the incorporation by reference to the 2000 edition of the Relative Values for Physicians
(RVP) as published by McGraw-Hill, and replace and incorporates by reference the most current
edition of the RVP (2003) as published by McGraw-Hill;
● specify that current American Medical Association's Current Procedural Terminology (CPT),
2003 edition listed in the RVP are to be used;
● specify updated conversion factors to maintain the competitive fees in relation to other revenue
sources for health care providers
● specify by rule the surgical codes for which the anesthesia relative value is to be used with a
separate conversion factor;
● specify by rule specific surgery codes' relative value units, anesthesia base units, and global
days that are different from those published in the 2003 RVP;
● clarify the use of starred procedures to be consistent with CPT 2003;
● move and update fees for office visit codes for Acupuncturist;
● increase fees for physicians rendering impairment ratings;
● increase the in-patient hospital per diem rates and corresponding outliers;
● update the Dental codes and fees to maintain access for injured workers to dental providers;
● clarify and update all other Rule XVIII established fees, as applicable or necessary; and,
● make minor grammatical and housekeeping corrections.
Pursuant to Section 24-4-103 (4) (b), C.R.S., the Director finds that: 1) There is a demonstrated need for
this rule amendment; 2) The proper statutory authority exists for this regulation; 3) To the extent
practicable, the rule is clearly stated so that its meaning will be understood by any party required to
comply with the regulation; 4) The rule does not conflict with other provisions of law; and 5) The
duplicating or overlapping of regulations is explained by the agency proposing the rule.
This rule shall be effective January 1, 2004.
Mary Ann Whiteside
Mary Ann Whiteside
Director
Division of Workers'
Compensation
August 13, 2003
Date
RULE I INTRODUCTION
A. Statement of Basis and Purpose
These rules are promulgated by the director pursuant to section 8-47-107, C.R.S. to implement
legislative requirements contained in the Workers' Compensation Act of Colorado, to set forth the
director's administrative interpretation of statutory provisions and to establish procedures for the
administration and enforcement of the act.
B. Rule-making Procedure
These rules have been promulgated in accordance with the State Administrative Procedure Act,
section 24-4-101 et seq., C.R.S., and shall be effective March 1, 1992.
RULE II GENERAL DEFINITIONS
A. The following definitions shall apply unless otherwise indicated in these rules.
1. “Act” means articles 40 through 47 of title 8 of the Colorado Revised Statutes.
2. “Claimant” means an employee or dependents of a deceased employee claiming entitlement to
benefits under the Act. For the purpose of notification and pleadings, the term “claimant” shall
include the claimant's legal representative.
3. “Director” means the director of the Division of Workers' Compensation.
4. “Division” means the Division of Workers' Compensation in the Department of Labor and
Employment.
5. “Employee” means an individual who meets the definition of “employee” in the Act.
6. “Employer” means anyone who meets the definition of “employer” in the Act.
7. “Insurance carrier” means every mutual company or association, every captive insurance
company, and every other insurance carrier, including the Colorado Compensation
Insurance Authority, providing workers' compensation insurance in Colorado, and every
employer authorized by the Executive Director of the Department of Labor and
Employment to act as its own insurance carrier.
8. “Calendar days” and the computation thereof is as defined by Colorado Rules of Civil
Procedure, Rule 6.
9. “Business days” or “working days” are synonymous and defined as business days for the
State of Colorado. The computation thereof is as defined by Colorado Rules of Civil
Procedure, Rule 6.
RULE III INSURANCE COVERAGE
A. REPORTING REQUIREMENTS FOR INSURANCE CARRIERS AND POLICYHOLDERS
1. The Division designates the National Council on Compensation Insurance, Inc. (“NCCI”) as its agent to
receive, process, and make available to the Division, the required notices in subsections (2), (3)
and (4) below. Insurance carriers shall transmit this data and all other data elements in the
electronic format as directed by the Division through NCCI.
2. Every insurance carrier shall advise the Division, by filing with NCCI, notice of the issuance or renewal
of insurance coverage within thirty (30) calendar days of the effective date of coverage.
3. Every insurance carrier shall advise the Division, by filing with NCCI, final notice of the cancellation of
insurance coverage no later than thirty (30) calendar days after coverage is actually canceled.
This subsection does not pertain to the preliminary notice of cancellation referenced in section 844-110, C.R.S.
4. Every employer shall provide on request to its insurance carrier all federal employer identification
number(s) (“FEINS”) or other taxpayer identification number(s) for all the employer's business
operations in Colorado to which the insurance applies. All changes in FEIN or other taxpayer I.D.
numbers shall be reported immediately to the insurance carrier. The insurance carrier shall report
all changes in FEINS and taxpayer I.D. numbers to NCCI within thirty (30) calendar days of
receipt.
B. CARRIER REPRESENTATIVE
Every insurance carrier shall notify the Division's designated agent of the name, address and telephone
number of its representative responsible for reporting coverage information. This information shall be
provided within thirty (30) days upon request of either the Division or its agent, or within thirty (30) days of
a change in the information.
C. SELF-INSURED EMPLOYERS
1. Any pool authorized to self-insure shall advise the Division in writing of the effective date of selfinsurance, the name and address of the pool administrator and the federal employer identification
number of each covered member.
2. All individual self-insurance permit holders shall advise the Division in writing of the federal employer
identification number of the permit holder as well as of all covered subsidiaries.
D. ELECTION TO REJECT COVERAGE
1. An officer of a corporation or a member of a Limited Liability Company who elects to reject the
provisions of the Act under section 8-41-202, C.R.S., shall complete and send Division Form WC
43, titled “Rejection of Coverage by Corporate Officers or Members of a Limited Liability
Company,” or a substantial equivalent, to the insurance carrier for the corporation's or company's
other employees, if any, by certified mail. A Certificate of Fact of Incorporation or a copy of datestamped Articles of Incorporation or, for a Limited Liability Company, a copy of the Articles of
Organization date-stamped by the Colorado Secretary of State shall be included with the form. An
agricultural corporation electing to reject coverage for its corporate officers pursuant to 8-40302(6), C.R.S., shall notify the insurance carrier in writing. A Certification of Fact of Incorporation
or a copy of date-stamped Articles of Incorporation shall be included with the notification. Failure
to attach the appropriate document(s) will render the application or notification incomplete. If
there is no insurance carrier, such documents shall be provided, by certified mail, to the Division.
2. The Notice of Election to Reject Coverage shall become effective the next business day following
receipt of the notice by the insurance carrier or, if none, by the Division.
E. NOTICES TO EMPLOYEES
1. Every employer shall continuously post a notice to employees in one or more conspicuous places on
the employer's work site advising employees that the employer is insured for workers'
compensation as required by law, identifying the name of the employer's insurance carrier or
stating that the employer is self-insured, and containing information about the Colorado workers'
compensation system on a form prescribed or approved by the Division and furnished by the
carrier or self-insured.
2. Every employer also shall continuously post a notice to employees in one or more conspicuous places
on the employer's work site meeting the requirements set forth in section 8-43-102(1) or (1.5),
C.R.S.
RULE IV CLAIMS ADJUSTING REQUIREMENTS
A. Filing of Employer's First Report of Injury
1. An employer shall report a work-related injury or illness on the employer's first report of injury form
prescribed by the Division. The employer shall transmit the employer's first report of injury form to
its insurance carrier within the 10-day period specified by Statute.
2. Whenever an Employer's First Report of Injury or Worker's Claim for Compensation form is filed with
the Division and assigned a workers' compensation claim number, the carrier shall state whether
liability is admitted or contested within 20 days after notice or knowledge of the injury pursuant to
statute.
3. Written report of injury by any employee of the employer shall constitute sufficient notice by the
claimant.
B. Initial Notice to Claimant
At the time an in or out-of-state insurance carrier notifies the Division of its position on a claim, the
insurance carrier shall notify the claimant in writing of the carrier's claim number, the name and address of
the individual assigned to the adjustment of the claim, and the toll-free telephone number of the adjuster.
C. Employer's Supplemental Report
Upon an employee's return to work, an employer's supplemental report shall be filed by the insurance
carrier on the form prescribed by the Division.
D. Filing of Medical Reports
1. Medical reports shall not be filed with the Division except under the following circumstances:
a. When attached to an admission of liability form, or a petition to suspend benefits, or
b. In connection with a request to the Division to determine the claimant's eligibility for vocational
rehabilitation benefits or to review a vocational rehabilitation plan, or to review requests
regarding the provision of vocational rehabilitation services, or
c. When otherwise required by any other rule or the Act, or
d. At the request of the director.
E. Timely Payment of Compensation Benefits
1. Benefits awarded by order are due on the date of the order, except when a petition to review the order
is filed or a request for specific findings of fact is filed. In such case benefits for those issues
under review are due on the date the order becomes final.
2. Temporary disability benefits awarded by admission are due on the date of the admission and payable
once every two weeks thereafter.
3. Permanent disability benefits awarded by admission are due on the date of the admission.
4. For all admissions dated on or after January 1, 1993, permanent disability benefits shall be paid every
two weeks.
F. Permanent Partial Disability Benefit Rate
Permanent partial disability benefits paid as compensation for a non-scheduled injury or illness which
occurred on or after July 1, 1991, shall be paid at the temporary total disability rate, but not less than one
hundred fifty dollars per week and not more than fifty percent of the state average weekly wage at the
time of the injury.
G. Final Payment of Compensation
1. Whenever an insurance carrier terminates temporary disability benefits pursuant to Rule IX on the
grounds the claimant has reached maximum medical improvement, the admission of liability form
shall contain an admission for permanent disability benefits, if any.
2. An insurance carrier shall receive credit against permanent disability benefits for any temporary
disability benefits paid beyond the date of maximum medical improvement.
a. Paragraph 2 of this section shall not apply in cases where vocational rehabilitation is offered,
or
b. In claims based upon an injury or illness occurring prior to 7/2/87 at 4:16 p.m. where the
claimant is ordered to undergo a vocational rehabilitation evaluation but has not
commenced a vocational rehabilitation program or received a director's determination
that the claimant is not eligible for vocational rehabilitation services.
3. Whenever a worker's compensation claim has been closed by final order of the director, administrative
law judge, Industrial Claims Appeal Panel or court, the insurance carrier shall file a final payment
notice within 30 days of the date of the final order.
H. Receipts
Upon demand of the director, an insurance carrier shall produce a receipt, canceled check, or other proof
substantiating payment of compensation to the claimant or medical reimbursement to a provider or
claimant.
I. Certificates Of Mailing
Any document that is certified for mailing, including admissions, must be placed in the U.S. mail or
delivered on the date of certification.
J. Information on Claims Adjusting
Every insurance carrier, or its designated claims adjusting administrator, in or out of state, shall provide
the following information on claims adjusting practices to the Division:
1. The name, address and telephone number of the administrator(s) responsible for its claims
adjusting. This information shall be provided upon request or within 30 days of any
change in the administrator(s) or the geographical location of the administrator(s). Notice
of such change shall be provided in writing to both the claimant and the Division. Notice
shall include the name, address, and toll-free telephone number of the claims
administrator(s).
2. A list of all claims established with the Division that are affected by the change described in the
preceding paragraph. The list shall include claimant name, social security number, date
of injury, carrier claim number, and workers' compensation claim number, if available.
3. Upon request of the director, any or all records, including any insurance carrier administrative
policies or procedures, pertaining to the adjusting of Colorado Workers' Compensation
claims. This authority shall not extend to personnel records of claims personnel. All
documents shall remain confidential.
K. Admission for Permanent Total Disability Benefits
1. An insurance carrier shall file an admission of liability for permanent total disability benefits on a final
admission of liability form prescribed by the Division.
2. An insurance carrier may terminate permanent total disability benefits without a hearing by filing an
admission of liability form with all of the following attachments:
a. A death certificate or written notice advising of the death of a claimant;
b. A receipt or other proof substantiating payment of compensation to the claimant through the
date of death; and
c. A statement by the carrier as to its liability for payment of:
(1) Death benefits and
(2) The unpaid portion of permanent total disability benefits the claimant would have
received had s/he lived until receiving compensation at the regular rate for a
period of six years.
L. Revising Admissions
1. Within the time limits for objecting to the final admission of liability pursuant to 8-43-203, the director
may allow a carrier to amend the admission for permanency, by notifying the parties that an error
exists due to a miscalculation, omission, clerical error, or misapplication of the statute.
2. The period for objecting to a final admission begins on the mailing date of the last final admission.
3. This subsection applies to claimants with an open claim with dates of injury on or after July 1, 1991
and before August 5, 1998 with the most recent and valid Final Admission of Liability filed before
September 1, 1999 to which a timely objection was filed by the claimant but no Division
independent medical examination was held before September 1, 1999. The carrier, self-insured
employer, or non-insured employer may file an amended Final Admission of Liability providing
notice to the claimant of the requirement to mail a notice and proposal to select an independent
medical examiner per C.R.S. section 8-42-107.2. Failure to provide such notice by amended Final
Admission of Liability as indicated in this subsection shall preclude the carrier, self-insured
employer or non-insured employer from asserting that the claimant failed to timely file a notice
and proposal to select an independent medical examiner per C.R.S. section 8-42-107.2. If the
notice is provided by amended Final Admission of Liability the carrier, self-insured employer or
non-insured employer is not precluded from subsequently raising any relevant equitable
argument, such as waiver, laches or estoppel, regarding whether the notice and proposal was
timely filed.
M. Filing of Vocational Rehabilitation Reports
1. All vocational rehabilitation forms and reports for claims based upon an injury occurring on or prior to
July 2, 1987 at 4:16 p.m. shall be filed with the Division and all parties copied.
2. Vocational reports for claims based upon an injury on or after July 2, 1987 at 4:16 p.m. shall not be
filed with the Division except when requested by the director, when attached to a final admission,
or filed pursuant to Rule VIII I. If the claimant participates in a vocational evaluation, or if the
carrier offers vocational services and the claimant accepts, written reports must be produced and
a copy of every vocational report not filed with the Division shall be exchanged with all parties
within 15 working days of receipt.
N. Admissions of Liability
1. When the final admission is predicated upon medical reports, such reports shall accompany the
admission including any evaluation record (worksheets) associated with an impairment rating.
The admission shall specify and describe the insurance carrier's position on the provision of
medical benefits after MMI, as may be reasonable and necessary within the meaning of the Act.
The admission shall make specific reference to the medical report by listing the physician's name
and the date of the report.
a. For dates of injury on or after August 5, 1998, an objection form prescribed by the Division,
shall accompany every final admission of liability and shall precede any other attachment.
2. When an admission is filed for medical benefits only, the admission shall include remarks outlining the
basis for denial of temporary and permanent disability benefits.
3. Admissions shall be filed with supporting attachments immediately upon termination or reduction in the
amount of compensation benefits. An admission shall be filed within 30 days of resumption or
increase of benefits.
4. For all injuries required to be filed with the Division with dates of injury on or after July 1, 1991:
a. Where the claimant is a state resident at the time of MMI:
(1) When an authorized treating physician providing primary care is not level II
accredited and has determined the claimant has reached MMI and has sustained
any permanent impairment, such physician shall, within 20 days after the
determination of MMI, refer the claimant to a level II accredited physician for a
medical impairment rating. If the referral is not timely made, the insurance carrier
shall refer the claimant to a level II accredited physician within 40 days after the
determination of MMI for a medical impairment rating.
(2) If the authorized treating physician determining MMI is level II accredited, within 20
days after the determination of MMI, such physician shall determine the
claimant's permanent impairment, if any.
b. Where the claimant is not a state resident at the time of MMI:
(1) When an authorized treating physician providing primary care is not level II
accredited and has determined the claimant has reached MMI and has sustained
any permanent impairment, within 20 days after the determination of MMI, such
physician shall conduct tests to evaluate impairment and shall transmit to the
insurance carrier all test results and relevant medical information. Within 20 days
of receipt of the medical information, the insurance carrier shall appoint a level II
accredited physician to determine the claimant's medical impairment rating from
the information that was transmitted.
(2) When the claimant chooses not to have the treating physician providing primary care
conduct tests to evaluate impairment, or if the information is not transmitted in a
timely manner, the insurance carrier shall arrange and pay for the claimant to
return to Colorado for examination, testing, and rating, at the expense of the
insurance carrier. The insurance carrier shall provide to the claimant at least 20
days advance written notice of the date and time of the impairment rating
examination, and a warning that refusal to return for examination may result in
the loss of benefits. Such notification shall also include information identifying
travel and accommodation arrangements.
5. For those injuries required to be filed with the Division with dates of injury on or after July 1, 1991, and
subject to section8-42-107(8), C.R.S., medical impairment:
Within 30 days after the date of mailing or delivery of a determination of medical impairment by
an authorized level II accredited physician, or within 30 days after the date of mailing or delivery
of a determination by the authorized treating physician providing primary care that there is no
impairment, the insurance carrier shall either:
a. File an admission of liability consistent with the physician's opinion, or
b. Request a Division Independent Medical Examination (IME) on the issue of medical
impairment in accordance with Rule XIV L.3.
6. Within 30 days after the date of mailing of the IME's report determining medical impairment pursuant
to Section8-42-107(8), the insurance carrier shall either admit liability consistent with such report
or file an application for hearing. This section does not pertain to IMEs rendered under Section 843-502.
7. The insurance carrier may modify an existing admission regarding medical impairment, whenever the
medical impairment rating is changed pursuant to a binding IME, an IME selected in accordance
with Part 5 of this Rule IV N., or an order. Any such modifications shall not affect an earlier award
or admission as to monies previously paid.
8. For those injuries required to be filed with the Division with dates of injury on or after July 1, 1991, and
subject to Section 8-42-107(2), scheduled injuries:
a. The time requirements as set forth in part 4 of this Rule IV N. apply.
b. Within 30 days after a determination of permanent impairment from an authorized level II
accredited physician is mailed or delivered, or a determination by the authorized treating
physician providing primary care that there is no impairment is mailed or delivered, the
insurance carrier shall either:
(1) File an admission of liability consistent with the physician's opinion, or
(2) Set the matter for hearing.
O. Compliance Review
1. Every insurance carrier shall submit to reviews of its claim files for injuries arising on or after July 1,
1991, by the Carrier Practices Unit, on behalf of the Division of Workers' Compensation. The
Division shall conduct reviews for the purpose of ensuring that benefits are calculated accurately
and paid timely and that claims are otherwise handled in accordance with the Workers'
Compensation Act and these Rules of Procedure.
a. The Division shall inform the insurance carrier of the review in writing and provide a list of files
to be reviewed at least 15 calendar days prior to the commencement of the review.
b. At the time of the review, and for each file listed, the insurance carrier shall make the file
available or provide to the Division a copy of the following documents: all wage records
and reports, all records of medical and compensation payments, all copies of paid
medical billings, all medical reports, all vocational rehabilitation reports, all notices of
contest, all admissions of liability, and all correspondence pertaining to that claim,
excluding work product. If an insurance carrier elects an on-site audit and the audit
requires that the reviewers travel out-of-state, said carrier shall cover travel costs
necessitated by and incidental to the review.
c. Failure to provide information as defined under 1.b. above shall be considered a violation of
the claims management efforts of the Division as subject to section 8-43-218, C.R.S., and
may subject the carrier to penalties pursuant to Rule XI G. and section 8-43-218(3),
C.R.S. In the event sanctions are imposed pursuant to the above section, the carrier shall
be provided remedies as set forth in section 8-43-207, C.R.S.
2. The insurance carrier shall establish dates of receipt by the carrier on all documents filed with the
Division and on all medical bills and reports required to be exchanged among parties of interest.
For those documents which are required to be exchanged by the insurance carrier, the carrier
shall verify the date of mailing on the face of the document. For those claims filed prior to the
effective date of this rule, if there is no date stamp, date of receipt may be presumed to occur
three days after the date of the document or billing date. The carrier may establish its date of
receipt of the Worker's Claim for Compensation by its date stamp in the first instance or by three
days after the date of the transmittal letter from the Division.
3. The issues to be considered during the review shall include, but shall not be limited to, the following:
a. A comparison of the date of receipt of the Employer's First Report of Injury or Worker's Claim
for Compensation form and the date of the admission or Notice of Contest pursuant to
the provisions of section 8-43-203, C.R.S.
b. The calculation of average weekly wage as set forth in sections 8-40-201(19) and 8-42-102,
C.R.S.; verification for the basis of the calculation may be required.
c. The calculation of compensation benefits pursuant to sections 8-42-105, 8-42-106, 8-42-107,
and 8-42-111, C.R.S.
d. The date of each payment of compensation to ensure that benefits are paid timely and
regularly, pursuant to section 8-42-105(2)(a), C.R.S. and Rule IV E.
e. A comparison of the medical billing date and the date of payment in accordance with Rule XVI
K.
f. Compliance with procedures for contesting liability for medical payments or for returning
medical billings due to insufficient data in accordance with Rule XVI(K).
g. Modification, termination or suspension of benefits pursuant to section 8-42-105 and Rule IX.
h. Service of documents in accordance with Rule XI, and other applicable Rules of Procedure.
4. Reporting Process
a. The Division shall provide a report of the review findings to the carrier within 30 calendar days
from the date the unit completes the review. The report shall contain the unit's findings
and recommendations, identifying each claim for which a correction is indicated, if
applicable.
b. The carrier shall have 30 calendar days from the date of the report to respond to or comply
with the recommendations contained in the report, unless otherwise specified.
The response shall be mailed to the Director of the Division of Workers' Compensation.
The carrier shall provide evidence of compliance by providing applicable documents such
as amended admissions, supplemental reports, wage history, medical reports, etc.
c. The carrier or the Division may request a conference to discuss the review, within 30 days
from the date of the report.
d. Nothing in this rule shall preclude the Division's ability to proceed under enforcement
mechanisms provided by statute or rule.
e. Information, documentation and reports obtained from any individual, carrier representative, or
any other person pursuant to the administration of this rule, in accordance with sections
8-47-202 and 8-47-203, C.R.S., except to the extent necessary for the proper
administration of a claim for workers' compensation, shall be held confidential and shall
not be published or be open to public inspection in any manner, other than to public
employees in the performance of their public duties or to an agent of the Division of
Workers' Compensation designated as such in writing for the purpose of accomplishing
the Division's functions under this rule.
RULE V VOCATIONAL REHABILITATION RULES APPLICABLE TO CLAIMS BASED UPON AN
INJURY OR ILLNESS OCCURRING PRIOR TO JULY 2, 1987 at 4:16 p.m.
A. Statement of Basis and Purpose
The rules of procedure governing the vocational rehabilitation component of worker's compensation are
promulgated to afford the injured worker an opportunity to re-enter the workforce with a minimum of lost
time. These rules accomplish that purpose through establishing procedures for early intervention by
providing guidelines for comprehensive vocational evaluation to yield appropriate, achievable vocational
rehabilitation plans. The rules also set guidelines for rehabilitation facilities and assisting in the vocational
rehabilitation process, to gain the approval of the Division pursuant to C.R.S. 1973, section 8-49-101(4).
B. Definitions
In addition to the definitions already adopted in the rules, the following definitions apply to vocational
rehabilitation procedures:
1. “Job Modification” is the environmental adaptation of a job either through the use of aids or
devices or the alteration of the physical environment of the job, or both, to allow an
impaired individual to perform within the scope of tasks originally designed for the job
flow.
2. “Job Restructuring” is a special application of job analysis that involves the identification of
jobs within the context of the system of which they are a part and the analysis and
rearrangement of the job tasks to achieve a desired purpose.
3. “Qualified Worker” means an employee who because of the effects of a work-related injury or
occupational disease, (a) is permanently precluded from engaging in his/her usual and
customary occupation and is unable to perform work for which the individual has previous
training or experience, and (b) can reasonably be expected to attain suitable, gainful
employment upon successful completion of a vocational rehabilitation program.
4. “Qualified Rehabilitation Consultant” means a person authorized by a rehabilitation vendor to
conduct a vocational evaluation and develop a rehabilitation plan for a qualified worker.
This individual must demonstrate a level of professional training and experience as may
be required by the director. The qualifications may consider, among other things
education, experience and cumulative levels of expertise.
5. “Rehabilitation Vendor” means an individual, firm or facility which exists to provide any or all of
the services necessary to determine an injured employee's eligibility as a qualified
worker, and/or provide those services designed to return an individual to work. A vendor
must register with the Division and be approved by the director.
6. “Suitable Gainful Employment” means employment which is reasonably attainable and which
offers an opportunity to restore the injured worker as soon as possible and as nearly as
possible to employment with the employee's qualifications, including but not limited to the
em-ployee's age, education, previous work history, interests and skills. Special
consideration shall also be given to the economic level of the employee at the time of
injury and to the present and future labor markets, to attempt to restore him/her to the
maximum level attainable.
7. “Transferable Skills” means those skills an individual possesses which were attained through
previous training or experience and are readily marketable and a need for them exists in
the current labor market and would provide suitable gainful employment. Transferable
skills may also mean those skills gained through experience which can be redirected into
a related occupation (Example: plumber-counter sales or sales representative for
plumbing supply house, or contract estimator for plumbing work).
8. “Vocational Evaluation” means the service and/or rehabilitation services required to determine
an injured employee's eligibility as a qualified worker. The services may include, but are
not limited to work evaluation, vocational testing, counseling, job analysis and labor
market analysis.
9. “Vocational Rehabilitation Plan” means a written document completed and signed by a
qualified rehabilitation consultant which describes the manner and means by which it is
proposed that a qualified worker may be returned to suitable gainful employment through
the participation in a rehabilitation program.
10. “Vocational Rehabilitation Program” means the actual providing of services as prescribed in
the vocational rehabilitation plan and approved by the director as reasonably necessary
to restore a qualified worker to suitable gainful employment. Such services shall include
but are not limited to medical services, counseling, education, vocational training
(including on-the-job training), books, supplies and tools, job development and placement
assistance and on-site followup.
C. Initiation of Vocational Evaluation and Director's Determination of Eligibility
1. A vocational avaluation shall be provided by a rehabilitation vendor designated by the insurance
carrier, or self-insured employer, or upon failure of such designation, by the Division in
consultation with the employee, as soon as the need is identified as outlined below. The carrier
shall commence a vocational evaluation upon the occurrence of either of the following:
a. Immediately upon receipt of the first report of an injury in which liability is admitted and
involves any of the following: (1) mangling, crushing or amputation of a major portion of
an extremity, (2) traumatic injury to spinal cord that has caused or may cause paralysis,
(3) severe burns that require burn center care, (4) serious head injury or loss of both
eyes.
b. Immediately upon knowledge that an injured employee is unlikely to be able to return to
his/her usual and customary occupation on a permanent basis as determined by
competent medical evidence and opinion.
2. Immediately following one hundred twenty (120) days of temporary total disability for injuries or
occupational diseases not evaluated under 1a & 1b above, one of the following must occur:
a. The employee will be referred for vocational evaluation.
b. The employee will be referred for re-evaluation of his/her medical conditions to determine
maximum medical improvement and the likelihood of a need for vocational rehabilitation
or that (s)he will return to work and a report thereupon shall be filed with the Division.
c. The self-insured employer or insurance carrier will file with the Division a report that the
employee will be able to return to work accompanied by competent medical evidence that
also provides a date for maximum medical improvement.
3. A vocational evaluation shall contain the elements listed below and be submitted in a summary report
to the director:
a. An on-site analysis of the tasks and duties of the job the employee was performing as his/her
usual and customary occupation at the time of injury.
b. An analysis of the previously submitted medical reports and physicians' evaluations as they
relate to the physical and skill requirements of the job the employee was performing as
his/her usual or customary occupation at the time of injury.
c. An analysis of the employee's work history and academic achievement to determine
transferable skills to other occupations within the scope of medical limitation and the
prognosis for rehabilitation.
d. A medical report, either supplemental or previously filed, from the authorized treating physician
providing: a diagnosis of the injury, a medical prognosis, prescribed medications, medical
limitations, necessary continued medical care, and a reasonable commencement date for
vocational rehabilitation, if applicable.
e. An assessment by a qualified rehabilitation consultant regarding the employee's likelihood of
benefiting from rehabilitation services, considering such factors as attitude, interests,
aptitudes, motivation and physical condition.
f. And where it is deemed necessary, the rehabilitation vendor shall provide for vocational testing
and shall attach a written justification for such provision to the summary report submitted
to the director.
g. In cases where it is determined that an individual possesses transferable skill or skills, there
must be an analysis that the skill or skills are current and marketable.
4. A vocational evaluation shall be completed within sixty (60) days of assignment to the rehabilitation
vendor or within one hundred eighty (180) days of the injury, whichever occurs first, at which time
a comprehensive summary report shall be submitted.
5. A summary report of the vocational evaluation, signed by the qualified rehabilitation consultant
responsible for the evaluation, shall be submitted to the director and shall contain a
recommendation that the injured employee is or is not eligible for a vocational rehabilitation
program.
6. If the recommendation indicates that the employee is in need of vocational rehabilitation, the
recommendation shall include a description of the suggested occupation(s) that would be
considered for plan development.
7. Upon submission of the summary report, the director shall determine the status of eligibility within
twenty (20) days and shall issue a “Notice of Determination of Eligibility for Vocational
Rehabilitation Benefits” to the self-insured employer or insurance carrier, and employee and
his/her attorney.
8. Either party may object to the determination concerning eligibility within fifteen (15) days of the date of
the director's determination. The objecting party may request a hearing or reserve the objection to
a later date in writing.
D. Submission and Implementation of the Vocational Rehabilitation Plan
1. If the employee is determined a qualified worker, the director shall order that a vocational rehabilitation
plan be developed. The plan shall be developed and submitted to the director and the parties
within forty-five (45) days of the Director's determination of eligibility, unless said determination
has been contested.
2. In developing the plan, the rehabilitation vendor shall strive to achieve vocational objectives in the
following priorities:
a. Return to work for the same employer to a modified or restructured job requiring rehabilitation
services, which is deemed to be suitable gainful employment and within the feasibility of
the medical and physical limitations determined in the vocational evaluation.
b. Return to work for the same or a new employer in a related occupation, deemed to be suitable
gainful employment, for which the individual has received rehabilitation services to
upgrade skills attained from previous training or experience so as to achieve marketable
transferable skills, and is within the feasibility of the medical and physical limitations
determined in the vocational evaluation.
c. Return to work in an on-the-job training capacity at an occupation which is deemed to be
suitable gainful employment and that is within the feasibility of the medical and physical
limitations determined in the vocational evaluation.
d. Return to work after the completion of a vocational program into a new occupation, deemed to
be suitable gainful employment, within the medical and physical limitations determined in
the vocational evaluation.
3. Once developed, the proposed plan shall be written and submitted to the parties. The written plan shall
include:
a. The vocational objective(s) leading to suitable gainful employment.
b. The name and location of the educational institution, vocational training agency, company or
business involved in vocational rehabilitation program.
c. The nature, extent, duration of services to be provided in the rehabilitation program which will
include, but are not limited to physical and occupational therapy, counseling, job
development and placement activities, and medical treatment.
d. The expected length of the vocational rehabilitation program.
e. A labor market analysis showing the feasibility of employment for a qualified worker retraining
for a new occupation if the proposed program is success-fully completed.
f. The amount of weekly income maintenance benefits, tuition, fees, and transportation costs, if
any, and the time and manner of such payments to the employee during rehabilitation.
g. The name of the qualified rehabilitation consultant responsible for the plan and the vendor's
name and registration number.
4. The vocational rehabilitation plan submitted to the parties shall include copies of the summary report in
its entirety.
5. The director, upon receipt of a proposed vocational rehabilitation plan and upon review, shall order the
plan either approved or disapproved or modified. Implementation of the plan may begin as soon
as the employee is capable of participating in the program, as indicated by competent medical
evidence. The plan shall begin upon the director's approval or the date specified in the plan as
applicable, whichever is later. The insurance carrier shall continue to provide temporary disability
benefits, if applicable, until implementation of the plan and the employee begins his vocational
rehabilitation program.
6. All matters regarding rehabilitation plans or programs shall be initially submitted to the director except
in those cases where the question of need for vocational rehabilitation first arises during the
course of a hearing or hearings on other issues.
7. Where the parties indicate area of disagreement, the director shall attempt to resolve the differences
and upon obtaining agreement, order the plan approved. If the differences cannot be resolved,
the director shall set the case for hearing to resolve the areas of disagreement.
8. If the employee does not choose to enroll in a vocational rehabilitation program, nothing in these rules
and regulations shall require the employee to do so.
E. Modification, Suspension or Termination of the Vocational Rehabilitation Plan or Vocational
Evaluation
Problems, disputes or other matters regarding modification, suspension, or termination of a vocational
rehabilitation plan or vocational evaluation shall be reviewed by the director upon the request of the
insurance carrier, or the self-insured employer, or the employee, or upon the director's own motion. The
Division shall issue an order modifying, suspending, or terminating the rehabilitation plan or vocational
evaluation if it finds:
1. That satisfactory progress is not being made, or
2. That the plan is not likely to prepare the employee for suitable, gainful employment due to unexpected
contingencies, or
3. That the employee refuses to complete or obstructs the vocational rehabilitation plan or vocational
evaluation, or
4. That a more suitable plan becomes available so that a vocational evaluation is no longer necessary as
shown by competent evidence.
F. Reporting Requirement
Copies of the vocational evaluation, interim reports, vocational rehabilitation plan, progress of the
rehabilitation plan, and final report including medical and vocational reports shall be sent to the employer
or its insurance carrier, the employee and his/her attorney by the rehabilitation vendor. Copies of the
vocational evaluation, vocational rehabilitation plan, and the final report shall be sent to the Division of
Workers' Compensation by the rehabilitation vendor. A certificate of mailing shall be attached to all reports
required under this rule.
G. Registration and Approval of a Rehabilitation Vendor
Every person, firm, or facility providing services as a rehabilitation vendor as defined, must register with
the Division and be approved as a qualified facility in accordance with C.R.S., 1973, section 8-49-101(4).
In granting approval the director may consider, among other things, that the vendor have available to it
the services of a qualified rehabilitation consultant who demonstrates one of the following credentials:
1. The individual is a Certified Rehabilitation Counselor under the guidelines of the Commission on
Rehabilitation Counselor Certification or can demonstrate equivalent credentials.
2. The individual has a Master's degree in Vocational Rehabilitation, Guidance and Counseling,
Psychology, or in a related field or can demonstrate equivalent work experience on a year for
year basis for formal education. The individual must also have one (1) year of experience as a
practitioner in the field of vocational rehabilitation.
3. The individual has a Bachelor's degree in Vocational Rehabilitation, Guidance and Counseling,
Psychology, or a related field or can demonstrate equivalent work experience on a year for year
basis for formal education. The individual must also have two (2) years experience as a
practitioner in the field of vocational rehabilitation
RULE VI APPLICATIONS FOR ADMISSION AND PAYMENT OF BENEFITS FROM THE MAJOR
MEDICAL INSURANCE FUND AND THE MEDICAL DISASTER FUND
A. Applications for Admission
1. All applications for admission shall be filed in duplicate with the Division on the prescribed forms. Upon
receipt of an application, the director shall examine the claim file to determine whether the
employer has exhausted its limits of liability for medical aid as provided in C.R.S. 1973, section 849-101. Those applications not meeting this requirement shall be dismissed and the applicant will
be so notified by the director.
2. Applications meeting the above requirement shall be examined by the director in accordance with the
relevant provisions of the act. The director may approve or disapprove an application for
admission from the fund without conducting a hearing.
B. Appeal of Order Denying Admission or denying benefits
1. A party who is dissatisfied with an order dismissing or denying an application for admission or
dissatisfied with a written denial of benefits may request mediation services and/or apply for a
hearing.
2. When mediation or a hearing is requested after a dismissal or denial of an application for admission or
for a denial of benefits from the fund, the director shall be listed as a party and served with all
notices, pleadings, reports, and other documents. Where an assistant attorney general has
entered an appearance for the director in a case, such service shall be made on that attorney.
RULE VII APPEAL PROCEDURES
A. Appeal of a Summary Order
A party may appeal a summary order by filing a request for specific findings of fact and conclusions of law
in accordance with section 8-43-215, C.R.S. Such request shall be a prerequisite to a petition to review
under section 8-43-301, C.R.S.
B. Petition to Review
1. A petition to review filed pursuant to section 8-43-301, C.R.S. shall:
a. set forth the date of the order which is the subject of the petition to review and the name of the
administrative law judge or director who entered the order.
b. include a designation of record which specifies the exact hearing date for any transcript being
ordered and the name of the court reporter preparing the transcript.
c. be served by mail on all parties at the same time it is filed.
2. A party appealing an order who is appearing without an attorney may use the petition to review form
provided by the Division.
3. A petition to review an order of the director shall be filed at the Division's office in Denver. A petition to
review an order entered by an administrative law judge shall be filed at the place indicated in the
order, or, if a place is not indicated, at the Division's office in Denver.
C. Requests for Transcripts
1. A party designating a transcript as part of the record shall contact the court reporter(s) directly and
make arrangements to pay for the transcript. A court reporter may demand payment of a deposit
prior to preparation of a transcript.
2. When arrangements to pay for a transcript have not been made with a court reporter on a timely basis,
the court reporter shall notify the Division. Upon such notification, an administrative law judge or
the director may determine, after reasonable notice to the parties, that the order of the transcript
has been withdrawn. An administrative law judge or the director may then issue a briefing
schedule pursuant to section 8-43-301 (4), C.R.S.
3. A party who wishes to cancel a request for a transcript shall contact the court reporter(s) directly. A
withdrawal of a petition to review does not automatically cancel a request for a transcript.
D. Submission of Briefs
1. When the transcript(s) designated as part of the record have been filed or the record is otherwise
complete, the Division or Division of Administrative Hearings shall issue a briefing schedule in
accordance with section 8-43-301, C.R.S.
2. The petitioner's brief shall be titled “Brief in Support of Petition to Review” and shall contain, in the
following sequence:
a. a short introduction of the matter to be reviewed including the date of the order which is the
subject of the petition and the name of the administrative law judge or director who
entered the order.
b. a statement of the issues presented for review.
c. the arguments of the petitioner regarding the issues presented, along with supporting
rationale, citations of authority, and references to the record. Where a party relies upon
testimony, reference shall be made to the page of the transcript on which the testimony
may be found. Where a party relies upon documentary evidence, reference shall be
made to the date, author and relevant page(s) of the document relied upon.
d. a short conclusion stating the precise relief sought.
3. A brief filed by an opposing party shall be titled, “Brief in Opposition to Petition to Review” and shall be
subject to the requirements of paragraph D.2. of this rule.
4. A request for an extension of time in which to file a brief shall be filed within the time period specified
for the filing of the brief or the request shall be denied. If the petitioner has not filed a brief or a
request for an extension of time on a timely basis, the opposing parties shall have 40 days after
the date of the certificate of mailing of the briefing schedule to file briefs in opposition to the
petition to review.
E. Appeal of a Supplemental Order
A petition to review a supplemental order shall be filed with a brief, as provided in section 8-43-301,
C.R.S.
F. Withdrawal of Petition to Review
A party may withdraw a petition to review by writing a letter addressed to the administrative law judge or
director who entered the order which was the subject of the petition to review. If the case has been
transmitted to the Industrial Claim Appeals Panel said letter shall be filed with it.
G. Attorney Fees
When the Industrial Claim Appeals Panel has determined that a party is entitled to reasonable attorney
fees and costs under section 8-43-301(14), C.R.S., the matter shall be remanded to the director for
determination of the amount of fees and costs to be awarded. The director may make this determination
based on an affidavit of the time spent, and the fees and costs incurred, in responding to the appeal. If
there is a dispute concerning the number of hours or the amount of fees and costs incurred in responding
to the appeal, the director may refer the matter to an administrative law judge for a hearing, or to a prehearing conference or a mediation conference to resolve the disputed issues.
RULE VIII WORKERS' COMPENSATION HEARINGS
It is the intent of these rules that all lay, expert and medical testimony shall be presented at or before the
hearing. These rules shall be referred to as the “Adjudication Rules.” Unless otherwise provided herein,
“days” shall be calculated pursuant to the provisions of Rules 6(a) and 6(e) of the Colorado Rules of Civil
Procedure.
A. REQUEST FOR FORMAL HEARING ON THE RECORD BEFORE THE DIVISION OF
ADMINISTRATIVE HEARINGS
When a formal hearing on the record is requested the following procedures shall prevail:
1. A written application shall be filed with the Division of Administrative Hearings on a prescribed form
and shall contain:
a. A statement of the issues(s) to be determined at the hearing.
(1) Issues brought before the ALJ must be ripe for adjudication.
(2) For cases with dates of injury on or after July 1, 1991, disputes about MMI, and or
whole person impairment determinations by the authorized treating physician are
not ripe for review until a Division Independent Medical Examination (IME) has
been completed or an administrative law judge determines that such issues are
ripe for hearing.
b. A statement setting forth the names and addresses of all witnesses to be presented at the
hearing, or to be presented by deposition.
2. The application for formal hearing shall be mailed by the requesting party to all parties. A certificate of
mailing shall be filed with the application. If an attorney has entered an appearance for a party,
mailing to the attorney is mandatory. The adverse party shall have 20 days after the date of the
setting to file a response. The response shall be filed on a prescribed form and shall contain all
information required by paragraph 1.a. and 1.b. of this section.
3. An application or response will not be accepted for filing unless it contains all information required by
this rule.
4. A party may not add a witness or an issue after the filing of the application or response except upon
agreement of all parties, or approval of an administrative law judge for good cause shown.
5. A party may not produce a witness at a formal hearing who has not been listed in the application or
response, or added by agreement or order, except to present rebuttal testimony or upon approval
of the administrative law judge for good cause shown.
6. The file at the Division of Workers' Compensation will be retained at the Division and is not subject to
subpoena for administrative hearings. Certified copies of any documents in the Division file can
be tendered by a party to the Division of Administrative Hearings. Parties may obtain certified
copies of documents in the Division file by contacting the Division of Workers' Compensation,
Customer Service Section.
B. SETTING PROCEDURES
1. A party who wishes to set a case for formal hearing on the record shall notify all parties and the
Division of Administrative Hearings of the date and time of the setting on a Notice to Set
prescribed form. The Notice to Set shall be accompanied by a completed application form. The
Notice to Set and Application for Hearing shall be mailed at least 10, but no more than 20 days
before the setting date. This 10 day minimum requirement may be waived by the parties and the
Division of Administrative Hearings.
2. When a formal hearing on the record is set by referral of the Director of the Division of Workers'
Compensation, or by a party appearing at the Division of Administrative Hearings or by
telephoning the Division of Administrative Hearings, the Notice of Hearing shall be prepared by
the Division of Administrative Hearings, unless setting counsel is requested to prepare the notice.
If requested, the party setting the formal hearing shall send written notice of the hearing, as
official agent of the Division of Administrative Hearings, to all other parties by regular mail on a
prescribed form within 20 days after the setting date and, in no event, fewer than 30 days prior to
the hearing date. The original copy of the notice shall be filed with the Division of Administrative
Hearings.
3. A party requesting a formal hearing on the records shall do so by filing an application for hearing in the
appropriate office of the Division of Administrative Hearings so the hearing is set at the hearing
location closest to the claimant's residence. The location of the hearing can be moved by order of
an administrative law judge for good cause shown. When a party requests a formal hearing on
the record in Denver, Boulder, Fort Collins, or Greeley, the application for hearing shall be filed in
the main office of the Division of Administrative Hearings in Denver. When a party requests a
formal hearing on the record in Colorado Springs, Pueblo, or Alamosa, the application for hearing
shall be filed with the Southern Regional Office of the Division of Administrative Hearings in
Colorado Springs. When a party requests a formal hearing on the record in Grand Junction,
Glenwood Springs, or Durango, the application for hearing shall be filed with the Western
Regional Office in Grand Junction.
4. The director may set any case for formal hearing on the record by order or by referral to the Division of
Administrative Hearings.
C. SCHEDULING OF FORMAL HEARINGS ON THE RECORD
1. If at least 20 days have passed since the insurance carrier or self insured employer has received
written notice of the claim, and no admission has been filed, or a denial has been filed within 45
days of the request for the formal hearing, the claimant may request an expedited hearing. The
request for an expedited hearing shall be made by a written request which shall certify that each
of the requirements for an expedited hearing is present in the case. Expedited cases under this
section shall be set pursuant to statute.
2. a. A hearing shall be set within 80 to 100 days of any occurrence listed in section 8-43-211(2),
C.R.S. At any time following the setting of the hearing, any party may, by written motion,
seek an extension of time to commence a hearing and a re-setting of the hearing upon
good cause shown, as provided in section 8-43-209, C.R.S. Once a case has
commenced, it may be continued only upon motion and good cause shown.
b. Good cause for an extension of time to commence a hearing or to continue a hearing that has
commenced includes, but is not limited to, the following:
(1) Death or incapacitation of a party or an attorney for a party;
(2) A court order staying proceedings or otherwise necessitating an extension;
(3) Entry or substitution of an attorney for a party a reasonable time prior the hearing, if
the entry or substitution reasonably requires an extension;
(4) A change in the parties or pleading sufficiently significant to require an extension;
(5) Failure of a witness to appear when the witness is under a valid subpoena;
(6) A showing that more time is clearly necessary to complete authorized discovery or
other mandatory preparation for the hearing; or
(7) Agreement of the parties that a settlement has been reached, or that settlement
negotiations are ongoing and likely to be approved.
c. Absent additional grounds, the following do not constitute good cause:
(1) Unavailability of counsel because of an engagement in another judicial or
administrative proceeding;
(2) Unavailability of a necessary witness who is not under a valid subpoena;
(3) Failure of an attorney timely to prepare for the hearing; or
(4) That a motion for an extension of time is unopposed or stipulated by other parties.
D. MOTIONS
1. A motion for entry of a procedural order may be submitted with a separate, properly captioned,
proposed order. The motion shall be filed in the location specified in Rule VIII L. The certificate of
mailing shall show the office in which the motion was filed.
2. A response to a motion shall be filed in the same location that the motion was filed within 10 days from
the date of the certificate of mailing of the motion, or the motion may be deemed confessed.
3. When appropriate to do so, every motion must include a certification by the party or counsel that he or
she has conferred, or attempted to confer, with opposing counsel and a statement regarding
whether the motion is contested, uncontested, or stipulated. If no conference has occurred, an
explanation must be included in the motion.
4. The Director of the Division of Administrative Hearings designee clerk in the main or regional offices of
the Division of Administrative Hearings may grant any unopposed or stipulated motion for:
a. Additional time to file a pleading or perform any act required by applicable statute or rules,
except (i) a motion to extend the time for a hearing when good cause is not alleged or an
extension of more than 20 days to commence the hearing is requested; or (ii) a motion to
continue a hearing that has been commenced;
b. Substitution or withdrawal of counsel; or
c. Adding or striking an issue or witness for hearing.
5. The proponent of an order shall submit a copy of the proposed order, and an addressed stamped
envelope or fax number. The proponent of the order is responsible for the timely distribution of the
conformed order to all parties.
6. Filing by facsimile is permitted as follows:
a. Motions shall not be filed by facsimile unless the hearing date is less than 15 days from the
date of the facsimile transmission. Motions filed by facsimile 15 or more days prior to the
hearing will not be considered.
b. Responses to motions may be filed by facsimile at any time within the limits set by this Rule
VIII.
c. Motions and responses to motions filed by facsimile must be served on opposing parties by
facsimile or personal delivery on the date of filing.
d. When a proposed order is filed by facsimile transmission, the Division clerk shall return the
signed order by facsimile to the party who submitted the proposed order. This party will
be instructed to serve copies of the order on all other parties.
e. When a motion, response or proposed order is filed by facsimile, copies of the motion,
response or proposed order and envelopes should not be filed with the Division clerk,
and will not be returned if filed.
7. The requirements of this section shall not apply when a motion for entry of a procedural order is made
during a formal hearing or during a prehearing conference.
E. DISCOVERY
Discovery in workers' compensation cases is limited to:
1. Interrogatories
a. One set of written interrogatories and requests for production of documents may be served
upon each adverse party. The number of interrogatories, including the requests for
production of documents, to any one party shall not exceed 20, each of which shall
consist of a single question or request.
b. The responses to the interrogatories and production of documents shall be provided to all
opposing parties within 20 days of mailing of the interrogatories and requests.
c. The interrogatories and the requests for production of documents may not be submitted later
than 40 days prior to hearing, except for expedited hearings.
2. Depositions
a. A deposition of a party may be taken upon written motion and order. Permission to take a
deposition of a party will be granted only when there is a specific showing:
(1) That a party who has been served with written interrogatories has failed to respond to
the interrogatories; or
(2) That the responses to the written set of interrogatories are insufficient; or
(3) All parties agree to the taking of a deposition.
b. Depositions of other witnesses may be taken upon written motion, order, and written notice to
all parties.
3. Each party is under a continuing duty to timely supplement or amend responses to discovery up to the
date of the hearing.
4. Discovery, other than evidentiary depositions, shall be completed no later than 20 days prior to the
hearing date, except for expedited hearings.
5. If any party fails to comply with the provisions of this rule and any action governed by it, an
administrative law judge may impose sanctions upon such party pursuant to statute and rule.
However, attorney fees may be imposed only for violation of a discovery order.
6. All asserted privileges shall be accompanied by a privilege log with sufficient description to allow the
other parties to assess the applicability of the privilege claims.
7. Once an order to compel has been issued and properly served upon the parties, failure to comply with
the order to compel shall be presumed willful.
8. Upon agreement of the parties or for good cause shown, an administrative law judge may allow
additional discovery, may limit discovery or may modify the time limits set forth in this rule. Setting
of a formal hearing on an expedited schedule shall constitute good cause. Good cause shall
include but not be limited to an agreement of the parties.
F. DATE OF FILING
The date of filing for purposes of this rule shall mean the date stamped on the document by the Division
of Administrative Hearings or Division when the document is delivered, or the date on the certificate of
mailing when the document is mailed. The date of filing for a facsimile received after 5:00 p.m. will be the
following business day.
G. MEDIATION, SETTLEMENT CONFERENCES, PREHEARING CONFERENCES AND
ARBITRATION
1. Mediation. Parties to a dispute may consent to submit any dispute to mediation pursuant to the
provisions of this Rule VIII and section 8-43-205, 3B C.R.S.
a. The Division shall schedule a mediation conference after all parties agree to participate
pursuant to any party's request for mediation services, in writing or orally. The mediation
conference shall be scheduled at the earliest practical time, but not later than 30 days
from the date of receipt of the request for such mediation conference by the Division.
2. Settlement Conferences. Parties to a dispute may request a settlement conference subject to the
limitations set forth in section 8-43-206, 3B C.R.S.
3. Prehearing Conferences. The director, administrative law judges in the Division of Administrative
Hearings, or any party to a claim may request a prehearing conference before a prehearing
administrative law judge. Prehearing administrative law judges may order any party to a claim to
participate in a prehearing conference.
a. The issues raised for consideration may be raised by motion, either written or oral. At least five
days prior to the prehearing conference, the parties shall notify each other of the issues
they intend to present to the prehearing administrative law judge. Additional time to
respond to an issue raised at the prehearing conference may be requested by any party.
It shall be within the discretion of the prehearing administrative law judge to determine if
such additional time is necessary to protect the rights of the parties.
b. Once a prehearing conference has been requested by a party to a claim, it shall be set. If any
party objects to the prehearing conference as set, the following procedures shall apply:
(1) Where a party objects to the setting of a prehearing conference or refuses to
participate therein, it shall fax or hand-deliver its objections to the prehearing
conference unit at the Division of Administrative Hearings within 2 days after the
date the prehearing conference is set. If the prehearing administrative law judge
orders that the prehearing conference proceed as set, the requesting party shall
send written notice of the time and place of the prehearing conference to all other
parties.
c. At the time of the prehearing conference, each party may submit a prehearing statement
setting forth a brief summary of the issues in dispute, the names of all witnesses each
party intends to call, the estimated time each party will require to present testimony and
evidence, and the status of settlement discussions. Each party may also submit any
discovery or pre-trial motion.
d. Any party to a claim may request, either in advance or on the date of the prehearing
conference, that the prehearing conference be recorded electronically or by court
reporter. If a request for electronic recording is made, a party shall have until the date of
the formal hearing on the record, if such hearing date is pending at the time of the
prehearing conference, or 100 days following the prehearing conference, whichever is
shorter, within which to request that the prehearing conference unit prepare a transcript.
The cost of preparing such transcripts shall be paid by the requesting party directly to the
vendor providing the service who shall be designated by the administrative law judge.
e. The prehearing administrative law judge may require a party to provide available vocational,
medical, hospital and employment records, or reports to the other parties.
4. Arbitration. Parties to a dispute may consent to submit any dispute to binding arbitration by written
agreement. Binding arbitration pursuant to the provisions of this Rule VIII and section 8-43-206.5,
3B C.R.S., shall be conducted by an administrative law judge of the parties' mutual choice from
the Division of Administrative Hearings, or pursuant to arbitration procedures as provided by the
Colorado Rules of Civil Procedure. Unless otherwise provided by the administrative law judge or
upon mutual consent of the parties and/or upon the order of the arbitrator(s), proceedings in any
such arbitration shall be conducted in a manner consistent with the Colorado Rules of Civil
Procedure.
H. SUBPOENAS
A subpoena to compel the attendance of witnesses or parties and the production of books, papers or
records at a scheduled deposition or formal hearing may be issued on behalf of the Division of
Administrative Hearings by an attorney who has entered an appearance in the case.
I. SUBMISSION OF REPORTS, OTHER DOCUMENTARY EVIDENCE, DEPOSITIONS, POSITION
STATEMENTS FOR FORMAL HEARING BEFORE THE DIVISION OF ADMINISTRATIVE
HEARINGS
1. All reports without limitation including medical and hospital reports, physicians' reports, vocational
reports, and records of the employer shall be provided to the opposing party or counsel if
represented at least 20 days prior to the formal hearing. If not so disclosed, the reports shall not
be introduced into evidence at hearing, absent a showing of good cause. Reports and records
previously provided to opposing parties do not have to be provided again. When provided, such
reports and records do not have to be identified as potential formal hearing exhibits.
2. An evidentiary deposition may be filed before or at the formal hearing.
3. After a hearing is set and at least 3 days prior to the formal hearing, the claimant shall file a copy of the
Worker's Claim for Compensation that has been filed with the Division of Workers' Compensation,
and the respondent shall file a copy of the employer's First Report of Accident and the most
recent Admission or Notice of Contest that has been filed with the Division of Workers'
Compensation; the party applying for the hearing shall file a copy of any order previously entered
in the claim granting or denying a benefit which is the same or similar to an issue designated for
hearing.
4. Copies of interlocutory orders previously issued in the case that a party intends to raise on appeal
shall be filed and identified at the formal hearing.
5. Oral argument at the conclusion of the formal hearing may be allowed in the discretion of the
administrative law judge. A party may file a position statement and/or proposed order upon
approval of the administrative law judge.
6. Only reports and records filed and identified at the formal hearing which are relevant to an issue set for
hearing will be considered as evidence.
7. Testimony presented by reports, records, deposition, or telephone is presumed to be equivalent of in
person hearing testimony.
J. TRANSCRIPTS OF HEARING
1. All testimony and argument of each hearing held pursuant to section 8-43-207, C.R.S. may be taken
by a hearing reporter provided by the Division of Administrative Hearings, or electronically
recorded by the Division of Administrative Hearings, or a private court reporter provided by any
party. If the hearing is recorded by more than one method, the administrative law judge shall
designate, at the time of the hearing, which will be the source for the transcript on appeal. That
source will be the source for the transcript on appeal unless the administrative law judge
determines that a transcript from a different source is more accurate.
2. The Division of Administrative Hearings shall provide parties and their counsel with as current
information as possible regarding the availability of hearing reporters for particular hearings.
However, if any party deems live reporting services to be essential, such party should make
arrangements for a private court reporter in order to ensure coverage.
K. CANCELLATIONS
A formal hearing on the record may be cancelled by the agreement of all parties. The parties may
stipulate that the cancellation will not result in a waiver of any issues. One party or counsel shall contact
the clerk of the Division of Administrative Hearings Office where the hearing is set to be held and advise
that all parties have agreed to a cancellation of the hearing. A new hearing can then only be set by filing a
new application for hearing. A formal hearing may also be cancelled by written motion made pursuant to
section D. of this rule, or oral motion made at the time of the prehearing conference or the formal hearing.
L. CONSOLIDATION
1. A motion to consolidate two or more claims for formal hearing shall be filed no later than the time the
response to the application for hearing is due, unless the moving party verified that any new party
has waived this requirement.
2. The motion shall contain a statement of any additional issues the moving party wishes to have
determined at the formal hearing, and the names and addresses of any witnesses the moving
party wishes to present at the hearing.
3. The moving party is responsible for appropriate notices to all interested parties.
M. PLACE OF FILING
1. All matters for the director's determination shall be filed with the Division of Workers' Compensation at
1515 Arapahoe Street, Tower 2, 5th Floor, Customer Service Unit, Denver, Colorado. Matters for
the Director's determination include:
(a) Show cause orders as set forth in subsection O of this rule;
(b) Requests for penalties for a violation of rules as set forth in subsection N of this rule;
(c) Requests for attorney fees made to the Director under subsection M of this rule;
(d) Matters regarding claims handling or administration, for example, benefit distribution, petitions
to modify, terminate or suspend temporary benefits, lump sum requests;
(e) Requests for payment of costs of a transcript pursuant to section 8-43-213(3), C.R.S.;
(f) Closure orders pursuant to Rule X. A.;
(g) Petition to Reopen pursuant to rule X B.;
(h) Matters involving uninsured employers pursuant to section 8-43-409, C.R.S.;
(i) Utilization reviews, unless the Director has referred the matter on appeal;
(j) Application for admission to the major medical or medical disaster funds;
(k) Settlement documents in which all parties are represented by counsel, unless settlement was
finalized before an administrative law judge, in which case an administrative law judge
may approve the settlement documents; and,
(l) Intent to practice forms and entries of appearance under subsection Q of this rule.
2. To avoid duplication, and unnecessary expense to all parties and the Division of Workers'
Compensation and the Division of Administrative Hearings, copies of matters for the
determination of the Director shall not be filed with the Division of Administrative Hearings.
However, copies of these documents may be filed if required as attachments, evidence
submissions, and other instances to complete the record at the Division of Administrative
Hearings.
3. All other motions and responses shall be filed, unless otherwise specifically ordered, with the Division
of Administrative Hearings office closest to the claimant's residence.
4. To avoid duplication, and unnecessary expense to all parties and the Division of Workers'
Compensation and the Division of Administrative Hearings, copies of these motions and
responses shall not be filed with the Division of Workers' Compensation. However, copies of
these documents may be filed if required as attachments, evidence submissions, and other
instances to complete the record for determination of a matter before the Director.
N. REQUESTS FOR ATTORNEY FEES
When the claim is based upon an injury or illness which occurred on or after July 1, 1991, attorney fees
may be requested by a Motion for Attorney Fees filed within 20 days after an order has become final or 20
days after a formal hearing has been cancelled, or, if the motion is made pursuant to section 8-43-408(4),
at such time as may be designated by the director or the administrative law judge. The motion shall be
accompanied by a detailed itemization of the time spent on the matter for which attorney fees are sought,
and an affidavit from the attorney that such time was reasonably necessary to prepare for or attend the
formal hearing or other matter, and stating the reasonable hourly rate. If no objection is filed by another
party within 10 days of the motion, it will be presumed that there is no objection to the number of hours or
the hourly rate, and the director or the administrative law judge shall enter an order awarding the amount
requested or denying the entire request. If an objection is filed, the director or the administrative law judge
may enter an order based upon the motion and objection, or may refer the matter for a mediation
conference, a prehearing conference, or a formal hearing on the record to resolve the disputed issues.
O. PENALTY PROCEDURES UNDER SECTION 8-43-304, 3B C.R.S.
1. A person requesting the assessment of penalties pursuant to section 8-43-304, 3B C.R.S. shall
proceed as follows:
a. When there are other issues pending hearing, by moving to add the issue of penalties to the
application or response. Thereafter the provisions of section 8-43-304(4), 3B C.R.S. shall
control.
b. When there are no other issues pending hearing, a party may request the imposition of
penalties by:
(1) Filing an application for hearing requesting assessment of penalties; or
(2) Filing a written motion with the director requesting the assessment of penalties
wherein the grounds therefore are stated with specificity.
2. When a motion is filed with the director pursuant to paragraph 1.b.(2) of this section N and the alleged
violator has not timely filed a written response to the motion pursuant to the provisions of section
D.2. of this Rule VIII, or when the director otherwise becomes aware of any alleged violation
contemplated by section 8-43-304(1), 3B C.R.S., the director may issue an order to show cause
pursuant to the provisions of section O. of this Rule VIII.
3. When a Motion is filed with the director pursuant to paragraph 1.b.(2) of this section N and the alleged
violator timely files a written response pursuant to the provisions of section D.2. of this Rule VIII,
the director shall issue a notice advising the alleged violator that unless the matter is set for a
formal hearing on the record within 20 days from the date of the notice, the director may:
a. Make a determination regarding the assessment of penalties as provided for in the Act; or
b. Refer the matter to an administrative law judge in the Division of Administrative Hearings to
conduct a hearing on the alleged violation, whereupon the administrative law judge shall
issue an order on the matter.
P. ORDERS TO SHOW CAUSE
Where the director determines that action shall be taken unless a person shows good cause, the following
procedures shall apply:
1. Unless otherwise specifically set forth in the order, a show cause order shall direct the respondent to
either set the matter for a formal hearing on the record within 20 days from the date of the show
cause order, or show cause in writing within twenty 20 days from the date of the show cause
order why the director should not take the action identified in the order.
Q. TRUST DEPOSITS AND SURETY BONDS UNDER 8-43-408(2)
1. The trustee for all funds held in trust under the provisions of section 8-43-408(2), 3B C.R.S. may be
the Colorado State Treasurer. If the Colorado State Treasurer is designated as trustee, an
employer depositing funds into the trust shall transmit such funds by check payable to the
Colorado State Treasurer as trustee for the employer.
2. If the Colorado State Treasurer is designated as trustee, the employer shall deliver the check for funds
to be deposited in trust or a surety bond to the Division within 10 days after the date of the order.
3. Interest on funds deposited in trust shall accrue for the benefit of the person(s) determined to be
entitled to such funds in the final order. If the trust funds are ordered to be distributed to more
than one person, each person shall receive the interest that has accrued on the principal amount
he or she is entitled to receive.
4. A person seeking distribution of a trust deposit, or enforcement of release of a surety bond, shall file a
written motion in accordance with the requirements of Rule VIII D., setting forth the reasons
justifying distribution, the person(s) to whom the distribution shall be made, and the amount(s) to
be distributed. The motion may be filed with the Division or with an administrative law judge.
5. Nothing set forth herein shall otherwise limit the authority and duties of the State Controller as
provided by section 24-30-202.4, 10A C.R.S.
R. PRACTICE BEFORE THE DIVISION
1. An attorney who wishes to practice before the Division or the Division of Administrative Hearings shall
file a notice of intent to practice on the prescribed form. Such form shall be filed with the Division
of Workers' Compensation.
2. To enter an appearance in a specific case, an attorney shall file an entry of appearance on the
prescribed form, or complete the entry of appearance section on the application for hearing or
response form, or file a notice of substitution of counsel containing the following:
a. The name of each party the attorney is representing, and
b. The attorney's address, telephone number, registration number and office code, if applicable.
c. Such form shall be filed with the Division of Workers' Compensation.
3. All pleadings shall contain the information required in section 2.b. above.
4. When the case has been closed by order or final admission, An attorney may withdraw from a specific
case by filing a notice of substitution of counsel signed by both attorneys, by providing notice to
all parties and filing a copy of the notice with the Division of Workers' Compensation or, when the
case is not closed, by filing a motion and obtaining an order authorizing withdrawal.
5. An attorney who wishes to request an order allowing withdrawal from a case that is not closed, shall
file a motion together with a copy of the notice of request to withdraw mailed to the client. The
notice to the client shall contain the following:
a. A statement that the attorney wishes to withdraw;
b. A statement that the client is responsible for keeping the Division informed of the client's
current address and telephone number and that a claim may be dismissed if the claim is
not pursued;
c. The date scheduled for any future hearing, the dates by which any legal pleadings or briefs are
to be filed and a statement that these dates will not be affected by the withdrawal of
counsel; and
d. A statement that the client may object to the request to withdraw by filing a written objection
within 10 days of the date on the certificate of mailing of the notice, and mailing a copy of
the objection to the attorney.
6. A motion to withdraw should be filed with the Division of Administrative Hearings.
7. Any attorney in good standing from any other jurisdiction in the United States may in the discretion of
the Director of the Division of Administrative Hearings, or an administrative law judge, be admitted
to practice before the Division of Administrative Hearings in a specific case when the attorney has
been employed by one of the parties in the case.
S. DISFIGUREMENT AWARD
A party may have an administrative law judge determine the amount of additional compensation due to a
claimant for disfigurement as follows:
1. By photograph: a party may submit a request for a disfigurement award to the Division of
Administrative Hearings. The request shall be accompanied by a photograph or photographs
clearly showing the disfigurement and the face of the claimant. The back of the photographs shall
be signed by the claimant and state the date the photograph was taken. The date the photograph
was taken must be at least six months after the date of the injury or surgery, or after the date of
maximum medical improvement. The signature of the claimant is the claimant's certification that
the photograph accurately depicts the disfigurement on the date the photograph was taken. A
copy of the request, and a copy of the photographs, shall be provided to all opposing parties. Any
party may request reconsideration of a disfigurement award by photograph by filing, within twenty
days of the date of the certificate of mailing of the disfigurement award, an application for hearing
listing disfigurement as an issue. If such an application is filed the disfigurement award will be
withdrawn and vacated.
2. At a hearing: a party may file an application for hearing with the Division of Administrative Hearings
listing disfigurement as an issue. If disfigurement is the only issue listed, the hearing shall be set
30 to 60 days after the date of the setting.
3. The employer or insurer may credit any disfigurement award by any amount previously paid for
disfigurement, unless provided otherwise in the disfigurement award. If the amount of the credit
exceeds the disfigurement award, the employer or insurer may credit any permanent disability
benefits not yet paid to the claimant.
RULE IX MODIFICATION, TERMINATION OR SUSPENSION OF TEMPORARY DISABILITY
BENEFITS
A. Termination of Temporary Disability Benefits by an Admission of Liability in Claims Arising
Prior to July 2, 1987, at 4:16 p.m.
1. In all claims based upon an injury or disease which occurred prior to July 2, 1987, at 4:16 p.m., an
insurance carrier may terminate temporary disability benefits without a hearing by filing an
admission of liability form with:
a. a report from the authorized treating physician who has provided the primary care stating the
claimant has reached maximum medical improvement and is released to return to an
occupation which the claimant regularly performed at the time of injury.
b. a report from the authorized treating physician who has provided the primary care stating the
claimant has reached maximum medical improvement and a director's determination that
the claimant is not eligible for vocational rehabilitation services.
c. a written report from the employer or the claimant stating the claimant has returned to work
and setting forth the wages paid for the work to which the claimant has returned; provided
such admission shall admit for temporary partial disability benefits, if any.
d. a letter or death certificate advising of the death of the claimant along with a statement by the
carrier as to its liability for death benefits.
e. a report from the authorized treating physician who has provided the primary care stating the
claimant has reached maximum medical improvement and documentation the claimant
has completed an approved vocational rehabilitation plan.
B. Termination of Temporary Disability Benefits by an Admission of Liability in Claims Arising
After July 2, 1987, at 4:16 p.m. and Before July 1, 1991
1. In all claims based upon an injury or disease which occurred after July 2, 1987, at 4:16 p.m., an
insurance carrier may terminate temporary disability benefits without a hearing by filing an
admission of liability form with:
a. a medical report from the authorized treating physician who has provided the primary care
stating the claimant has reached maximum medical improvement; provided such
admission of liability shall state a position on permanent disability benefits as provided in
Rule IV, G. This paragraph shall not apply in cases where vocational rehabilitation has
been offered and accepted.
b. a medical report from the authorized treating physician who has provided the primary care
stating the claimant is able to return to regular employment provided such admission of
liability shall state a position on permanent partial disability benefits as provided in Rule
IV, G.
c. a written report from the employer or the claimant stating the claimant has returned to work
and setting forth the wages paid for the work to which the claimant has returned; provided
that such admission of liability shall admit for temporary partial disability benefits, if any.
d. a letter or death certificate advising of the death of the claimant with a statement by the carrier
as to its liability for death benefits.
C. Termination of Temporary Disability Benefits in Claims Arising From Injuries Arising On or
After July 1, 1991
1. In all claims based upon an injury or disease occurring on or after July 1, 1991, an insurance carrier
may terminate temporary disability benefits without a hearing by filing an admission of liability
form with:
a. a medical report from an authorized treating physician stating the claimant has reached
maximum medical improvement; provided such admission of liability shall state a position
on permanent disability benefits as provided in Rule IV(G). This paragraph shall not apply
in cases where vocational rehabilitation has been offered and accepted.
b. a medical report from the authorized treating physician who has provided the primary care,
stating the claimant is able to return to regular employment.
c. a written report from an employer or the claimant stating the claimant has returned to work and
setting forth the wages paid for the work to which the claimant has returned provided that
such admission of liability shall admit for temporary partial disability benefits, if any, or
d. a certified letter to the claimant or copy of a written offer delivered to the claimant with a
signed certificate of service, containing both an offer of modified employment, setting
forth duties, wages and hours and a statement from an authorized treating physician that
the employment offered is within the claimant's physical restrictions, or
(e) a copy of a certified letter to the claimant or a copy of a written notice delivered to the
claimant with a signed certificate of service, advising that temporary disability benefits will
be suspended for failure to appear at a rescheduled medical appointment, and a
statement from the authorized treating physician documenting the claimant's failure to
appear.
f. a letter or death certificate advising or the death of the claimant with a statement by the carrier
as to its liability for death benefits.
D. Suspension, Modification or Termination of Temporary Disability Benefits by a Petition
1. When an insurance carrier seeks to suspend, modify or ter-minate temporary disability benefits
pursuant to a provision of the act, but is not able to proceed under sections A, B, C, E, F or G
herein, the insurance carrier may file a petition to suspend, modify or terminate temporary
disability benefits on a form prescribed by the Division. All documentation upon which the petition
is based shall be attached to the petition. The petition shall indicate the type, amount and time
period of compensation for which the petition has been filed and shall set forth the facts and law
upon which the petitioner relies.
2. A copy of a response form prescribed by the Division shall be mailed with a copy of the petition to the
claimant and claimant's attorney. Certification of this mailing shall be filed with the petition.
3. If the claimant does not file a written objection with the Division within twenty (20) days of the date of
mailing of the petition and response form, the insurance carrier may suspend, modify or terminate
disability benefits as of the date of the petition.
4. When a claimant files a timely objection to a petition, the insurance carrier shall continue temporary
disability benefits at the previously admitted rate until an application for hearing is filed pursuant
to Rule VIII, and the matter is resolved by order. The director finds that good cause exists to
expedite a hearing to be held within forty (40) days from the date of the setting, because
overpayment of benefits may result if the suspension, modification or termination is granted.
5. When a hearing is continued at the request of the claimant, the administrative law judge shall
temporarily grant the relief requested in the petition, pending the continued hearing, if the reports
and evidence attached to the petition and objection indicate a reasonable probability of success
by the petitioner. The continued hearing shall be held no later than 30 days from the date of the
request for continuance.
6. When a hearing is continued at the request of the insurance carrier, temporary disability benefits shall
continue pending the continued hearing, subject to the provision of the administrative law judge's
order.
E. Modification of Temporary Disability Benefits Pursuant to Statutory Offset
An insurance carrier may modify temporary disability benefits to offset social security, disability pension or
similar benefits pursuant to statute by filing an admission of liability form with the Division, with
documentation which substantiates the offset and figures showing how the amount of the offset was
calculated pursuant to statute.
F. Termination or Modification of Temporary Disability Benefits Due to Confinement
An insurance carrier may terminate or modify temporary disability benefits pursuant to statute, by filing an
admission of liability form with the Division with a certified copy of a mittimus, or other document issued
by a court of criminal jurisdiction, which establishes that the claimant is confined in a jail, prison, or any
department of corrections facility as the result of a criminal conviction.
G. Termination of Temporary Disability Benefits Pursuant to Third-Party Settlement
An insurance carrier may terminate temporary disability benefits pursuant to statute, by filing an
admission of liability form with the Division with a copy of a fully executed third-party settlement
agreement which establishes that the claimant has agreed to a monetary settlement for damages from a
third party in an action based upon the same injury/illness that is the basis of the worker's compensation
claim.
H. Failure to Comply With Requirements of Rule IX
1. Temporary disability benefits may not be suspended, modified or terminated except pursuant to the
provisions of this rule or pursuant to an order of the Division following a hearing.
2. If a claimant alleges the insurance carrier has modified or terminated temporary disability benefits
without following the provisions of this rule, the claimant may file an objection with the director
within 60 days of the date the claimant's benefits were terminated or modified. If the director
concludes the insurance carrier has not met the applicable requirements of this rule, the director
may set the matter for hearing to be held within 60 days of the filing of the objection, or the
director may order the insurance carrier to continue payment of temporary disability benefits,
pursuant to §§8-42-105(3) and 8-42-106(2), C.R.S., until the requirements of this rule are
followed or until a hearing is held and further order entered. The director's review of a claimant's
objection to a termination of benefits is not a prerequisite to an administrative law judge's ruling
upon such objection.
I. Termination of Temporary Disability Benefits Due to Refusal to Return to Colorado for
Permanent Impairment Evaluation
When a claimant has elected to proceed under C.R.S. Section 8-42-107(8) (b.5) (I) (B) and subsequently
refuses to return to Colorado for examination and rating, an insurance carrier may terminate temporary
disability benefits by filing an admission of liability with a copy of the claimant's written refusal to return to
Colorado for examination.
J. Termination of Temporary Disability Benefits Due to Failure to Respond to an Offer of Modified
Employment From a Temporary Help Contracting Firm in Claims for Injuries Occurring on
or After July 1, 1996
1. An insurance carrier may terminate temporary disability benefits by filing an admission of liability with:
a. a copy of the initial written offer of modified employment provided to the claimant, which
clearly states that future offers of employment need not be in writing, a description of the
policy of the temporary help contracting firm regarding how and when employees are
expected to learn of such future offers, and a statement that benefits shall be terminated
if an employee fails to timely respond to an offer of modified employment;
b. a written statement from the employer representative giving the date, time, and method of
notification which forms the basis for the termination of temporary disability benefits; and
c. a statement from the attending physician that the employment offered is within the claimant's
restrictions.
RULE X CLOSURE OF CLAIMS AND PETITIONS TO REOPEN
A. Closure of Claims
1. A claim may be closed by final order, final admission, or pursuant to paragraph 2 of this section.
2. When no action in furtherance of prosecution has occurred in a claim for at least 6 months, any of the
parties may file a petition to close the claim for lack of prosecution.
a. Following receipt of a request to close the claim for lack of prosecution, the director will issue
an order requiring the parties to show cause why the request should not be granted. A
response to such order shall be filed within 30 days of the date the order was mailed.
b. If no response is filed within 30 days of the date the order was mailed, the claim shall be
automatically closed, subject to the reopening provisions of the statute. If a response is
filed within 30 days of the date the order was mailed, the director will determine whether
the claim should remain open.
B. Petitions to Reopen
1. A petition to reopen filed pursuant to statute shall be filed with the Division and copied to the opposing
party on the form prescribed by the Division.
2. A petition to reopen based upon a change of medical condition shall be filed with a medical report
containing a description of the claimant's present condition and how the claimant's condition has
deteriorated or improved.
3. A petition to reopen based upon an error, mistake, fraud, or overpayment shall identify specifically the
error or mistake to be corrected or the basis for the alleged fraud or overpayment.
4. For those injuries arising after July 2, 1987 at 4:16 p.m. and prior to July 1, 1991, a Petition to Reopen
shall be filed when a claimant is requesting a redetermination of the original permanent partial
disability award pursuant to Section 8-42-110(3), C.R.S. (Repealed 7/1/91). The petition shall be
filed with a statement outlining the circumstances of termination from employment.
5. Response to the Petition to Reopen shall be sent to the opposing party and the Division of Workers'
Compensation.
6. For those injuries arising on or after July 1, 1991, resulting in permanent total disability, a petition to
reopen based upon a request to terminate permanent total disability benefits shall contain a
statement of the basis for the petition.
a. If within thirty (30) days of the date of mailing of the petition the claimant does not file a written
objection with the Division, the insurance carrier or self-insured employer may terminate
disability benefits as of the date of the petition.
b. Objection to the petition filed in a timely manner shall cause the case to be set for hearing to
be held within sixty (60) days of the mailing of the petition.
RULE XI GENERAL RULES
A. Completion of Division Forms
Information required on Division forms shall be typed, or legibly written in black or blue ink, and completed
in full, in accordance with Division requirements as to form and content. Forms, other than position
statements relative to liability, which do not comply with this rule may not be accepted for filing. Position
statements relative to liability which do not meet Division requirements, will be returned to the carrier.
B. Service of Documents
1. Whenever a document is filed with the Division, a copy of the document shall be mailed to each party
to the claim and attorney(s) of record, if any.
2. A copy of every medical report not filed with the Division shall be exchanged with all parties within
fifteen (15) working days of receipt,
a. For claims which are not required to be reported to the division, the parties shall exchange
medical information immediately upon request for such information by any interested
party. Five (5) working days is considered to be a reasonable time within which to
exchange information.
3. When mailing or serving any documents or correspondence on a party, whether it is filed with the
Division, a copy shall be mailed to the attorney(s) of record.
4. The claimant or any other person or entity shall have fifteen (15) days from the date of mailing to
complete and return any requests for release of medical, financial or other information as allowed
by law.
C. Lump Sum Payment of an Award
1. A request for a lump sum payment of permanent partial, permanent total, or dependents benefits shall
be made by submitting an application to the insurance carrier on the form prescribed by the
Division. Within fifteen (15) days of the date the application was mailed, the insurance carrier
shall file the required benefit payment information with the Division, with any objection the
insurance carrier may have to the request for a lump sum payment. A copy of this filing shall be
mailed to the claimant, or, if represented, to the claimant's attorney.
2. The claimant shall have ten (10) days from receipt of the benefit payment information provided by the
insurance carrier to object to the accuracy of this information. In the absence of an objection, a
lump sum order issued by the Division will be based upon such information and the insurance
carrier shall pay the lump sum in the amount set forth in the order.
3. When the permanent partial disability award results from the application of C.R.S. 8-42-107(8) where
the injury or illness occurred on or after July 1, 1991, the following applies:
a. where the injury or illness occurred on or after July 1, 1991, but prior to April 29, 1992, a lump
sum of $10,000.00 or the remainder, if less, may be paid on the injured employees
written request to the carrier. The insurance carrier shall respond within fifteen (15) days
from the date of the mailing of the request as to whether they will grant the lump sum.
b. where the injury or illness occurred on or after April 29, 1992, a lump sum of $10,000.00 or the
remainder, if less, shall automatically be paid, less discount, on the injured employees
request to the carrier.
The carrier shall calculate the sum certain and issue payment taking applicable offsets
(i.e. disability benefits, incarceration, garnishments) within fifteen (15) days from the date
of the mailing of the request by the claimant.
c. when a claimant requests the initial $10,000.00 or less, the request shall be directed to the
carrier. The director may consider an application for lump sum on the remaining benefits
if the claimant has indicated that the admission will be accepted as filed, relative to
permanency. Where the claimant is asserting a claim for permanent total disability, the
Director may consider an application for lump sum on benefits awarded by final
admission.
4. The Director may consider an application for lump sum on awards for scheduled impairment. The
claimant is not limited to payment of the initial $10,000.00 but may request a lump sum payment
for the entire award, up to the maximum as pursuant to section 8-43-406(2), C.R.S.
5. The insurance carrier shall issue payment within fifteen (15) days from the date of the mailing of the
order by the Director.
D. Approval of Settlement Agreements
1. A request for approval of a settlement agreement shall be made by filing the following documents:
a. Original settlement agreement signed by all parties to the agreement. The agreement shall be
signed and sworn to by the claimant. Where the parties do not request an appearance
before the director to review the terms of the settlement, this right must be expressly
waived in the agreement.
b. A proposed order in the form prescribed by the Division.
2. Whenever a pro se claimant requests approval of a settlement agreement, or whenever a party
requests the right to an appearance before the director to review the terms of the agreement, a
settlement proceeding shall be scheduled.
3. A settlement proceeding shall be scheduled in the Division of Administrative Hearings at least two days
in advance, except for good cause shown. All medical reports contained in the files of the
insurance carrier shall be filed with the Division at least two days prior to the proceeding.
E. Employer Credit for Wages Paid Under 8-42-124 (2), C.R.S.
1. An employer who wishes to pay salary or wages in lieu of temporary disability benefits may apply to
the director for authorization to proceed pursuant to section 8-42-124 (2), C.R.S.
2. The application to the director shall contain the following information:
a. a reference to the contract, agreement, policy, rule or other plan under which the employer
wishes to pay salary or wages in excess of the temporary disability benefits required by
the act, and
b. a description of the employees covered by the application and a statement that these
employees will not be charged with earned vacation leave, sick leave, or other similar
benefits during the period the employer is seeking a credit or reimbursement.
3. An employer who has received authorization from the director to proceed under section 8-42-124(2),
C.R.S., shall stamp every employer's first report of injury form involving an employee subject to
the authorization with the words, “SUBJECT TO 8-42-124(2)”, in letters approximately 3/8 inches
high.
F. Notarization of Authorization for Release of Information
The claimant's signature shall be notarized on all releases filed with the Division of Workers'
Compensation pursuant to section 8-47-203(1) (e), C.R.S.
G. Penalties
Whenever any rule in the Workers' Compensation Rules of Procedure has been violated, the director
may:
1. impose penalties pursuant to section 8-43-304, C.R.S.,
2. request that the commissioner of insurance revoke or suspend the insurance carrier's license,
pursuant to section 8-44-106, C.R.S.,
3. request that the executive director revoke or suspend an employer's self-insurance permit or impose
additional terms and conditions for the permit, or
4. impose penalties otherwise authorized by the act.
H. Notice of Third Party Action or Demand
When a third party action or demand is initiated as a result of an injury or death and the claimant is
eligible for worker's compensation benefits, a notice shall be filed by the claimant with the Division as well
as with all interested parties indicating what action is being taken. Such notice shall contain the following:
The name and address of the third party and the person and address upon which the demand
was made.
The court or forum in which the action is filed, if any.
The case number of the action, if any.
The name and address of the claimant's attorney in the action.
I. REPEALED AND RESERVED
J. REPEALED AND RESERVED
K. Requests for Orders under Section 8-47-203(2), 3B C.R.S.
1. Requests made to the Division of Workers' Compensation pursuant to section 8-47-203(2), 3B C.R.S.
(1994 Supp.), for copies or inspection of orders entered by the Director or an Administrative Law
Judge shall:
a. be made in writing and addressed to the Director of the Division of Workers' Compensation;
and,
b. state the name of the person requesting the orders and include the person's mailing address
and phone number; and,
c. specifically identify the criteria for orders being requested, for example, all orders on the merits
from a specified time period or all orders involving specified issues or injuries, etc.; and,
d. state the purpose for reviewing the orders.
2. The person identified as the requestor shall provide to the Division, upon request, all information
necessary to clarify the request. Within thirty days from receipt of the request, the Division shall
acknowledge receipt of the request and provide an estimate of the time required to process the
request. Processing the request includes development of a cost estimate. Based on the cost
estimate for the request provided by the Division, the requestor shall accept or reject further
processing of the request. Acceptance constitutes the requestor's agreement to pay the actual
cost before or upon receipt of the orders.
3. To protect the confidentiality of the claimant and employer named in requested orders:
a. requests shall not be accepted for orders based on claimant or employer names, or other
uniquely identifying claimant or employer information; and,
b. requests shall not be accepted for any criteria resulting in the inclusion of fewer than 3
claimants or employers in the group of orders inspected, unless approved by the Director
or the Director's designee following an in-camera review of the request; and,
c. the names and other identifying information concerning the claimant and employer shall be
excised from all orders requested prior to receipt.
4. Questions regarding the least expensive methods of retrieval may be directed to the Division.
RULE XII REQUESTS FOR BENEFITS FROM THE SUBSEQUENT INJURY FUND
A. Offset of Liability to Subsequent Injury Fund
1. Offset of liability to the Subsequent Injury Fund, shall be initiated by filing a request for offset with the
Division upon the prescribed form and serving the director with a copy of the request for offset.
The party filing the request for offset with the director shall also simultaneously file with the
director a copy of all available relevant documents that support the request for offset.
2. A request pursuant to section 8-46-101, C.R.S., shall list, to the extent available by every
reasonable effort by the movant, all prior or pending workers' compensation cases by
name and number, a brief description of each injury and the award in each case.
3. A request pursuant to section 8-41-304(2), C.R.S., shall indicate the types of exposures alleged,
the approximate dates of each exposure, and the location and the name of the employer in
whose employ each exposure allegedly occurred.
4. A request for offset shall be filed no later than the date the party requesting offset files an
application for hearing or response to application for hearing, unless an administrative law
judge rules that good cause has been shown for filing later. However, in no event shall a
request for offset be filed after a determination, by admission or order, that a claimant is
permanently and totally disabled under 8-46-101 or disabled under 8-41-304(2).
5. The party requesting offset shall also file a proposed order joining the director as a party on
behalf of the Subsequent Injury Fund. Sufficient copies of the order and pre-addressed
envelopes for all parties shall also be filed.
6. The Subsequent Injury Fund shall file a response to a request for offset within 30 days of the
date the director is served with a request for offset.
7. The administrative law judge shall consider the request and response and rule on whether to
join the director as a party. The ruling shall be based on whether the procedural
requirements of this Rule XII have been met and whether the request states a sufficient
basis upon which offset could be granted. Until the director is joined, notices and orders
are not binding on the Subsequent Injury Fund.
8. When the director is joined as a party and when an assistant attorney general has entered an
appearance on behalf of the Subsequent Injury Fund, the party who filed the request for
offset shall serve the Office of the Attorney General with copies of transcripts of
proceedings prior to the date of the order joining the director in the pending workers'
compensation cases.
9. When the director is joined as a party and when an assistant attorney general has entered an
appearance on behalf of the Subsequent Injury Fund, copies of all reports, pleadings or
other documents thereafter filed by any party shall be served on the Office of the Attorney
General.
B. Status of Director, on Behalf of the Subsequent Injury Fund, in Fatal Cases
1. The director shall be deemed to be an interested party in all fatal cases and shall be served
with all pleadings, notices, reports, and documents as required for any party. Where an
assistant attorney general has entered an appearance for the director in a case, such
service shall be made upon that attorney.
2. In the event a compensable injury results in a death which has not been reported to the
Division, the director may initiate a claim for the death benefits provided by statute.
RULE XIII WORKERS' COMPENSATION PREMIUM SURCHARGES
A. PREMIUM REPORTING REQUIREMENTS
Every insurance carrier shall semi-annually file a surcharge return with the Division within the time period
specified in section (D) of this rule. The return shall be verified by affidavits of its president and secretary
or other chief officers or agents, and shall state the amount of premiums written, including any policy
expense constants, membership fees, finance and service, or other administrative fees charged to the
policyholder in connection with the issuance or renewal of a policy, as reported to the Division of
Insurance in accordance with Section 10-3-208, C.R.S., and regulations promulgated thereunder, during
the period covered by such return. With this filing the insurance carrier shall pay the surcharges required
by statute. Forms for such returns shall be provided by the Division.
B. PAYROLL REPORTING REQUIREMENTS
Every self-insured employer shall semi-annually file a surcharge return with the Division, within the time
period specified in section (D) of this rule. The return shall be verified by affidavits of its president and
secretary or other chief officers or agents, and shall state the total amount of its payroll for the period
covered by such return. With this filing the employer shall pay the surcharges required by statute. Forms
for such return shall be provided by the Division.
C. COMPUTATION OF PAYROLL SURCHARGES PAID BY SELF-INSURED EMPLOYERS
1. Surcharges paid by self-insured employers shall be based upon the manual premium, discounted by
the Colorado Compensation Insurance Authority rate discount applicable for the surcharge period
covered. The discounted premium shall then be modified by the experience rating factor as
calculated by the National Council on Compensation Insurance (N.C.C.I.). No other rating factor
shall be allowable. The self-insured employer may elect not to provide such a rating factor;
however, failure to submit the required rating factor will result in the premium surcharge being
computed on the basis of manual premium only.
2. If the self-insured employer is unable to develop the experience rating factor due to the unavailability
of reliable and adequate data, the employer may apply to the director for approval to use a 1.0
experience rating factor for the following two semiannual surcharge periods. If at the conclusion
of the two semiannual surcharge periods that the 1.0 factor is used, the N.C.C.I. has been unable
to develop an experience modification, the director may permit an extension of time for the 1.0
factor to be used.
3. In order that consideration be given to the experience modification, a completed N.C.C.I. form setting
forth all of the information and methodology used in the calculation of the experience modification
shall accompany each corresponding payroll report.
D. PAYMENT PERIODS AND CREDITS
1. The premium and payroll surcharges for the semiannual period beginning July 1, shall be based upon
premiums written, including any policy expense constants, membership fees, finance and service,
or other administrative fees charged to the policyholder in connection with the issuance or
renewal of a policy, as reported to the Division of Insurance in accordance with Section 10-3-208,
C.R.S., and regulations promulgated thereunder, for Colorado workers' compensation insurance
or the self-insured employer's total payroll during the previous six months, and shall be paid to the
Division on or before July 31 of that year, with a return form provided by the Division.
2. The premium and payroll surcharges for the semiannual period beginning January 1 shall be based
upon premiums written, including any policy expense constants, membership fees, finance and
service, or other administrative fees charged to the policyholder in connection with the issuance
or renewal of a policy, as reported to the Division of Insurance in accordance with Section 10-3208, C.R.S., and regulations promulgated thereunder, for Colorado workers' compensation
insurance or the self-insured employer's total payroll during the previous six months, and shall be
paid to the Division on or before January 31 of that year, with a return form provided by the
Division.
3. An insurance carrier is entitled to a credit for canceled or returned premiums, including any policy
expense constants, membership fees, finance and service, or other administrative fees charged
to the policyholder in connection with the issuance or renewal of a policy, as reported to the
Division of Insurance in accordance with Section 10-3-208, C.R.S., and regulations promulgated
thereunder, actually refunded. The credit must be taken as an offset against surcharges due
within one year of the date the premium amount was refunded.
4. An insurance carrier or employer is not entitled to offset a credit of one subsidiary against the
surcharge owed by another subsidiary.
E. SURCHARGE RATE
1. For the annual period beginning July 1, 2001 and continuing indefinitely with annual review by the
director, the workers' compensation cash fund premium surcharge rate authorized under section
8-44-112(1)(a), C.R.S., shall be 1.47 percent of the amount of all premiums written, including any
policy expense constants, membership fees, finance and service, or other administrative fees
charged to the policyholder in connection with the issuance or renewal of a policy, as reported to
the Division of Insurance in accordance with Section 10-3-208, C.R.S., and regulations
promulgated thereunder, or the premium equivalent amount established in section (C) of this rule,
for Colorado workers' compensation insurance during the period of January 1, 2001 continuing
indefinitely.
2. For the purpose of funding the direct and indirect costs of the premium cost Containment program of
the Division as authorized under section 8-44-112(1)(b)(I), C.R.S., there is added to the
surcharge imposed pursuant to Section (E) of this rule, an additional increment for the annual
period beginning July 1, 2001 and continuing indefinitely with annual review by the director,
against workers' compensation insurance premiums written, including any policy expense
constants, membership fees, finance and service, or other administrative fees charged to the
policyholder in connection with the issuance or renewal of a policy, as reported to the Division of
Insurance in accordance with Section 10-3-208, C.R.S., and regulations promulgated thereunder,
during the period of January 1, 2001, continuing indefinitely. The amount of this assessment shall
be 0.03 percent. No assessment shall be imposed upon self-insured employers under this
subsection.
3. For the purposes of funding the financial liabilities of the Subsequent Injury Fund as authorized under
Section 8-46-101(2)(A)(I) And the Major Medical Fund under Section 8-46-202, for the period
beginning July 1, 2001, and continuing indefinitely with annual review by the director, the tax shall
be assessed at 2.318 percent of the amount of Workers' Compensation premiums written,
including any policy expense constants, membership fees, finance and service, or other
administrative fees charged to the policyholder in connection with the issuance or renewal of a
policy, as reported to the Division of Insurance in accordance with section 10-3-208, C.R.S., and
regulations promulgated thereunder, or the premium equivalent amount established in Section (C)
of this rule, for Colorado Workers' Compensation insurance during the period of January 1, 2001,
continuing indefinitely.
RULE XIV MEDICAL COST CONTAINMENT
A. CROSS-REFERENCES TO MEDICAL COST CONTAINMENT RULES FORMERLY ADDRESSED IN
RULE XIV.
1. Medical Treatment Guidelines
- See Rule XVII
2. Utilization Standards
- See Rule XVI
3. Reimbursement of all Medical Procedures and Services
- See Rule XVIII, Medical Fee Schedule
4. Recognized Health Care Providers
- See Rule XVI, Utilization Standards
5. Utilization Review Program
- See Rule XV, Utilization Review
6. Timely Payment for Services
- See Rule XVI, Utilization Standards
7. Billing Rates, Fees, Procedures, Documentation Requirements
- See Rule XVI, Utilization Standards
8. Medical Fee Schedule Disputes
- See Rule XVI, Utilization Standards
9. Prior Authorization of Payment
- See Rule XVI, Utilization Standards
10. Review of Hospital Charges (Audit)
- See Rule XVI, Utilization Standards
11. Failure to Comply with Rules
- See Rule XVI, Utilization Standards
12. Physicians Accreditation Program
- See Rule XX, Accreditation of Physicians
PARTS B. THROUGH K. – REPEALED AND RESERVED
L. MEDICAL REVIEW PANEL – INDEPENDENT MEDICAL EXAMINATION (IME)
1. Qualifications
These rules apply to parties and physicians participating in the workers' compensation IME
program pursuant to the authority of the Workers' Compensation Act.
A physician who seeks appointment to the Division's medical review panel for the purpose of
performing IME's under the authority of the Workers' Compensation Act, Title 8, Articles 40
through 47 of the Colorado Revised Statutes, shall make application and meet the following
qualifications:
a. Be licensed by the Board of Dental Examiners, the Board of Chiropractic Examiners, the
Colorado Podiatry Board, the Board of Medical Examiners and board certified (or board
eligible) by the American Board of Medical Specialties or the American Osteopathic
Association or another organization acceptable to the Division;
b. For determination of maximum medical improvement (MMI), have attained at least level I
accreditation and have 384 hours per year of direct patient care (excluding medical/legal
evaluation); and
c. For purposes of determining permanent impairment have attained level II accreditation and
either have 384 hours per year of direct patient care (excluding medical/legal evaluation)
or demonstrated additional competency in the field of disability evaluation through
certification by the American Board of Independent Medical Examiners or the American
Academy of Disability Evaluation Physicians.
d. Shall have a license which is current, active and unrestricted.
e. A physician who has agreed to perform an IME as a result of negotiation and agreement by
the parties, and who has not applied for appointment to the Division's IME panel, is not
required to complete the application for appointment to the IME panel as set forth in
subsection L.2. However, such physician shall comply with all other qualifications and
procedures governing the conduct of IME proceedings as established by this rule.
2. Appointment Procedures
The physician shall complete the Division application form, certify to and, upon approval of the
application, comply with the following:
a. Unless otherwise approved by both parties, or the Division, the physician shall conduct an IME
no earlier than 35 calendar days, nor later than 50 calendar days from the telephone call
requesting an appointment;
b. Within 20 calendar days of the examination submit the original report with all attachments to
the Division and a copy to all parties;
c. Decline a request to conduct an IME only on the basis of good cause shown, as determined by
the director;
d. Comply with the Workers' Compensation Rules of Procedure;
e. Conduct an IME pursuant to this section in an objective and impartial manner;
f. Not refer any ME claimant to another physician for treatment or testing;
g. Not become the treating physician for the IME claimant, unless approved by the director,
ordered by an administrative law judge, or by both party written agreement;
h. Not evaluate an ME claimant if the appearance of or an actual conflict of interest exists for any
reason; a conflict of interest includes, but is not limited to, instances where the physician
or someone in the physician's office has treated the claimant. Further, a conflict may be
presumed to exist when the IME physician and a physician that previously treated the
claimant have a relationship which involves a direct or substantial financial interest. The
following guidelines are to assist in determination of conflict:
i. direct or substantial financial interest is a substantial interest which is a business
ownership interest, a creditor interest in an insolvent business, employment or
prospective employment for which negotiations have begun, ownership interest
in real or personal property, debtor interest or being an officer or director in a
business.
ii. The relationship should be determined as of the time the IME is being requested.
Relationships in existence before or after the review will have no bearing, unless
a direct and substantial interest is present at the time of the IME.
iii. Being members of the same professional association, society or medical group,
sharing office space or having practiced together in the past are not the types of
relationships that will be considered a conflict, absent the present existence of a
direct or substantial financial interest.
i. Not employ invasive diagnostic procedures unless approved as provided hi L.4.a., below;
j. Not substitute any other physician as the designated IME physician without written permission
of the director;
k. In order to assure fair and unbiased IME's, not engage in communication regarding the IME
with any person other than Division staff, except under the following circumstances: the
claimant during the IME examination, the requesting party when setting the appointment,
by approval of the director, both party written agreement, an order by an administrative
law judge, by deposition or subpoena as approved by an administrative law judge;
l. No later than 30 calendar days after the cancellation of an examination, refund to the paying
party part or all of the fee paid by that party as may be required by these rules or by the
director.
m. For each IME case assigned, address the following issues and make findings if relevant:
maximum medical improvement, permanent impairment, and apportionment of
impairment. Also consider any issues presented on the “Application for IME” or as
directed by an administrative law judge. If the IME is requested pursuant to section 8-42107(8)(b)(II)(A-D), C.R.S., the requesting party shall clearly note such on the IME
application form.
3. Requests for an IME:
a. Application Process:
1) Either party that disputes the determination of MMI or impairment made by an
authorized treating physician in a workers' compensation case may apply for an
IME.
2) Requirement to Negotiate: Prior to Division intervention, the parties must attempt to
negotiate the selection of a physician to conduct the ME. Parties that have
agreed upon a physician to conduct the ME shall schedule the appointment
pursuant to section L.2.a. of this rule and shall notify the Division on the ME
application form. If despite the good faith efforts of the parties, an agreement that
was reached fails, either party may apply to the Division for the selection of an
IME physician, using the form required under L.3.b., below, within 30 days of
such failure.
3) The requesting party shall submit an application for an ME according to L.3.b., below.
If the parties did not agree on the physician, the insurance carrier shall notify the
Division and the other party on a prescribed form regarding the failed negotiation
within 30 calendar days of their failure to agree. The party disputing the
determinations of the authorized treating physician, and seeking review of those
determinations (“requesting party”) shall file an application for ME within 30 days
of the date of the failure to agree upon an ME physician.
4) Insurance carriers are not designated the requesting party simply due to their
obligation to submit the documents referenced above. The requesting party is the
party disputing the determinations of the authorized treating physician and
seeking review of those determinations. The requesting party must complete the
application for ME.
5) The parties may agree to limit the issues addressed in an IME exam. Such agreement
shall be reduced to writing, signed by both parties, and provided to the ME unit
no later than five (5) days prior to the IME appointment date. An opinion from an
ME examiner concerning MMI, impairment or apportionment in a case in which
the parties agreed to limit such issue, is not entitled to any weight before an
administrative law judge.
b. Form Required: The prescribed form, “Application for a Division Independent Medical
Examination” shall be used in all cases to request an IME. The Division requires that the
party requesting the IME designate:
1) The preferred geographic location for the IME examination;
2) The body part(s) or medical conditions to be evaluated, including whether mental
impairment shall be evaluated;
3) Other physicians that have previously evaluated, treated, or are currently treating the
claimant.
The requesting party shall certify that all parties and the Division have been sent the application
form at the same time by the same means. Only the Division application form or a materially
substantial equivalent duplication approved by the Division is acceptable.
c. IME Physician Selection: If the parties are unable to agree upon a physician to conduct the
IME, the division will select via a revolving selection process a panel of three qualified
physicians from its list of qualified physicians, from which one physician shall be
designated to perform the IME. To obtain a pool of qualified physicians from which the
Division shall make the selection of the three physician panel, the Division shall consider
to the extent possible the criteria identified in the application for IME as set forth hi
section L.3.b. of this rule. The Division will correlate the body parts or medical conditions
on the IME application with the appropriate medical treatment guideline on the table
designated in part Q of this rule XIV. The three-physician panel will be comprised of
physicians based on their accreditation to perform impairment ratings on the body part(s)
and/or medical conditions designated by the requesting party on the IME application. At
the time a physician applies to join the IME panel of physicians, he/she shall designate
the body parts or medical conditions that he/she is willing and able to evaluate.
Physicians electing not to perform impairment ratings on certain body parts or conditions
shall not be included in any three-doctor panel where those body parts or conditions are
listed on the IME application pursuant to part L.3.b.2) of this rule.
d. The Division will apply the same selection process for designation of the three-physician panel
for injuries or conditions for which no Division medical treatment guideline exists.
e. All potential candidate names will be kept confidential until the selection of the three physician
panel is made. The Division will notify the parties in writing by mail or fax of the names
and the medical specialties of the three physician panel within ten calendar days after
receipt of the application. The physician names and related information will be listed on a
form generated and provided by the Division. Should a party be contacted by telephone,
and the party is unavailable, that information will be left on voice mail or with an
answering person. Pro se claimants without telephone availability shall be notified by
mail.
f. Within seven (7) business days of issuance of the three-physician list by the Division, the
requesting party shall strike one name and inform the other party. Within five (5) business
days of receiving that information from the requesting party, the other party shall strike
one of the two remaining physicians and inform the Division's IME Unit, with confirmation
to the requesting party, of the name of the remaining physician. That information shall be
provided to the Division via fax or telephone. The parties may exchange information
under this rule via fax, e-mail or telephone.
If the division is not notified of the selected physician within fifteen (15) business days of
the date the Division issued the three-physician panel, the Division shall randomly select
one name from the three-physician list. If one party fails to timely strike a physician from
the list, the other party shall notify the Division and at the same time provide to the
Division the name of the physician that party wishes to strike. In that situation the Division
will randomly select one name from the remaining two physicians. The Division shall
confirm to the parties by telephone and/or in writing the name of the selected physician.
If the selected physician declines or is unable to perform the IME, the Division shall
provide one replacement name to the original list of three physicians, and present that
revised list to the parties where each shall strike one name according to the procedures
set forth in this section.
Additionally, if a physician is removed from the three-physician panel for any reason other
than having been struck by one of the parties, the Division will issue one replacement
name using the same criteria and process set forth in subsection 3.c.., above.
g. When a physician is selected from the three-physician panel to perform the IME, the Division
will remove his/her name from the revolving list of physicians for a period of time so that
he/she is not available for assignment to another three-physician panel. This period of
time may be adjusted by the Division as necessary to balance the mandate to reduce
over utilization of individual physicians, yet ensure that an adequate pool of physicians is
available in each geographic area. This procedure shall not preclude the parties from
agreeing-upon such physicians to perform division IMEs.
h. Appointment Date: The date of the examination shall be set in accordance with Subsection
L.2.a. of Rule XIV. The requesting party shall call the IME physician within five business
days after providing and/or receiving notice of the final IME physician selection to
schedule the examination, and shall immediately notify the Division and the opposing
party by telephone, and confirm in writing, the date and time of the examination. Absent
good cause as determined by the director or an administrative law judge, failure to make
the appointment and advise all parties within five business days permits the opposing
party, after notifying the Division of such failure, to either schedule the IME appointment
or to request cancellation of the IME.
i. Submission of Medical Records: The insurance carrier shall concurrently provide to the IME
physician and all other parties, a complete copy of all medical records in their possession
pertaining to the subject injury, postmarked or hand-delivered no fewer than 14 calendar
days prior to the IME examination. If the insurance carrier or its representative fails to
timely submit medical records to the designated IME physician, the claimant may request
the Division cancel the IME; or the claimant may submit all medical records he/she has
available no later than 10 calendar days prior to the IME examination; or as otherwise
arranged by the Division with the IME physician. This rule does not prohibit the
rescheduling of the IME. The defaulting party may supplement the records pursuant to
subsection L.3.k. of Rule XIV.
j. Form/Content of Medical Records Package: Pertinent medical records shall include all medical
reports and medical records reflecting the diagnosis and treatment of the claimant's workrelated injury, and shall include available medical records regarding relevant pre-existing
condition(s) or work-related injury(ies). The medical file shall be two-hole punched at the
top center of each page and clipped at the top with paper fasteners. A dated cover sheet
shall be included listing the claimant's name, IME physician's name, date and time of the
appointment, and the workers' compensation number. The medical file shall be in
chronological order and tabbed by year. It shall include a written summary of medical
providers with the range of dates of treatment. Medical records not meeting these
requirements shall be resubmitted to the IME physician and all other parties in the correct
format within three business days of notification by the Division. Failure to timely and
properly resubmit such records may result in cancellation of the IME by the director, at
the cost of the submitting party. Penalties otherwise available under these rules and the
Act may be determined by the Director.
Medical bills, adjustor notes, surveillance tapes, admissions, denials, vocational
rehabilitation reports, non-treating case manager records or commentaries to the IME
physician shall not be submitted without written agreement of all parties, order of an
administrative law judge, or prior permission of the Division.
k. Submission of Supplemental Medical Records: Supplemental medical records shall be
prepared according to subsection L.3.J., above, and may be mailed or hand-delivered by
any party concurrently to the IME physician and all other parties no later than seven
calendar days prior to the IME examination.
l. Depositions: Medical depositions may be submitted as part of the medical records package
only by written agreement of all parties or pursuant to an order issued by the director or
an administrative law judge. The ME physician shall be reimbursed for time spent
reviewing medical depositions at the rate set forth in Rule XVIII, Testimony Fees. The
party submitting the medical deposition shall be responsible for payment of the additional
fees.
m. Interpreter: The claimant shall be responsible for notifying the insurance carrier of the
necessity for a language interpreter, a minimum of 14 calendar days before the
examination. The paying party shall be responsible for arranging for the services of and
paying for such language interpreter. The language interpreter shall be impartial and
independent, and have no professional or personal affiliation with any party to the claim
or the IME physician.
n. IME Proceedings Held in Abeyance: If a party files a motion involving a pending IME
proceeding, the moving party shall provide a copy of the motion directly to the Division's
IME section. The IME proceeding shall be held in abeyance until the Division IME section
is notified of the disposition as provided in this rule. When the motion is disposed of by
written order or other means, the moving party shall provide a copy of the order or other
dispositive document to the Division's IME section.
4. Payments/Fees: Unless the party requesting the IME is determined indigent pursuant to part P of this
rule, the following shall apply to payments and fees:
a. The physician performing the IME shall be prepaid a total fee of $675.00 for each ME by the
requesting party unless otherwise stipulated or ordered by the director or an
administrative law judge. If the record review is unusually extensive and requires longer
than an hour for review, the physician shall contact the Division and request additional
payment. This request should be made no later than three calendar days prior to the IME
examination. The Division will transmit the request to the requesting party. If the
requesting party declines to pay, the IME physician shall complete the IME process to the
best of his/her ability without expending the additional time on record review. If additional
file review charges are approved, the physician shall bill at the rate set forth in Rule XVIII
F.7.C The same process described in this paragraph shall apply with regard to any
clinical or diagnostic testing requested by physicians performing IMEs
It is expected that a test essential under the AMA Guides, 3rd Edition (revised) or the level
II accreditation curriculum for an impairment rating to be rendered will have been
performed prior to the IME. Routine tests necessary for a complete IME should be
performed as part of the IME with no additional cost. If an essential test is non-routine or
requires special facilities or equipment, and such test was not previously performed, or
was previously performed but the findings are not usable at the time of the IME, the
physician performing the IME shall notify the Division, who will notify the parties. Unless
extraordinary circumstances exist that result in an ALJ issuing a ruling to the contrary, the
physician performing the IME will either perform the essential test or refer out the
essential test for completion, and the insurer or self-insured employer shall be
responsible for paying for the essential test.
b. Payment for an ME shall be made at least 10 calendar days prior to the scheduled
examination. Failure of the requesting party to timely submit the IME examination fee
shall allow the physician to charge up to an additional $100.00 for the IME review which
the requesting party shall pay.
c. An IME examination may be canceled only by the requesting party, or the Division, no later
than three (3) business days prior to the examination. The non-canceling party may
contact the Division to determine whether the IME may be rescheduled. If the IME is not
timely canceled or the claimant fails to keep the IME appointment, or the medical records
are not submitted in a timely manner, the IME physician shall be entitled to retain $150.00
from the total fee when the IME was requested by the defaulting party. If the fee has not
yet been paid, or the party responsible for the untimely cancellation is not the requesting
party, the physician shall be entitled to collect from the defaulting party a $150.00
cancellation/penalty fee. The insurance carrier may be entitled to offset the cancellation
fee against any future permanent or temporary benefits if the claimant fails to appear for
the IME examination without good cause as determined by the director or an
administrative law judge.
d. Services rendered by an ME physician shall conclude upon acceptance by the Division of the
final ME report. An IME report is final for the purpose of this subsection L.4.d. of this rule,
when it includes the requested determination regarding MMI and/or final impairment
rating worksheets. A party who seeks the presence of an IME physician as a witness at a
proceeding for any purpose, by subpoena or otherwise, shall be responsible for payment
to the ME physician pursuant to Rule XVIII, Testimony Fees.
5. Multiple Impairment Rating IMEs
Only one IME impairment rating per case shall be administered by the Division's IME Section,
pursuant to 8-42-107 (8), C.R.S., unless otherwise directed by written agreement of the parties,
by order of an administrative law judge or the director, or by request of the originally designated
impairment rating IME physician.
6. Communication with an IME Physician
a. During the IME process, there shall be no communication allowed between the parties and the
IME physician unless approved by the director, or an administrative law judge. Any
violation may result in cancellation of the IME.
b. After acceptance by the Division of the final report, no communication with the IME physician
shall be allowed by any party or their representative except under the following
circumstances: approval by the director, both party written agreement, an order by an
administrative law judge, by deposition or subpoena as approved by an administrative
law judge. The parties shall provide the Division IME section with copies of any
correspondence permitted under this section with the IME physician. See Rule XIV L.4.d.
for fee information.
7. IME Follow-Up
Sections of this Rule XIV apply to follow-up procedures, as appropriate. If a Level n IME
physician determines a claimant has not reached MMI and recommends further treatment or
return for range of motion validation, a follow-up IME examination shall to the extent possible be
scheduled with the original ME physician. The party requesting the follow-up appointment shall
provide written notification of such request to the Division's IME section, with a copy to the other
party.
A new IME physician may be selected only if agreed upon by both parties. The parties shall have
reached prior agreement on who shall pay the $675.00 to the new IME physician prior to the
patient visit. Upon good cause shown, an administrative law judge may also order a new
physician and designate which party shall pay the examination fee.
Absent both party agreement or an order from an administrative law judge, the party requesting
the follow-up shall pay any additional examination expense according to the Relative Value for
Physicians Fee Schedule, incorporated by reference in Rule XVIII, set forth in the RVP's
Evaluation & Management Section, “Consultations.”
99241 Follow-up for repeat Range of Motion measurements.
99242 Follow-up evaluation is within six months of the original evaluation.
99243 Follow-up for evaluation on cases that are older than six months and less than one
year from the original evaluation.
Follow-up for evaluation on cases older than one year from the original evaluation. These followups may be charged at the full fee of $675.00. Charges described above are allowed due to the
need for additional history-taking.
8. Removal of a Physician from the Medical Review Panel Complaints regarding an IME physician may
be submitted to the director or to the medical director. A physician under consideration for
removal from the medical review panel shall be notified by the director and provided an
opportunity to respond. The director, in consultation with the medical director, may remove a
physician from the medical review panel on the following grounds:
a. A misrepresentation on the application for appointment to the panel;
b. Refusal and/or substantial failure to comply or two or more incidents of failure to comply with
the provisions of these Workers' Compensation Rules of Procedure and any statutes
relevant to physicians;
c. Loss of Level I and/or Level II accreditation; or
d. Any other reason for good cause as determined by the director.
After six months from the date of removal, a physician may apply to the director for reinstatement
on the panel for good cause.
9. Failure to comply with any of the ME rules for which no penalty has been specified shall subject the
entity or party to the penalty provided in Rule XIG.
10. Members of the medical review panel and any person acting as a consultant, witness, or complainant
shall be immune from liability in any civil action brought against said person for acts occurring
while the person was acting as a panel member, consultant, witness, or complainant,
respectively, if such person was acting in good faith within the scope of the respective capacity,
made a reasonable effort to obtain the facts of the matter as to which action was taken, and acted
in the reasonable belief that the action taken by such person was warranted by the facts. Such
grant of immunity from liability is necessary to ensure that the purposes of the IME provisions are
met and participating physicians can exercise their professional knowledge, skills and judgment.
11. Disputes concerning the division IME process that arise in individual cases that cannot be resolved
by agreement of the parties, may be taken to an administrative law judge for resolution.
PARTS M. AND N.- REPEALED AND RESERVED
O. Task Forces Under the Division
1. The Division may develop task forces as needed for development of utilization standards, medical
treatment guidelines, impairment ratings, and/or other specific needs.
2. The MCAC may recommend the composition of these task forces to the director.
3. The director, with advice from the medical director, may appoint the members to the task force.
4. The task force shall be under the guidance of a Division representative.
5. A final deadline for completion of the task force objectives may be set by the director with advice from
the MCAC.
6. The appropriate draft document shall be returned to the Division from the task force and shall include
outcome criteria to assess the effect of its recommendations.
7. The Division with input from the Medical Director and MCAC shall review this document and may
make any appropriate revisions, which, if requested, shall be considered and acted upon by the
designated task force.
8. Public input shall be solicited by the MCAC from local and regional medical providers, legal
community, risk management departments, business community, claimants, and other entities as
appropriate.
9. The Division shall review and consider all comments from the public, MCAC, and medical director prior
to adoption. The Division may utilize the designated task force for consideration of public input
and revisions.
P. Indigent claimant
1. When a claimant applying for an IME pursuant to section L.3.a. of this Rule asserts indigence, this
process shall be followed:
a. At the same time the “Notice and Proposal to Select an Independent Medical Examiner” form
is submitted, the claimant may also indicate on the form whether indigence is asserted.
b. Within twenty (20) days following submission of the Notice and Proposal to Select an
Independent Medical Examiner and statement asserting indigence, the claimant wishing
to assert indigent status shall file an “Application for Indigent Determination (IME)” form at
the Division of Administrative Hearings, and provide a copy to the other parties. A blank
Application for Indigent Determination (IME) form may be obtained at the Division of
Workers' Compensation Customer Service Unit, at the IME unit, on the Division's
website, or at the Division of Administrative Hearings.
c. The IME process will not be held in abeyance during the pendency of indigent application
except that an IME physician will not be selected by the Division until a determination is
made as to whether the claimant is indigent.
d. Within eight (8) days after the date of mailing of the Application for Indigent Determination
(IME) form, any other party to the claim may file a response at the Division of
Administrative Hearings. Any such response shall state with specificity the grounds for
objection.
e. Within twenty (20) days after the Application for Indigent Determination (IME) is filed, an
Administrative Law Judge shall issue an order based on the written submissions
determining whether or not the claimant is indigent for purposes of paying for the ME. A
hearing will be held only if the Administrative Law Judge determines that one is
necessary because a timely submitted response raises genuine issues of disputed
material fact that must be resolved. In the event no response is filed but an Administrative
Law Judge determines there is a lack of sufficient information in the Application for
Indigent Determination (IME), the Administrative Law Judge may hold a hearing to obtain
additional information. Any such hearing shall be held as expeditiously as possible, and if
a hearing is held a determination must be issued within thirty (30) days of the date of
filing of the Application for Indigent Determination (ME).
f. The determination regarding indigence shall be based on the claimant's financial status as of
the date the Application for Indigent Determination (IME) is filed. In making the
determination on the Application for Indigent Determination (IME), the ALJ shall apply the
following standard. A person shall be found to be indigent only if income is at or below the
eligibility guidelines with liquid assets of $1,500 or less; or, income is up to 25% above
the eligibility guidelines, liquid assets equal $1,500 or less, and the claimant's monthly
expenses equal or exceed monthly income; or, if “extraordinary circumstances” exist
which merit a determination of indigence. The following definitions shall apply in making
the determination:
Income eligibility guidelines
Family size
1
2
3
4
5
6
7
8
Monthly income
guidelines
$935
$1,263
$1,590
$1,917
$2,244
$2,571
$2,898
$3,225
Monthly income
guideline plus 25%
$1,169
$1,578
$1,987
$2,396
$2,805
$3,214
$3,622
$4,031
Yearly income guide
$11,225
$15,150
$19,057
$23,000
$26,925
$30,850
$34,775
$38,700
For family units with more than eight members, add $327 per month for “monthly income” or
$3,925 per year for “yearly income” for each additional family member.
i. Income is gross income from all members of the household who contribute monetarily
to the common support of the household.
ii. Liquid assets include cash on hand or in accounts, stocks, bonds, certificates of
deposit, equity and personal property or investments which could readily be
converted into cash without jeopardizing the applicant's ability to maintain home
and employment; “Liquid assets” exclude any equity in any vehicle which the
injured worker or his/her family must use for essential transportation unless the
ALJ makes an affirmative finding of fact that the worker is credit worthy, can
borrow against the equity in this vehicle, and can afford to pay back a loan
without compromising his/her needs for food, clothing, shelter, and
transportation.
iii. Expenses for nonessential items such as cable television, club memberships,
entertainment, dining out, alcohol, cigarettes, etc. shall not be included.
iv. “Extraordinary circumstances” are deemed to be those which cause extraordinary
financial hardship by depriving the claimant of the ability to provide for basic
necessities that cannot be deferred, such as food, shelter, clothing, utilities, and
medical costs not covered by insurance.
g. The Administrative Law Judge shall provide the determination regarding indigence in writing to
all the parties. The determination shall include discussion sufficient to explain the basis of
determination.
2. Payment for the IME
a. If an Administrative Law Judge determines that the claimant is not indigent, the claimant shall
be responsible for payment of the ME. The process for selection of the physician and
completion of the IME shall be as set forth in this rule.
b. If an Administrative Law Judge determines that the claimant is indigent, the insurer or
employer shall advance payment for the cost of the IME. Such a payment must be made
to the doctor no later than ten (10) days prior to the date of the scheduled IME
appointment. The insurer or employer shall also pay for any additional costs as identified
in parts L.3., L.4., and L.7. of this Rule.
c. The IME will proceed as set forth in section L.3. of this Rule. The claimant shall be considered
the requesting party.
d. After a final order is issued, a final admission of liability is uncontested, or the parties have
settled the case on a full and final basis, claimant shall reimburse the cost of the IME to
the insurer or employer who paid initially. The obligation to reimburse the cost does not
arise until a final order or order approving the settlement is issued. Any reimbursement
shall be taken as an offset against permanent indemnity benefits.
Q. TABLE OF DIAGNOSES OR MEDICAL CONDITIONS -INDEPENDENT MEDICAL EXAMINATIONS
PROGRAMMedical Treatment Guidelines - List of Specified Diagnoses or Conditions
Guideline
Conditions
Body Part or System
Accreditation Units
Lower Extremity
Talar fracture
Calcaneal fractures
Midfoot (Lisfranc's)
Fracture Dislocation
Metatarsal-Phalangeal,
Tarsal-Metatarsal, and
Interphalangeal Joint
Arthropathy
Pilon Fracture
Puncture wounds of the
foot
Achilles Tendon
Injury/Rupture
Ankle Osteoarthropathy
Ankle or Subtalar Joint
Dislocation
Heel Spur
Syndrome/Plantar
Fasciitis
Tarsal Tunnel Syndrome
Neuroma
Knee - Chondral Defects
Aggravated Osteoarthritis
Anterior Cruciate
Ligament Injury
Posterior Cruciate Injuries
Meniscus Injury
Patellar Subluxation
Retropatellar Pain
Syndrome
Tendonitis/Tenosynovitis
Bursitis of the Lower
Extremity
Hip fracture
Acetabulum Fracture
Hamstring Tendon
Rupture
Ankle Sprain/Fracture
Foot
Knee
Hip
Ankle
Lower Extremity
Hip Dislocation
Trochanteric Fracture
Femur Fracture
Tibia Fracture
Hip, leg, pelvis
Leg Pelvis
Pelvic Fracture
Leg Pelvis
Spine Lower Extrem
Incomplete Spinal Cord
Injury Syndrome:Anterior
Cord SyndromeBrownSequard
SyndromeCentral Cord
SyndromePosterior Cord
Syndrome
Cervical Spine
Neuro/Spine
No diagnoses other than
Low Back Pain given.
Lumbar Spine
Spine
Traumatic Brain Injury
Mild TBI (MTBI)
HeadSkullBrain
Neuro
Moderate-Severe TBI
Cumulative Trauma
Disorder
DeQuervain's
Tenosynovitis
Arm
Upper Extremity
Cervical Spine Injury
Soft Tissue Injury,
Quebec Classification,
Grades I-IV
Disc Herniation
Low Back Pain
Extensor Tendinous
Disorders
Flexor Tendinous
Disorders
Lateral Epicondylitis
Medial Epicondylitis
Cubital tunnel syndrome
Hand-Arm Vibration
Syndrome
Guyon Canal (Tunnel)
Syndrome
Pronator Syndrome
Radial Tunnel Syndrome
Elbow Musculoskeletal
Disorders (Epicondylitis)
Wrist Tendonitis,
including DeQuervain's
Tenosynovitis
Trigger Finger
Upper Extremity
Tendonitis or bursitis
Chronic Pain Disorder
Elbow
Wrist
Hand, finger
Elbow, shoulder
Chronic Pain
N/A
Reflex Sympathetic
Dystrophy/Complex
Regional Pain Syndrome
CRPS-I (RSD), Stages 13CRPS-II (Causalgia)
Neurologic system; also
match specialty to body
part, e.g., upper/lower
extremity
Occupational Carpal
Tunnel Syndrome
Carpal Tunnel Syndrome
Hand Wrist
Upper Extremity
Thoracic Outlet
Syndrome
Definite Thoracic Outlet
SyndromeProbable
Thoracic Outlet
SyndromePossible
Thoracic Outlet
Syndrome
Acromioclavicular Joint
Sprains/DislocationsAdhe
sive Capsulation/Frozen
Shoulder
DisordersBicipital
Tendon
Thoracic spineThoracic
nerves
Neuro
Shoulder
Upper Extremity (Sp
cervical spine
involvement)
Shoulder
Not rated separately
refer to initial injury
Neuro; also check to
if the initial injury
requires rating
DisordersBrachioplexus
InjuriesBursitis of the
ShoulderImpingement
SyndromeRotator Cuff
TearRotator Cuff
TendinitisShoulder
FracturesShoulder
Instability
Other Conditions
Condition
Dermatological
Limited-Accredited
Specialist: Dermatology
Ophthalmic
Limited-Accredited
Specialist:
Ophthalmology
Ear, Nose & Throat
deformities
Limited-Accredited
Specialists:
Allergist, Otolaryngology,
Plastic surgery
Hearing or vestibular
problems
Limited-Accredited
Specialist:
Otolaryngology
Cardiac
Limited-Accredited
Specialist: Cardiac
Surgery
Allergies (not isolated to
skin or lungs)
Limited-Accredited
Specialists:
Allergist, Otolaryngology
Pulmonary
Limited-Accredited
Specialists:
Specialty
Fully Accredited
Specialists (Level II);
Body Part or System
Skin
Fully Accredited
Specialists (Level II);
Eye, visual system
Fully Accredited
Specialists (Level II)
Ear, nose & throat;
deformities
Fully Accredited
Specialists (Level II)
Ear, middle ear
Fully Accredited
Specialists (Level II)
Heart, cardiopulmonary
system
Fully Accredited
Specialists (Level II)
Sinus
Fully Accredited
Specialists (Level II)
Lungs, cardiopulmonary
system
Allergist, Pulmonology
Hernia
Surgery
Mental/Psychological
Disorders
Limited-Accredited
Specialists:
Psychiatry,
Neurology/Neurosurgery
Fully Accredited
Specialists (Level II)
Go to specific condition
and choose surgical
specialty accordingly
Fully Accredited
Specialists (Level II)
Gastrointestinal
N/A
Mental/Behavioral
RULE XV MEDICAL UTILIZATION REVIEW
A. Statement of Purpose
1. This rule is promulgated to implement and establish procedures for the medical utilization review
program, by which the treatment rendered by a health care provider to a workers' compensation
claimant may be professionally reviewed on issues of whether such treatment is reasonable,
necessary and/or appropriate according to accepted professional standards.
B. Requests for Utilization Review
1. A party shall request a utilization review on a case-by-case basis by filing the Request for Utilization
Review form (request form) prescribed by the Division. In order to reduce costs, the request form
may be photocopied/duplicated or reproduced using computer type devices as long as either
process results in an exact reproduction of the form in both appearance and content.
2. The provider under review shall remain as an authorized provider for the associated claimant until the
director or an administrative law judge issues an order to the contrary as a result of the utilization
review process. The provider shall continue to submit bills for services rendered to the associated
claimant during the review period and the insurance carrier shall continue to pay the provider's
bills as provided in these rules of procedure.
3. As provided in section C., below, an information package and medical records package shall be filed
with the request form.
C. Filing a Request for Utilization Review
1. One copy of an information package shall be filed and shall contain the following items:
a. A completed and signed Division prescribed request form,
b. Copies of all admissions filed or orders entered in the case,
c. A list containing the full names and medical degrees of all providers, including the provider
under review, other treating providers, and individuals who are considered as referrals or
who performed consultations, independent medical examinations and/or second
opinions, and
d. The minimum filing fee as provided in section C.6.
2. Seven (7) identical copies of a medical records package shall be filed with the request form and each
copy shall contain the following items:
a. A case report which shall be prepared, signed and dated by a licensed medical professional.
This report shall be dated within thirty (30) days prior to the date of filing with the Division.
The case report shall be limited to the following:
(1) Name, discipline of care and specialty of the provider under review,
(2) Claimant's standard demographic information (age, sex, marital status, etc.),
(3) Claimant's employer and occupation/job title,
(4) Date(s) of claimant's work-related injury/exposure(s), and
(5) Date of initial treatment, a brief chronological history of treatment to the present date,
and any significant contributing factors which may have had a direct effect on the
length of treatment (e.g., diabetes).
b. Table of contents
c. The following sections:
Section 1 – a copy of the Employer's First Report of Injury and/or the Worker's Claim for
Compensation form.
Section 2 – all reports, notes, etc., from the provider under review as submitted to the
requesting party.
Section 3 – all reports, notes, etc., of other treating providers as submitted to the
requesting party.
Section 4 – all reports resulting from referrals, consultations, independent medical
examinations and second opinions as submitted to the requesting party.
Section 5 – all diagnostic test results as submitted to the requesting party.
Section 6 – all medical management reports as submitted to the requesting party.
Section 7 – all hospital/clinic records related to the injury as submitted to the requesting
party.
3. The medical records package shall not contain billing statements, adjustor notes, vocational
rehabilitation records, surveillance tapes or reports, admissions, denials or comments directed to
the utilization review committee.
4. In order to reduce costs, all material contained in the medical records package shall be presented in
identified sections, each section's contents presented in chronological order.
5. In order to reduce costs, the presentation of the medical records package shall be as follows:
a. Seven (7) separate and identical copies.
b. Each copy two-hole punched at the top center of each page and securely fastened. Notebooks
and plastic type covers and binders shall not be used.
c. A blank sheet of paper shall be placed and bound to the front and back of each copy of the
submitted material.
d. If tabs are used to divide sections, they shall be positioned to the right side of the document.
6. A minimum filing fee of $1,250.00 shall be paid at the time of filing by the requesting party. The
Division shall notify the requesting party of additional costs incurred which require a supplemental
fee.
D. Official Notification of Utilization Review
1. The Division shall notify in writing the provider under review of the review request. Each party to the
case shall receive a copy of the written notification as their official notification of the review
request.
2. The provider under review shall receive, as an attachment to the written notification, one copy of the
medical records package as filed by the requesting party. Each party to the case shall receive
one copy of the medical records package as filed by the requesting party.
E. Adding Medical Records to the Utilization Review File
1. The Division shall not accept additional medical records filed by any individual who has not been
identified as a party to the case.
2. The Division shall incorporate all properly and timely filed additional medical records into the review file
as provided in sections E.3. through E.5., below.
3. Parties filing additional medical records should not duplicate records already submitted for review.
4. Each party has thirty (30) days from the mailing of the review notification to file additional medical
records. Absent a timely showing of good cause, any additional medical records shall not be filed
after the specified time.
5. The presentation of additional medical records shall be as follows:
a. The first item in each copy shall be a dated and signed transmittal letter which contains the
following information:
(1) The UR# and claimant's name,
(2) Submitting party name and position in the case,
(3) A certification stating the seven (7) copies of additional medical records contain the
same documents, and
(4) An index of the attached material.
b. The presentation of the additional medical records is identical to those provided in section
C.5., above.
6. Each party to the case shall receive from the Division a copy of all properly filed additional medical
records.
F. Selection Of Utilization Review Committee Members
1. The director, with input from the medical director, shall appoint appropriate peer professionals to serve
on the utilization review committees for three years.
2. A committee member may be suspended from participation if the member has been the subject of a
utilization review which resulted in an order for change of provider, retroactive denial of payment
and/or revocation of accreditation.
3. Committee members shall be paid a fee of $225 per hour for their time incurred in preparing and
completing their reports and recommendations to the director. Services rendered by the
committee members on behalf of the Division shall be concluded upon acceptance by the
Division of their final reports and recommendations. Any party to a claim for benefits or any party
to a urilization review proceeding who requests the presence as a witness of one or more
committee members at a proceeding for any purpose, by subpoena or otherwise, shall be
responsible for payment to said committee member(s) pursuant to the fee schedule set forth in
these rules of procedure.
4. A provider may not serve on a UR Committee unless his or her professional license or certification, if
applicable, is current, active and unrestricted.
5. Members of UR Committees shall not engage in communication regarding the Utilization Review with
any person other than Division staff, except under the following circumstances: by approval of the
director; by written agreement of the parties to the case, including the provider under review; by
order of an administrative law judge; or by deposition or subpoena as approved by an
administrative law judge.
G. Composition of Utlization Review Committees
1. The composition of the utilization review committees shall reflect a fair balance of interests.
Committees shall be established to review cases submitted for utilization review. Membership of
the committees will include the following:
a. Joints/Musculoskeletal Committee – Two practitioners licensed in the same discipline of care
as the provider under review and one occupational medicine practitioner (M.D. or D.O.)
with a minimum of 2 years experience in occupational medicine where 30% of practice
time is in occupational medicine cases or a minimum of 5 years of experience with a
minimum of 15% of practice time in occupational medicine cases;
b. Dental Committee (Teeth only) – Three dentists;
c. Psychiatry Committee – One occupational medicine practitioner (M.D. or D.O) and two
psychiatrists;
d. Other – Committee shall be determined by the director to meet the specific circumstances of
the utilization review case.
H. Responsibilities of Utilization Review Committee Members
1. Each committee member shall work independently while performing his/her review. The review shall
be a paper review only unless a specialist opinion is requested by a majority of the committee
members. The specialist's opinion may require a physical examination of the claimant.
2. When performing a utilization review, the members of the medical utilization review committee shall
consider all applicable medical treatment guidelines under these rules of procedure. The Division
shall provide copies of the appropriate guidelines to the committee upon request.
3. Report of the Utilization Review Committee
a. The report of each member of the utilization review committee shall be restricted to specific
questions submitted by the Division.
b. Each committee member shall prepare and submit a written narrative demonstrating how the
answers were determined for each of the questions as provided in section H.3.a., above.
I. Change of Medical Provider
1. If the director orders that a change of provider be made, the claimant and insurer or self-insured
employer shall notify the Division, on the prescribed form, as to whether the parties have agreed
upon a new provider. The parties may request mediation or pre-hearing services from the Division
to assist them in this matter.
2. If the claimant chooses to remain under the care of the provider under review during the period of
appeal resolution, the payor shall be responsible for payment of medical bills to the provider until
an order on appeal is issued. If the insurance carrier, employer or self-insured employer prevails
on appeal, the claimant may be held liable by the prevailing party for such medical costs paid
during the appeal period.
3. A provider who wishes to participate in the UR Program as a new treating provider candidate shall not
be eligible unless his or her professional license or certification, if applicable, is current, active
and unrestricted.
J. Utilization Review Appeals
1. The appealing party shall complete the appeal form prescribed by the Division. The form shall be filed
with the Medical Utilization Review coordinator.
2. Should the appealing party be entitled to a de novo hearing, the hearing shall be scheduled according
to the instructions on the appeal form.
RULE XVI UTILIZATION STANDARDS
A. STATEMENT OF PURPOSE
1. In an effort to comply with its legislative charge to assure appropriate and timely medical care at a
reasonable cost, the Director of the Division of Workers' Compensation (Division) has
promulgated these “Utilization Standards.” This rule defines the standard terminology,
administrative procedures and dispute resolution procedures required to implement the Division's
“Medical Treatment Guidelines” and “Medical Fee Schedule.”All providers and payers shall use
the “Medical Treatment Guidelines,” Rule XVII, and the “Medical Fee Schedule,” Rule XVIII, as
incorporated and defined in the Workers' Compensation Rules of Procedure, 7 C.C.R. 1101-3.
B. STANDARD TERMINOLOGY FOR THIS RULE
The following terms are used throughout this rule and are defined as indicated:
1. Authorized Treating Provider (ATP) – (may be any of the following):
a. the initial treating physician chosen by either the employer or insurer, or, in the absence of
choice, the health care provider chosen by the injured worker;
b. a health care provider to whom an authorized treating physician refers the injured worker for
treatment, consultation, or impairment rating;
c. a provider who is designated by agreement of the injured worker and the payer; or
d. a provider selected by the injured worker with permission from the payer, the Division, or after
a hearing with an administrative law judge.
2. Billed Service(s) – any billed service, procedure, equipment or supply provided to an injured worker
by a provider.
3. Billing Party – a service provider or an injured worker who has incurred authorized medical costs.
4. Certificate of Mailing – a signed and dated statement containing the names and mailing addresses of
all persons receiving copies of attached or referenced document(s), certifying the documents
were placed in the U.S. Mail, postage pre-paid, to those persons.
5. Day – for the purpose of Rule XVI, day is defined as a calendar day unless otherwise noted.
6. Medical Fee Schedule – Division's RULE XVIII and the documents incorporated by reference in that
rule.
7. Hospital – the Division incorporates the definition established by the Colorado Department of Public
Health and Environment in its Rules of Procedure, 6 C.C.R. 1011-1, Chapter 1, Definitions.
8. MCAC – Medical Care Advisory Committee to the Director.
9. Medical Treatment Guidelines – the medical treatment guidelines as incorporated into Rule XVII,
“Medical Treatment Guidelines.”
10. Payer – an insurer, employer, or their designated agent(s) who is responsible for payment of medical
expenses.
11. Provider – a person or entity providing authorized healthcare service to an injured worker in
connection with an injury or occupational disease.
C. REQUIRED USE OF THE MEDICAL TREATMENT GUIDELINES
1. When an injury or occupational disease falls within the purview of Rule XVII “Medical Treatment
Guidelines”and the date of injury occurs on or after July 1, 1991, providers shall use the medical
treatment guidelines, in effect, to prepare their treatment plan(s) for the injured worker.
D. REQUIRED USE OF THE MEDICAL FEE SCHEDULE
When services provided to an injured worker fall within the purview of the fee schedule, all payers shall
use the fee schedule to determine maximum allowable fees.
E. RECOGNIZED HEALTH CARE PROVIDERS
1. Physician and Non-Physician Providers
a. For the purpose of this rule, recognized health care providers are divided into the major
categories of “physician” and “non-physician”. Recognized providers are defined as
follows:
1) “Physician providers” are those individuals who are licensed by the State of Colorado
through one of the following state boards:
(1) Colorado State Board of Medical Examiners;
(2) Colorado State Board of Chiropractic Examiners;
(3) Colorado Podiatry Board; and
(4) Colorado State Board of Dental Examiners.
2) “Non-physician providers”are those individuals who are registered or licensed by the
State of Colorado Department of Regulatory Agencies, or certified by a national
entity recognized by the State of Colorado as follows:
(1) Audiologist (CCC-AUD) – certified by the American Speech and Hearing
Association;
(2) Acupuncturist (RAc) – registered by the Office of Acupuncturist Registration,
Colorado Department of Regulatory Agencies;
(3) Licensed Clinical Social Worker (LCSW) – licensed by the Colorado State
Board of Social Work Examiners;
(4) Licensed Practical Nurse (LPN) – licensed by the Colorado State Board of
Nursing;
(5) Licensed Professional Counselor (LPC) – licensed by the Colorado State
Board of Professional Counselor Examiners;
(6) Marriage and Family Therapist (LMFT) – licensed by the Colorado State
Board of Marriage and Family Therapist Examiners;
(7) Nurse Practitioner (NP) – licensed by the Colorado State Board of Nursing;
(8) Occupational Therapist (OTR) – certified by the National Occupational
Therapy Certification Board;
(9) Optometrist (OD) – licensed by the Colorado State Board of Optometric
Examiners;
(10) Orthopedic Technologist (OTC) – certified by the Board for Certification of
Orthopedic Technologists, National Association of Orthopedic
Technologists;
(11) Psychologist (PsyD, PhD, EdD) – licensed by the Colorado State Board of
Psychologist Examiners;
(12) Physical Therapist (LPT) – licensed by the Colorado State Board of
Physical Therapy;
(13) Physician Assistant (PA) – licensed by the Colorado State Board of Medical
Examiners;
(14) Registered Nurse (RN) – licensed by the Colorado State Board of Nursing;
(15) Respiratory Therapist (RT, LRT) – certified by the National Board of
Respiratory Care;
(16) Speech Language Pathologist (CCC-SLP) – certified by the American
Speech and Hearing Association; and
(17) Surgical Technologist (CST) – certified under direction of the Association of
Surgical Technologists.
b. Any provider not listed in Rule XVI.E.1. a.1) or 2) must comply with Rule XVI.I., Prior
Authorization when providing all services.
c. All non-physician providers must have a referral from an authorized treating physician. An
authorized physician making the referral to any listed or unlisted non-physician provider is
required to clarify any questions concerning the scope of the referral, prescription, or the
reasonableness or necessity of the care.
d. Any listed or non-listed non-physician provider is required to clarify any questions concerning
the scope of the referral, prescription, or the reasonableness or necessity of the care with
the referring authorized treating physician.
e. Any healthcare provider must be an “authorized treating provider (ATP) ”in each specific
workers' compensation case to obtain payment. An authorized provider is defined in this
Rule XVI.B.1.
2. Upon request, healthcare providers must provide copies of license, registration, certification or
evidence of healthcare training for billed services.
3. Out-of-State Provider – Injured Worker Relocated
a. Upon receipt of the “Employer's First Report of Injury” or the “Worker's Claim for
Compensation ”form, the payer shall notify the injured worker that the procedures for
change-of-provider, should s/he relocate out-of-state, can be obtained from the payer.
b. A change of provider must be made:
1) Through referral by the injured worker's authorized provider; or
2) In accordance with Section 8-43-404(5)(a), C.R.S.
4. Out-of-State Provider – Injured Worker Referred
a. In the event an injured worker has not relocated out-of-state but is referred to an out-of-state
provider for treatment or services not available within Colorado, the referring provider
shall obtain prior authorization from the payer as set forth in Rule XVI.I. Prior
Authorization, and J. Contest of a request for Prior Authorization. The referring provider's
written request for out-of-state treatment shall include the following information:
1) Medical justification prepared by the referring provider;
2) Written explanation as to why the requested treatment/services cannot be obtained
within Colorado;
3) Name, complete mailing address and telephone number of the out-of-state provider;
4) Description of the treatment/services requested, including the estimated length of time
and frequency of the treatment/service, and all associated medical expenses;
and
5) Out-of-state provider's qualifications to provide the requested treatment or services.
5. The Colorado fee schedule should govern reimbursement for out-of-state providers.
F. BILLING RATES/FEES
1. Payment for billed services identified in the fee schedule shall not exceed those scheduled rates/fees
or the provider's actual billed charges, whichever is less.
2. Payment for billed services not identified in the fee schedule shall require prior authorization from the
payer as set forth in this Rule XVI.I. Prior Authorization and Rule XVI.J. Contest of a Request for
Prior Authorization. Determination of the payment amount shall be made by the payer and reflect
the complexity, time, level of training and expertise required to perform the service or procedure,
but shall at no time exceed the amount billed. The methodology for determination of payment
used by the payer shall be made available to the provider upon request. Rule XVI.K. Payment of
Medical Benefits, sets forth the procedures for contesting any portion of a bill. If there are no
reasonable methods to determine a fee, the payer shall pay the billed charges.
G. REQUIRED BILLING FORMS AND ACCOMPANYING DOCUMENTATION
1. Providers may use electronic reproductions of any required form(s) referenced in this section;
however, any such reproduction shall be an exact duplication of such form(s) in content and
appearance.
2. Required Billing Forms
a. All health care providers shall use only the following billing forms or electronically produced
formats when billing for services:
1) HCFA 1500 – shall be used by all providers billing for professional services with the
exception of those providers billing for dental services or procedures; hospitals
are required to use the HCFA 1500 when billing for professional services.
2) UB-92 – shall be used by all hospitals and facilities, meeting the definition of “hospital”
as found in section (B) “Standard Terminology” of this Rule XVI, when billing for
hospital services; or any facility fees billed by any other provider, such as
ambulatory surgery centers.
3) American Dental Association's Dental Claim Form, Version 2000 – shall be used by all
providers billing for dental services or procedures.
4) With the agreement of the payer, a nationally recognized electronic billing transaction
containing the same information as in 1), 2), or 3) in this subsection may be
used.
3. Required Billing Codes
a. All billed services shall be itemized on the appropriate billing form as set forth in this Rule
XVI.G.1 and 2, and shall include applicable billing codes and modifiers from the fee
schedule.
b. Outpatient services billed by a hospital on a UB-92 require CPT coding for the following
revenue codes:
30X – Laboratory
31X – Laboratory, Pathological
32X – Radiology – Diagnostic
33X – Radiology – Therapeutic
34X – Nuclear Medicine
35X – CT Scan
40X – Other imaging Services
42X – Physical Therapy
43X – Occupational Therapy
44X – Speech Language Pathology
51X – Clinic
52X – Free-standing Clinic
53X – Osteopathic Services
57X – Home Health – Home Health Aide
58X – Home Health – Other Visits
59X – Home Health – Units of Service
61X –Magnetic Resonance Technology (MRI)
64X – Home IV Therapy Services
73X – EKG/ECGT
74X – EEG
90X – Psychiatric/Psychological Treatments
91X – Psychiatric/Psychological Services
92X – Other Diagnostic Services
94X – Other Therapeutic Services
96X – Professional Fees
97X – Professional Fees
98X – Professional Fees
4. Inaccurate Billing Forms or Codes
a. Payment for any services not billed on the forms identified and/or not itemized as instructed in
this Rule XVI.G.2 and 3, may be contested until the provider complies. However, when
payment is contested, the payer shall comply with the applicable provisions set forth in
Rule XVI.K. “Payment of Medical Benefits”.
5. Accompanying Documentation:
a. Authorized treating physicians submit to the payer, with their initial and final visit billings, a
completed “Physician's Report of Workers' Compensation Injury” (Form WC164)
specifying:
1) The report type as “initial” when the injured worker has their initial visit with the
authorized treating physician for this workers' compensation injury. This form
includes a treatment plan and may require the attachment of additional materials;
2) The report type as “closing” when the physician determines the injured worker has
reached maximum medical improvement (MMI) for all injuries or diseases
covered under this workers' compensation claim. If the injured worker has
sustained a permanent impairment, the following additional information shall be
attached to the bill at the time MMI is determined:
(1) All necessary permanent impairment rating reports when the authorized
treating physician is Level II Accredited, or
(2) The name of the Level II Accredited physician designated to perform the
permanent impairment rating when a rating is necessary and the
authorized treating physician is not determining the permanent
impairment rating.
b. The physician shall supply the injured worker with a copy of all completed Physician's Medical
Report (WC164) forms. When the injured worker is represented, a copy of the completed
form(s) shall be supplied to the injured worker for his/her representative.
c. The provider shall submit to the payer the completed WC164 form as specified in this Rule
XVI.G.5, no later than fourteen (14) days from the date of service.
d. Providers, other than hospitals, shall provide the payer with all supporting documentation at
the time of submission of the bill unless other agreements have been made between the
payer and provider. This shall include copies of the examination, surgical, and/or
treatment records.
e. Hospital documentation shall be available to the payer upon request. Payers shall specify
what portion of a hospital record is being requested. (For example, only the emergency
room (ER) chart notes, in-patient physician orders and chart notes, x-rays, pathology
reports, etc.)
f. In accordance with this Rule XVI.K, the payer may contest payment for billed services until the
provider completes and submits the required accompanying documentation as specified
by this Rule XVI.G.5.
H. REQUIRED MEDICAL RECORD DOCUMENTATION
1. A provider shall maintain medical records for each injured worker when the provider intends to bill for
the provided services.
2. All medical records shall contain legible documentation substantiating the services billed. The
documentation shall itemize each contact with the injured worker and shall detail at least the
following information per contact or, at a maximum, be summarized once per week:
a. Patient's name;
b. Date of contact, office visit or treatment;
c. Name and professional designation of person providing the billed service;
d. Assessment or diagnosis of current condition with appropriate objective findings;
e. Treatment status or patient's functional response to current treatment;
f. Treatment plan including specific therapy with time limits and measurable goals and detail of
referrals;
g. If being completed by an authorized treating physician, all pertinent changes to work and/or
activity restrictions which reflect lifting, standing, stooping, kneeling, hot or cold
environment, repetitive motion or other appropriate physical considerations; and
h. All prior authorization(s) for payment received from the payer (i.e., who approved the prior
authorization for payment, services authorized, dollar amount, length of time, etc.).
I. PRIOR AUTHORIZATION
1. Prior authorization for payment shall be requested by the provider when:
a. A prescribed service exceeds the recommended limitations set forth in the medical treatment
guidelines;
b. The medical treatment guidelines otherwise require prior authorization for that specific service;
c. A prescribed service is identified within the medical fee schedule as requiring prior
authorization for payment; or
d. A prescribed service is not identified in the fee schedule as referenced in Rule XVI.F.2.
2. All prior authorization for a prescribed service or procedure may be granted immediately and without
medical review. However, the payer shall respond to all providers requesting prior authorization
within seven (7) business days from receipt of the provider's completed request as defined in
Rule XVI.I.5. To complete the contest, refer to procedures in Rule XVI.J.
3. The payer, upon receipt of the “Employer's First Report of Injury” or a “Worker's Claim for
Compensation,” shall give written notice to the injured worker stating that the requirements for
obtaining prior authorization for payment are available from the payer.
4. The payer, unless they have previously notified said provider, shall give notice to the provider of these
procedures for obtaining prior authorization for payment upon receipt of the Division form titled
“Physician's Report of Workers' Compensation Injury” (WC164).
5. To complete a prior authorization request, the provider shall concurrently explain the medical necessity
of the services requested and provide relevant supporting medical documentation. Supporting
medical documentation is defined as documents used in the provider's decision-making process
to substantiate the need for the requested service or procedure.
6. To contest a request for prior authorization, the payer is required to comply with the provisions outlined
in Rule XVI.J.
7. The Division recommends payers confirm in writing, to providers and all parties, when a request for
prior authorization is approved.
8. If, after the service was provided, the payer agrees the service provided was reasonable and
necessary, lack of prior authorization for payment does not warrant denial of payment.
J. CONTEST OF A REQUEST FOR PRIOR AUTHORIZATION
1. If the payer contests a request for prior authorization for non-medical reasons as defined under this
Rule XVI.K.2.a, the payer shall notify the provider and parties, in writing, of the basis for the
contest within seven (7) business days. A certificate of mailing of the written contest must be sent
to the provider and parties.
2. If the payer is contesting a request for prior authorization for medical reasons, the payer shall, within
seven (7) business days of the completed request:
a. Have the request reviewed by a Physician or other health care professional, as defined in Rule
XVI.E.1.a.1, who holds a license and is in the same or similar specialty as would typically
manage the medical condition, procedures, or treatment under review; and
b. The reviewing provider may call the requesting provider to expedite communication and
processing of prior authorization requests. However, the written contest or approval still
needs to be completed within the specified seven (7) days under this Rule XVI.J.2.
c. Furnish the provider and the parties with either a verbal or written approval, or a written
contest that sets forth the following information:
1) An explanation of the specific medical reasons for the contest, including the name and
professional credentials of the person performing the medical review and a copy
of the medical reviewer's opinion;
2) The specific cite from the division's Medical Treatment Guidelines exhibits to Rule
XVII, when applicable;
3) Identification of the information deemed most likely to influence the reconsideration of
the contest when applicable; and
4) A certificate of mailing to the provider and parties.
3. Prior Authorization Disputes
a. The requesting party or provider shall have seven (7) business days from the date of the
certificate of mailing on the written contest to provide a written response to the payer,
including a certificate of mailing. The response is not considered a “special report” when
prepared by the provider of the requested service.
b. The payer shall have seven (7) business days from the date of the certificate of mailing of the
response to issue a final decision, including a certificate of mailing to the provider and
parties.
c. In the event of continued disagreement, the parties should follow dispute resolution and
adjudication procedures under Rule VIII.
4. An urgent need for prior authorization of health care services, as recommended in writing by an
authorized treating provider, shall be deemed good cause for an expedited hearing under Rule
VIII.
5. Failure of the payer to timely comply in full with the requirements of Rule XVI.J.1 or Rule XVI.J.2, shall
be deemed authorization for payment of the requested treatment unless a hearing is requested
within the time prescribed for responding as set forth in Rule XVI.J.1 or Rule XVI.J.2.
6. Unreasonable delay or denial of prior authorization, as determined by the director or an administrative
law judge, may subject the payer to penalties under the Workers' Compensation Act.
K. PAYMENT OF MEDICAL BENEFITS
1. Uncontested Payment For Billed Services
a. Providers shall submit their bills for services rendered within one hundred twenty (120) days of
the date of service. Bills first received later than one hundred twenty (120) days may be
denied unless extenuating circumstances exist.
b. Unless contested in accordance with the provisions set forth in this section K. 2. and 3., all
bills submitted by a provider are due and payable in accordance with the Medical Fee
Schedule within thirty (30) days after receipt of the bill by the payer. Date of receipt may
be established by the payer's date stamp or electronic acknowledgement date; otherwise,
receipt is presumed to occur three (3) days after the date the bill was mailed to the
payer's correct address. The payer shall notify the billing provider that the injured worker
shall not be balance-billed for services related to a compensable work-related injury or
occupational disease.
c. In the event the injured worker has directly paid a medical provider for uncontested medical
services, the payer shall reimburse the injured worker for actual costs incurred for
authorized services within thirty (30) days after receipt of the bill by the payer. If the
actual costs exceed the maximum fee allowed by the medical fee schedule (rule XVIII),
the payer may seek a refund from the medical provider for the difference between the
amount charged to the injured worker and the maximum fee. Each request for a refund
shall indicate the service provided and the date of service(s) involved.
d. When the payer fails to make timely payment of uncontested billed services, the billing party
shall first attempt to resolve payment with the payer. Where such attempt is unsuccessful,
the billing party may request assistance from the Division's Carrier Practices Unit.
2. Contested Payment for Billed Services Based on Non-Medical Issues.
a. Non-medical reasons for contesting payment may include, but are not limited to:
compensability has not been established; the billed services are not related to the
admitted injury; the provider is not authorized to treat; the insurance coverage is at issue;
or the billed code does not appear to be accurate based upon the information submitted.
b. In all cases where a billed service is contested by the payer, the payer shall, within thirty (30)
days of receipt of the bill, submit to the billing party a written notification of contest.
The written non-medical notification of contest shall include the following information:
1) Name of the injured worker;
2) Date of service(s) being contested;
3) Payer's accident number and/or Division's workers' compensation claim number;
4) If applicable, acknowledgement of specific uncontested and paid items submitted on
the same bill as contested services;
5) Reference to the bill and each item of the bill being contested;
6) Reason(s) for contesting the payment of any item. The explanation shall include the
citing of appropriate statutes, rules and /or documents supporting the payer's
reasons for contesting payment; and
7) Notice that the billing party may resubmit the bill or corrected bill within sixty (60)
days.
c. Prior to modifying a billed code, the payer must contact the billing provider and determine if the
modified code is accurate
1) If the billing provider agrees with the payer, then the payer shall process the service
with the agreed upon code and shall document on their explanation of benefits
(EOB), the agreement with the provider. The EOB shall include the name of the
person at the provider's office who made the agreement.
2) If the provider is in disagreement, then the payer shall proceed according to this Rule
XVI.K.2.b or K.3, as appropriate.
d. If the payer agrees a service or procedure was reasonable and necessary, the provider's lack
of prior authorization for payment does not warrant denial of liability for payment.
3. Contested Payment for Billed Services Based on Medical Issues:
a. The payer shall within thirty (30) days of receipt of the medical bill and supporting medical
documentation do the following:
1) Have the request reviewed by a physician or other healthcare professional as defined
in Rule XVI.E.1.a.1, who holds a license and is in the same or similar specialty as
would typically manage the medical condition, procedures, or treatment under
review. This reviewing provider may call the billing provider to expedite
communication and timely processing of the contested or paid medical bill.
However, the written contest or payment still needs to be completed within the
specified thirty (30) days under this Rule XVI.K.
2) Furnish the provider and the parties with a written contest setting forth the following
information:
(1) An explanation of the specific medical reasons for the decision, including the
name and professional credentials of the person performing the medical
review and a copy of the medical reviewer's opinion;
(2) The specific cite from the division's Medical Treatment Guidelines exhibits to
Rule XVII, when applicable;
(3) Identification of the information deemed most likely to influence the
reconsideration of the contest, when applicable; and
(4) A certificate of mailing to the provider and parties.
4. Medical Bill Disputes
a. The billing party shall have sixty (60) days to respond to the payer's written notification of
contest. If a dispute occurs between the billing party and the payer in relation to the
Medical Fee Schedule, the parties shall attempt to resolve the dispute themselves. If the
parties are unable to resolve the dispute, either party may contact the Medical Policy Unit
(MPU) at the Division.
b. When seeking clarification or dispute resolution from the MPU, the requesting party must
provide:
1) A copy of the bill with the contested codes and dates of services in dispute;
2) A copy of the payer's explanation as to why the billed services are being contested;
and
3) A copy of any applicable medical record documentation.
The MPU will try to provide a written analysis and opinion to the parties regarding the appropriate
application of the Medical Fee Schedule within thirty (30) days of receipt of the complete
documentation and the written request for assistance; or as soon thereafter as possible.
c. In the event of continued disagreement, the parties should follow dispute resolution
and adjudication procedures under Rule VIII.
L. REVIEW OF HOSPITAL CHARGES
1. The payer may conduct a review of billed and non-billed hospital charges related to a specific worker's
compensation claim.
2. The payer shall comply with the following procedures:
a. Make payment to the hospital of at least 80 percent of the maximum allowed under the fee
schedule for the discharge billing prior to the start of the review; and
b. Within thirty (30) days of receipt of the discharge billing, notify the hospital of its intent to
conduct a review. Notification shall be in writing and shall set forth the following
information:
1) Name of the injured worker;
2) Claim and/or hospital I.D. number associated with the injured worker's discharge bill;
3) An outline of the items to be reviewed; and
4) If applicable, the name, address and telephone number of any person who has been
designated by the payer to conduct the review (reviewer).
3. The hospital shall comply with the following procedures:
a. Allow the review to begin within thirty (30) days of the payer's notification, provided, prior to the
start of the review, the hospital has received payment related to the discharge billing of at
least 80 percent of the maximum allowed under the fee schedule;
b. Upon receipt of the patient's signed release of information form, allow the reviewer access to
all items identified on the injured worker's signed release of information form;
c. Designate an individual(s) to serve as the primary liaison(s) between the hospital and the
reviewer who will acquaint the reviewer with the documentation and charging practices of
the hospital;
d. Provide a written response to each of the preliminary review findings within ten (10) days of
receipt of those findings; and
e. Participate in the exit conference in an effort to resolve discrepancies.
4. The reviewer shall comply with the following procedures:
a. Obtain from the injured worker a signed information release form;
b. Negotiate the starting date for the review;
c. Assign staff members who are familiar with medical terminology, general hospital charging and
medical records documentation procedures or have a level of knowledge equivalent at
least to that of an LPN;
d. Establish the schedule for the review which shall include, at a minimum, the dates for the
delivery of preliminary findings to the hospital, a 10-day response period for the hospital,
and the delivery of an itemized listing of discrepancies at an exit conference upon the
completion of the review; and
e. Provide the payer and hospital with a written summary of the review within twenty (20) working
days of the exit conference.
RULE XVII MEDICAL TREATMENT GUIDELINES
A. STATEMENT OF PURPOSE
1. In an effort to comply with its legislative charge to assure appropriate medical care at a reasonable
cost, the director of the Division has promulgated these “Medical Treatment guidelines.” This rule
provides a system of evaluation and treatment guidelines for high cost or high frequency
categories of occupational injury or disease to assure appropriate medical care at a reasonable
cost.
2. Pursuant to section 8-42-101(3)(a)(I), C.R.S., prior to July 1 of each year the Division Director shall
review all medical treatment guidelines. Written comments which have been submitted by the
public to the director or the Division's medical director will be considered during such reviews.
B. USE OF THE MEDICAL TREATMENT GUIDELINES
1. All health care providers shall use the medical treatment guidelines adopted by the Division.
2. Payers shall routinely and regularly review claims to ensure that care is consistent with the Division's
medical treatment guidelines.
C. STANDARD TERMINOLOGY FOR THIS RULE
1. See Rule XVI, Utilization Standards, Section B.
D. PROVIDER'S RESPONSIBILITIES
1. The health care provider shall prepare a diagnosis-based treatment plan that includes specific
treatment goals with expected time frames for completion in all cases where treatment falling
within the purview of the medical treatment guidelines continues beyond 6 weeks.
2. Within 14 days of request by any party, the provider shall supply a copy of the treatment plan both to
the patient and to the payer. Should the patient otherwise require care that deviates from the
medical treatment guidelines, the provider shall supply the patient and the payer with a written
explanation of the medical necessity for such care.
E. PROCEDURE FOR QUESTIONING CARE
1. In cases where treatment falls within the purview of a medical treatment guideline, prior authorization
for payment is unnecessary unless the guideline specifies otherwise, or Rule XVI.I.1.a - d apply.
a. If prior authorization is required by the Medical Treatment Guidelines or a provider requests
prior authorization then the procedure for contesting a request for prior authorization for
payment is under Rule XVI.J.
b. If the payer questions whether treatment is consistent with the medical treatment guidelines
then the procedure for contesting payment of a billed service is covered under Rule
XVI.K.2 and 3.
F. FAILURE TO COMPLY
1. See Rule XI, General Rules, Section G
G. EXHIBITS TO RULE XVII
1. Exhibit A – Low Back Pain Medical Treatment Guidelines
2. Exhibit B – Upper Extremity Medical Treatment Guidelines
3. Exhibit C – Lower Extremity Medical Treatment Guidelines
4. Exhibit D – Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome Medical Treatment
Guidelines
5. Exhibit E – Cervical Spine Injury Medical Treatment Guidelines
6. Exhibit F – Chronic Pain Disorder (Evaluation and Management) Medical Treatment Guidelines
7. Exhibit G – Traumatic Brain Injury Medical Treatment Guidelines
RULE XVII, EXHIBIT A Low Back Pain Medical Treatment Guidelines December 1, 2001
(Previously Adopted April 1993, revised April 30, 1994, March 2, 1995 & March 15, 1998)
Presented By:
State of Colorado Department of Labor and Employment DIVISION OF WORKERS'
COMPENSATION
TABLE OF CONTENTS
Low Back Pain Medical Treatment Guideline
SECTION
DESCRIPTION
A.
B.
INTRODUCTION
GENERAL GUIDELINE PRINCIPLES
1.
APPLICATION OF GUIDELINES
2.
EDUCATION
3.
TREATMENT PARAMATER DURATION
4.
ACTIVE INTERVENTIONS
5.
ACTIVE THERAPEUTIC EXERCISE PROGRAM
6.
POSITIVE PATIENT RESPONSE
7.
RE-EVALUATE TREATMENT EVERY 3 TO 4
WEEKS
8.
SURGICAL INTERVENTIONS
9.
SIX-MONTH TIME FRAME
10.
RETURN-TO-WORK
11.
DELAYED RECOVERY
12.
GUIDELINE RECOMMENDATIONS AND
INCLUSION OF MEDICAL EVIDENCE
13.
CARE BEYOND MAXIMUM MEDICAL
IMPROVEMENT (MMI)
INITIAL DIAGNOSTIC PROCEDURES
1.
HISTORY-TAKING AND PHYSICAL
EXAMINATION (HX & PE)
a.
History of Present In
b.
Past History:
c.
Physical Examinatio
2.
RADIOGRAPHIC IMAGING
3.
LABORATORY TESTING
FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES
1.
IMAGING STUDIES
a.
Magnetic Resonance
Imaging (MRI)
b.
Computerized Axial
Tomography (CT)
c.
Lineal Tomography
d.
Bone Scan (Radioiso
Bone Scanning)
e.
Myelography
f.
CT Myelogram
g.
Electrodiagnostic Stu
C.
D.
h.
2.
3.
E.
OTHER TESTS
a.
b.
c.
d.
e.
SPECIAL TESTS
a.
(EMG/NCV)
Other Radionuclide
Scanning
Personality/Psycholo
/Psychosocial/Evalua
Electrodiagnostic Tes
Injections — Diagno
Discography
Thermography
Computer-Enhanced
Evaluations
b.
Functional Capacity
Evaluation (FCE)
c.
Jobsite Evaluation
d.
Vocational Assessme
e.
Work Tolerance
Screening
THERAPEUTIC PROCEDURES — NON-OPERATIVE
1.
ACUPUNCTURE
a.
Acupuncture
b.
Acupuncture with
Electrical Stimulation
c.
Other Acupuncture
Modalities
2.
BIOFEEDBACK
3.
INJECTIONS — THERAPEUTIC
a.
Therapeutic Spinal
Injections
b.
Facet Rhizotomy (Ra
Frequency Medial Br
Neurotomy)
c.
Sacroiliac Joint Injec
d.
Trigger Point Injectio
e.
Prolotherapy
f.
Sympathetic Injectio
4.
MEDICATIONS
a.
Acetaminophen
b.
Minor
Tranquilizer/Muscle
Relaxants
c.
Narcotics
d.
Nonsteroidal AntiInflammatory Drugs
(NSAIDs)
e.
f.
5.
6.
7.
8.
9.
10.
11.
12.
Oral Steroids
Psychotropic/Antianxiety/Hypnotic Ag
g.
Tramadol
h.
Topical Drug Deliver
OCCUPATIONAL REHABILITATION PROGRA
a.
Non-Interdisciplinary
b.
Interdisciplinary
ORTHOTICS
a.
Foot Orthoses
b.
Lumbosacral Bracing
PATIENT EDUCATION
PERSONALITY/PSYCHOLOGICAL/PSYCHOSO
AL INTERVENTION
RESTRICTION OF ACTIVITIES
RETURN-TO-WORK
a.
Establishment of a
Return-To-Work Stat
b.
Establishment of Act
Level Restrictions
c.
Compliance with Act
Restrictions
THERAPY — ACTIVE
a.
Activities of Daily L
(ADL)
b.
Aquatic Therapy
c.
Functional Activities
d.
Functional Electrical
Stimulation
e.
Lumbar Stabilization
f.
Neuromuscular ReEducation
g.
Therapeutic Exercise
THERAPY — PASSIVE
a.
Electrical Stimulation
(Unattended)
b.
Infrared Therapy
c.
Iontophoresis
d.
Manipulation
e.
Massage — Manual
Mechanical
f.
Mobilization (Joint)
g.
Mobilization (Soft
Tissue)
h.
Superficial Heat and
Therapy
i.
j.
k.
l.
F.
Short-Wave Diatherm
Traction — Manual
Traction — Mechani
Transcutaneous Elec
Nerve Stimulation
(TENS)
m.
Ultrasound
n.
Vertebral Axial
Decompression (VAX
o.
Whirlpool/Hubbard T
13.
VOCATIONAL REHABILITATION
THERAPEUTIC PROCEDURES — OPERATIVE
1.
DISCECTOMY
2.
CHEMONUCLEOLYSIS
3.
PERCUTANEOUS DISCECTOMY (NUCLECTO
OR LASER DISCECTOMY
4.
LAMINOTOMY/LAMINECTOMY/FORAMENO
MY/FACETECTOMY
5.
SPINAL FUSION
6.
SACROILIAC JOINT FUSION
7.
IMPLANTABLE SPINAL CORD STIMULATOR
8.
INTRADISCAL ELECTROTHERMAL
ANNULOPLASTY (IDEA)
A. INTRODUCTION
This document has been prepared by the Colorado Department of Labor and Employment, Division of
Workers' Compensation (Division) and should be interpreted within the context of guidelines for
physicians/providers treating individuals qualifying under Colorado's Workers' Compensation Act as
injured workers with low back pain.
Although the primary purpose of this document is advisory and educational, these guidelines are
enforceable under the Workers' Compensation rules of Procedure, 7 CCR 1101-3. The Division
recognizes that acceptable medical practice may include deviations from these guidelines, as individual
cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of
professional care.
To properly utilize this document, the reader should not skip nor overlook any sections.
B. GENERAL GUIDELINE PRINCIPLES
The principles summarized in this section are key to the intended implementation of all Division of
Workers' Compensation guidelines and critical to the reader's application of the guidelines in this
document.
1. Application of Guidelines
The Division provides procedures to implement medical treatment guidelines and to foster communication
to resolve disputes among the provider, payer and patient through the Worker's Compensation Rules of
Procedure, Rule XVII and Rule VIII. In lieu of more costly litigation, parties may wish to seek
administrative dispute resolution services through the Division.
2. Education
Education of the patient and family, as well as the employer, insurer, policy makers and the community
should be the primary emphasis in the treatment of low back pain and disability. Currently, practitioners
often think of education last, after medications, manual therapy and surgery. Practitioners must develop
and implement an effective strategy and skills to educate patients, employers, insurance systems, policy
makers and the community as a whole. An education-based paradigm should always start with
inexpensive communication providing reassuring information to the patient. More in-depth education
currently exists within a treatment regime employing functional restorative and innovative programs of
prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or
group patient education as a means of facilitating self-management of symptoms and prevention.
3. Treatment Paramater Duration
Time frames for specific interventions commence once treatments have been initiated, not on the date of
injury. Obviously, duration will be impacted by patient compliance, as well as availability of services.
Clinical judgment may substantiate the need to accelerate or decelerate the time frames discussed in this
document.
4. Active Interventions
Interventions emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment,
are generally emphasized over passive modalities, especially as treatment progresses. Generally,
passive interventions are viewed as a means to facilitate progress in an active rehabilitation program with
concomitant attainment of objective functional gains.
5. Active Therapeutic Exercise Program
Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and
education. This includes functional application in vocational or community settings.
6. Positive Patient Response
Positive results are defined primarily as functional gains that can be objectively measured. Objective
functional gains include, but are not limited to, positional tolerances, range-of-motion, strength,
endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures
that can be quantified. Subjective reports of pain and function should be considered and given relative
weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on
objective findings.
7. Re-Evaluate Treatment Every 3 to 4 Weeks
If a given treatment or modality is not producing positive results within 3 to 4 weeks, the treatment should
be either modified or discontinued.
Reconsideration of diagnosis should also occur in the event of poor response to a seemingly rational
intervention.
8. Surgical Interventions
Surgery should be contemplated within the context of expected functional outcome and not purely for the
purpose of pain relief. The concept of “cure” with respect to surgical treatment by itself is generally a
misnomer. All operative interventions must be based upon positive correlation of clinical findings, clinical
course and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific
diagnosis with positive identification of pathologic conditions.
9. Six-Month Time Frame
The prognosis drops precipitously for returning an injured worker to work once he/she has been
temporarily totally disabled for more than six months. The emphasis within these guidelines is to move
patients along a continuum of care and return-to-work within a six-month time frame, whenever possible.
It is important to note that time frames may not be pertinent to injuries that do not involve work-time loss
or are not occupationally related.
10. Return-to-Work
Return-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 and the patient should never be
released to “sedentary” or “light duty.” The following physical limitations should be considered and
modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, bending at the waist,
awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data
entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors. Even if there is
residual chronic pain, return-to-work is not necessarily contraindicated.
The practitioner should understand all of the physical demands of the patient's job position before
returning the patient to full duty and should request clarification of the patient's job duties. Clarification
should be obtained from the employer or, if necessary, including, but not limited to, an occupational health
nurse, occupational therapist, vocational rehabilitation specialist, or an industrial hygienist.
11. Delaved Recoverv
Strongly consider a psychological evaluation, if not previously provided, as well as initiating
interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to
make expected progress 6 to 12 weeks after an injury. The Division recognizes that 3 to 10% of all
industrially injured patients will not recover within the timelines outlined in this document despite optimal
care. Such individuals may require treatments beyond the limits discussed within this document, but such
treatment will require clear documentation by the authorized treating practitioner focusing on objective
functional gains afforded by further treatment and impact upon prognosis.
12. Guideline Recommendations and Inclusion of Medical Evidence
Guidelines are recommendations based on available evidence and/or consensus recommendations.
When possible, guideline recommendations will note the level of evidence supporting the treatment
recommendation. When interpreting medical evidence statements in the guideline, the following apply:
Consensus means the opinion of experienced professionals based on general medical principles.
Consensus recommendations are designated in the guideline as “generally well accepted,”
“generally accepted,” “acceptable,” or “well established.”
“Some” means the recommendation considered at least one adequate scientific study, which
reported that a treatment was effective.
“Good” means the recommendation considered the availability of multiple adequate scientific
studies or at least one relevant high-quality scientific study, which reported that a treatment was
effective.
“Strong” means the recommendation considered the availability of multiple relevant and high
quality scientific studies, which arrived at similar conclusions about the effectiveness of a
treatment.
All recommendations in the guideline are considered to represent reasonable care in appropriately
selected cases, regardless of the level of evidence or consensus statement attached to it. Those
procedures considered inappropriate, unreasonable, or unnecessary are designated in the guideline as
being “not recommended.”
13. Care Beyond Maximum Medical Improvement (MMI)
MMI should be declared when a patient's condition has plateaued to the point where the authorized
treating physician no longer believes further medical intervention is likely to result in improved function.
However, some patients may require treatment after MMI has been declared in order to maintain their
functional state. The recommendations in this guideline are for pre-MMI care and are not intended to limit
post-MMI treatment.
The remainder of this document should be interpreted within the parameters of these guideline principles
that may lead to more optimal medical and functional outcomes for injured workers.
C. INITIAL DIAGNOSTIC PROCEDURES
The Division 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 workrelated low back pain complaint, are listed below.
1. History-Taking and Physical Examination (Hx & PE)
History taking and physical examinations are generally accepted, well established and widely used
procedures that establish the foundation/basis for and dictates 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. History of Present Injury:
1) Mechanism of injury. This includes details of symptom onset and progression;
2) Relationship to work. This includes a statement of the probability that the illness or injury is workrelated;
3) Location of pain, nature of symptoms, and alleviating/exacerbating factors (e.g., sitting tolerance);
4) Presence of lower extremity numbness, weakness, or paresthesias, especially if precipitated by
coughing or sneezing;
5) Alteration in bowel, bladder, or sexual function;
6) Prior occupational and non-occupational injuries to the same area including specific prior treatment,
chronic or recurrent symptoms, and any functional limitations; and
7) Ability to perform job duties and activities of daily living.
b. Past History:
1) Past medical includes neoplasm, gout, arthritis, hypertension, kidney stones, and diabetes;
2) Review of systems includes symptoms of rheumatologic, neurologic, endocrine, neoplastic, infectious,
and other systemic diseases;
3) Smoking history; and
4) Vocational and recreational pursuits.
c. Physical Examination
Physical examinations should include accepted tests and exam techniques applicable to the area being
examined, including:
1) General inspection, including stance and gait;
2) Visual inspection;
3) Palpation;
4) Lumber range of motion, quality of motion, and presence of muscle spasm. Motion evaluation of
specific joints may be indicated;
5) Nerve tension testing;
6) Sensory and motor examination of the lower extremities with specific nerve root focus;
7) Deep tendon reflexes with or without Babinski's;
8) If applicable to injury, anal sphincter tone and/or perianal sensation; and
9) If applicable, abdominal examination, vascular examination, circumferential lower extremity
measurements, or evaluation of hip or other lower extremity abnormalities.
2. Radiographic Imaging
Radiographic imaging of the lumbosacral spine is a generally accepted, well-established and widely used
diagnostic procedure when specific indications based on history and/or physical examination are present.
It should not be routinely performed. The mechanism of injury and specific indications for the radiograph
should be listed on the request form to aid the radiologist and x-ray technician. Suggested indications
include:
1) History of significant trauma, especially blunt trauma or fall from a height;
2) Age over 55 years;
3) Unexplained or persistent low back pain for at least 6 weeks or that is worse with rest;
4) Localized pain, fever, constitutional symptoms, or history or exam suggestive of intravenous drug
abuse, prolonged steroid use, or osteomyelitis;
5) Suspected lesion in the lumbosacral spine as a part of a systemic illness such as a
rheumatic/rheumatoid disorder or endocrinopathy. Suspected lesions may require special views;
6) Past medical history suggestive of pre-existing spinal disease, spinal instrumentation, or tumor; and
7) Roentgenographic evaluation may be appropriate before high-velocity/low amplitude manipulation or
Grade IV to V mobilization.
3. Laboratory Testing
Laboratory tests are generally accepted well established and widely used procedures. They are, however,
rarely indicated at the time of initial evaluation, unless there is suspicion of systemic illness, infection,
neoplasia, or underlying rheumatologic disorder, connective tissue disorder, or based on history and/or
physical examination. Laboratory tests can provide useful diagnostic information. Tests include, but are
not limited to:
1) CBC with differential can detect infection, blood dyscrasias, and medication side effects;
2) Erythrocyte sedimentation rate, rheumatoid factor, ANA, HLA, and C-reactive protein can be used to
detect evidence of a rheumatologic, infection, or connective tissue disorder;
3) Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect
metabolic bone disease;
4) Urinalysis for bacteria (usually with culture and sensitivity), calcium, phosphorus, hydroxyproline, or
hematuria; and
5) Liver and kidney function may be performed for prolonged anti-inflammatory use or other medications
requiring monitoring.
D. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES
One diagnostic imaging procedure may provide the same or distinctive information as obtained by other
procedures. Therefore, prudent choice of procedure(s) for a single diagnostic procedure, a
complementary procedure in combination with other procedures(s), or a proper sequential order in
multiple procedures will ensure maximum diagnostic accuracy; minimize adverse effect to patients and
cost effectiveness by avoiding duplication or redundancy.
All diagnostic imaging procedures have a significant percentage of specificity and sensitivity for various
diagnoses. None is specifically characteristic of a certain diagnosis. Clinical information obtained by
history taking and physical examination should be the basis for selection and interpretation of imaging
procedure results.
Magnetic resonance imaging (MRI), myelography, or CT scanning following myelography may provide
useful information for many spinal disorders. When a diagnostic procedure, in conjunction with clinical
information, can provide sufficient information to establish an accurate diagnosis, the second diagnostic
procedure will become a redundant procedure. At the same time, a subsequent diagnostic procedure can
be a complementary diagnostic procedure if the first or preceding procedures, in conjunction with clinical
information, cannot provide an accurate diagnosis. Usually, preference of a procedure over others
depends upon availability, a patient's tolerance and/or the treating practitioner's familiarity with the
procedure.
1. Imaging Studies
Imaging studies are generally accepted, well established and widely used diagnostic procedures. When
indicated, imaging studies can be utilized for further evaluation of the low back, based upon the
mechanism of injury, symptoms, and patient history. Prudent choice of a single diagnostic procedure, a
complementary combination of procedures, or a proper sequential order of complementary procedures
will help ensure maximum diagnostic accuracy and minimize adverse effect to the patient. When the
findings of the diagnostic imaging and testing procedures are not consistent with the clinical examination,
the clinical findings should have preference. The studies below are listed in frequency of use, not
importance:
a. Magnetic Resonance Imaging (MRI)
MRI is rarely indicated in patients with non-traumatic acute low back pain with no neuropathic signs or
symptoms. It is generally the first follow-up imaging study in individuals who respond poorly to proper
initial conservative care. MRI is useful in suspected nerve root compression, myelopathy, masses,
infections, metastatic disease, disc herniation, annular tear, and cord contusion. It is contraindicated in
patients with certain implants.
In general, the high field, conventional, MRI provides better resolution. A lower field scan may be
indicated when a patient cannot fit into a high field scanner or who is too claustrophobic despite sedation.
Inadequate resolution on the first scan may require a second MRI using a different technique. All
questions in this regard should be discussed with the MRI center and/or radiologist.
b. Computerized Axial Tomography (CT)
CT provides excellent visualization of bone and is used to further evaluate bony masses and suspected
fractures not clearly identified on radiographic evaluation. It may sometimes be done as a complement to
MRI scanning to better delineate bony osteophyte formation in the neural foramen. Instrument-scatter
reduction software provides better resolution when metallic artifact is of concern.
c. Lineal Tomography
Lineal tomography is infrequently used, yet may be helpful in the evaluation of bone surfaces, bony
fusion, or pseudoarthrosis.
d. Bone Scan (Radioisotope Bone Scanning)
Bone scanning is generally accepted, well established and widely used. Bone scanning is more sensitive
but less specific than MRI. 99MTechnecium diphosphonate uptake reflects osteoblastic activity and may be
useful in metastatic/primary bone tumors, stress fractures, osteomyelitis, and inflammatory lesions, but
cannot distinguish between these entities.
e. Myelography
Myelography is the injection of radiopaque material into the spinal subarachnoid space with x-rays then
taken to define anatomy. It may be used as a pre-surgical diagnostic procedure to obtain accurate
information of characteristics, location, and spatial relationships among soft tissue and bony structures.
Myelography is an invasive procedure with complications including nausea, vomiting, headache,
convulsion, arachnoiditis, CSF leakage, allergic reactions, bleeding, and infection. Therefore,
myelography should only be considered when CT and MRI are unavailable, for morbidly obese or
multiple-operated patients, and when other tests prove non-diagnostic in the surgical candidate. The use
of small needles and a less toxic, water-soluble, nonionic contrast is preferred.
f. CT Myelogram
CT myelogram provides more detailed information about relationships between neural elements and
surrounding anatomy and is appropriate in patients with multiple prior operations or tumorous conditions.
g. Electrodiagnostic Studies (EMG/NCV)
Electrodiagnostic studies include, but are not limited to, electromyography (EMG) and nerve conduction
studies (NCS). These are generally accepted, well established, and widely used diagnostic procedures.
Electrodiagnostic studies may be useful in the evaluation of patients with suspected radiculopathy.
h. Other Radionuclide Scanning
Indium and gallium scans are generally accepted, well established, and widely used procedures usually to
help diagnose lesions seen on other diagnostic imaging studies. 67Gallium citrate scans are used to
localize tumor, infection, and abcesses. 111Indium-labeled leukocyte scanning is utilized for localization of
infection or inflammation.
2. Other Tests
The following studies are listed by frequency of use, not importance:
a. Personality/Psychological/Psychosocial/Evaluation
Personality/psychological/psychosocial evaluations are generally accepted and well-established
diagnostic procedures with selective use in the acute low back pain population, but have more
widespread use in sub-acute and chronic low back pain populations.
Diagnostic testing procedures may be useful for patients with symptoms of depression, delayed recovery,
chronic pain, recurrent painful conditions, disability problems, and for pre-operative evaluation as well as
a possible predictive value for post-operative response. Psychological testing should provide
differentiation between pre-existing depression versus injury-caused depression, as well as posttraumatic stress disorder.
Formal psychological or psychosocial evaluation should be performed on patients not making expected
progress within 6–12 weeks following injury and whose subjective symptoms do not correlate with
objective signs and tests. In addition to the customary initial exam, the evaluation of the injured worker
should specifically address the following areas:
1) Employment history;
2) Interpersonal relationships — both social and work;
3) Leisure activities;
4) Current perception of the medical system;
5) Results of current treatment;
6) Perceived locus of control; and
7) Childhood history, including abuse and family history of disability.
Results should provide clinicians with a better understanding of the patient, thus allowing for more
effective rehabilitation. The evaluation will determine the need for further psychosocial interventions, and
in those cases, a DSM IV diagnosis should be determined and documented.
An individual with a PhD, PsyD, or Psychiatric MD/DO credentials may perform initial evaluations, which
are generally completed within one to two hours. When issues of chronic pain are identified, the
evaluation should be more extensive and follow testing procedures as outlined in Division Rule XVII,
Exhibit F, Chronic Pain Disorder Medical Treatment Guideline.
(1) Frequency: One time visit for evaluation. If psychometric testing is indicated as a portion of the initial
evaluation, time for such testing should not exceed an additional two hours of professional time.
b. Electrodiagnostic Testing
Electrodiagnostic tests include, but are not limited to, Electromyography (EMG), Nerve Conduction
Studies (NCS), and Somatosensory Evoked Potentials (SSEP). These are generally accepted, wellestablished and widely used diagnostic procedures. The SSEP study, although it is generally accepted,
has limited use. Electrodiagnostic studies may be useful for patients with suspected neural involvement
whose symptoms are persistent or unresponsive to initial conservative treatments. They are used to
differentiate peripheral neural deficits from radicular and spinal cord neural deficits and to rule out
concomitant myopathy. Current Perception Threshold Evaluation (CPT) may be useful as a screening
tool, but its diagnostic efficacy in the evaluation of industrial low back pain has not been determined.
In general, these diagnostic procedures are complementary to imaging procedures such as CT, MRI,
and/or myelography or diagnostic injection procedures. Electrodiagnostic studies may provide useful,
correlative neuropathophysiological information that would be otherwise unobtainable from the standard
radiologic studies discussed above.
c. Injections — Diagnostic
1) Description — Diagnostic spinal injections are generally accepted, well-established procedures. These
injections may be useful for localizing the source of pain, and may have added therapeutic value
when combined with injection of therapeutic medication(s). Each diagnostic injection has inherent
risk and risk versus benefit should always be evaluated when considering injection therapy. Since
these procedures are invasive, less invasive or non-invasive procedures should be considered
first. Selection of patients, choice of procedure, and localization of the level for injection should be
determined by clinical information indicating strong suspicion for pathologic condition(s) and the
source of pain symptoms.
The interpretation of the test result is primarily based upon pain response. The diagnostic significance of
the test result should be evaluated in conjunction with clinical information and the results of other
diagnostic procedures. Injections with local anesthetics of differing duration are required to confirm the
diagnosis of pain. In some cases, injections at multiple levels may be required to accurately diagnose low
back pain. Refer to “Injections – Therapeutic” for information on specific injections.
2) Special Requirements for Diagnostic Injections — Since fluoroscopic, arthrographic and/or CT
guidance during procedures is required to document technique and needle placement, an
experienced physician should perform the procedure. The subspecialty disciplines of the
physicians may be varied, including, but not limited to: anesthesiology, radiology, surgery, or
physiatry. The practitioner should have experience in ongoing injection training workshops
provided by organizations such as the International Spinal Injection Society (ISIS) and be
knowledgeable in radiation safety. In addition, practitioners should obtain fluoroscopy training and
radiation safety credentialing from their Departments of Radiology, as applicable.
3) Complications — General complications of diagnostic injections may include transient neurapraxia,
nerve injury, infection, headache, urinary retention, and vasovagal effects, as well as epidural
hematoma, permanent neurologic damage, dural perforation and CSF leakage, and spinal
meningeal abscess. Permanent paresis, anaphylaxis and arachnoiditis have been rarely reported
with the use of epidural steroids.
4) Contraindications — Absolute contraindications of diagnostic injections include: (a) bacterial infection –
systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions,
and (d) possible pregnancy. Relative contraindications of diagnostic injections may include: (a)
allergy to contrast, (b) poorly controlled Diabetes Mellitus or hypertension, (c) ASA/antiplatelet
therapy (drug may be held for 3 days prior to injection), and (d) shellfish allergy, if contrast to be
used.
5) Specific Diagnostic Injections — In general, relief should last for at least the duration of the local
anesthetic used and give significant relief of pain. Refer to “Injections – Therapeutic” for
information on specific therapeutic injections.
(a) Medial Branch Blocks are primarily diagnostic injections, used to determine whether a patient
is a candidate for facet rhizotomy.
(b) Transforaminal injections are useful in identifying spinal pathology and can require repeat
injections at multiple levels. When used for diagnosis, small amounts of local anesthetic
(with or without steroid) up to a total volume of 1.0 to 1.5 cc should be used to determine
the level of nerve root irritation. The relief should last for at least the duration of the local
anesthetic used and give significant relief of pain.
d. Discography
1) Description — Discography is a generally accepted, wellestablished invasive diagnostic procedure to
identify a discogenic source of pain for patients who are surgical candidates. Discography should
only be performed by physicians who are experienced and have been proctored in the technique.
2) Indications — Discography may be indicated when a patient has a history of unremitting low back pain
of greater than three months duration, with or without leg pain, which has been unresponsive to
all conservative interventions. A patient who does not desire surgical intervention is not a
candidate for an invasive non-therapeutic intervention, such as provocative discography.
Discography may prove useful for the evaluation of the presurgical spine, such as
pseudoarthrosis, discogenic pain at levels above or below a prior spinal fusion, annular tear, or
internal disc disruption. Discography is not useful in previously operated discs. In addition,
discography may prove useful in evaluation of the number of lumbar spine levels that might
require fusion. It has also been utilized to differentiate organic from psychogenic factors. CTDiscography provides further detailed information about morphological abnormalities of the disc
and possible lateral disc herniations.
3) Preconditions for provocative discography include:
(a) A patient with unremitting back and/or leg pain greater than 3 months duration in whom
conservative treatment has been unsuccessful and in whom the specific diagnosis of the
pain generator has not been made apparent on the basis of other noninvasive imaging
studies (e.g., MRI, CT, plain films, etc.) and in whom a psychosocial evaluation has been
considered.
(b) Patients who are considered surgical candidates (e.g., symptoms are of sufficient magnitude
and the patient has been informed of the possible surgical options that may be available
based upon the results of discography). Discography should never be the sole indication
for surgery.
(c) Informed consent regarding the risks and potential diagnostic benefits of discography has
been obtained.
4) Complications — Complications include, but are not limited to, discitis, nerve damage, chemical
meningitis, pain exacerbation and anaphylaxis may occur with discography. Therefore, prior to
consideration of discography, the patient should undergo other diagnostic modalities in an effort
to define the etiology of the patient's complaint including psychological screening, myelography,
CT and MRI.
5) Contraindications — Contraindications for provocative discography may include: (a) active infection of
any type or continuing antibiotic treatment for infection; and/or (b) bleeding diathesis or
pharmaceutical anticoagulation with warfarin, etc.; and/or (c) significant spinal stenosis at the
level being studied as visualized by MRI, myelography or CT scan; and/or (d) presence of clinical
myelopathy; and/or (e) effacement of the cord, thecal sac or circumferential absence of epidural
fat; and (f) known allergic reactions.
6) Special Considerations:
(a) Discography should not be done by the treating surgeon, and the procedure should be
carried out by an experienced individual who has received specialized training in the
technique of provocative discography.
(b) Discography should be performed in a blinded format that avoids leading the patient with
anticipated responses. The procedure should always include one or more disc levels
thought to be normal or nonpainful in order to serve as an internal control. The patient
should not know what level is being injected in order to avoid spurious results.
(c) Sterile technique should be utilized.
(d) Judicious use of sedation during the procedure is acceptable and represents the most
common practice nationally at the current time and is recommended by most experts in
the field.
(e) CT or MRI must have established spinal dimensions and ruled out spinal stenosis.
(f) Intradiscal injection of local anesthetic should be carried out after the provocative portion of
the examination and the patient's response.
(g) It is recommended that a post-discogram CT be considered as it frequently provides
additional useful information about disc morphology or other pathology.
7) Reporting of Discography—In addition to a narrative report, the discography report should contain a
standardized classification of (a) disc morphology and (b) the pain response. Both results should
be clearly separated in the report from the narrative portion. Asymptomatic annular tears are
common and the concordant pain response is an essential finding for a positive discogram.
Alternative reporting techniques using pressure monitors are being investigated and may prove
useful in identifying patients with discogenic pain.
Caution should be used when interpreting results from discography. In one study of patients
without lumbar pathology, 10 percent of pain free patients experienced pain with discography and
83 percent of patients with somatization disorder experienced pain with lumbar discography.
(a) Reporting disc morphology as visualized by the postinjection CT scan (when
available) should follow the Modified Dallas Discogram Scale where:
Grade 0 = Normal Nucleus
Grade 1 = Annular tear confined to inner one-third of annulus fibrosis.
Grade 2 = Annular tear extending to the middle third of the annulus fibrosis.
Grade 3 = Annular tear extending to the outer one-third of the annulus fibrosis.
Grade 4 = A grade 3 tear plus dissection within the outer annulus to involve more
than 30 degrees of the disc circumference.
Grade 5 = Full thickness tear with extra-annular leakage of contrast, either focal
or diffuse.
(b) Reporting of pain response should be according to the modified Aprill Scheme. In this
scheme, codes are assigned a response during the initial injection (“P”
provocative response) and the response to an injection of the local anesthetic
(“R” response) where:
P0 = No Pain
P1 = Procedural pain, or pain that is nonconcordant with the patient's familiar pain
P2 = Concordant pain
R0 = No pain relief with injection of local anesthetic
R1 = Partial relief
R2 = Complete relief
N = Nondiagnostic, nonphysiologic injection. The final category of “N” is
suggested when the discographer concludes that the provocative portion of the
injection is nondiagnostic. For example, a patient with a morphologically normal
disc who responds when typical pain is reproduced is considered to have a nondiagnostic or nonphysiologic response. Other circumstances may occur that
cause the discographer to conclude that the provocative portion of the injection is
invalid. The category “N” should be used for these situations.
(1) Time to produce effect: Immediate
(2) Frequency: One time only
(3) Optimal duration: One time
(4) Maximum duration: Repeat discography is rarely indicated.
e. Thermography
Thermography is an accepted and established procedure, but has limited use as a diagnostic test for low
back pain. It may be used to diagnose regional pain disorders and in these cases, refer to Division Rule
XVII, Exhibit D, Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome Medical Treatment
Guidelines.
3. Special Tests
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 physical work demand classifications
and tolerance.
a. Computer-Enhanced Evaluations
Computer-enhanced evaluations may include isotonic, isometric, isokinetic and/or isoinertial
measurement of movement, range of motion, 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.
(1) Frequency: One time for evaluation. Can monitor improvements in strength every 3 to 4 weeks up to
a total of 6 evaluations.
b. Functional Capacity Evaluation (FCE)
Functional capacity evaluation is a comprehensive or modified evaluation of the various aspects of
function as they relate to the worker's ability to return to work. Areas such as endurance, lifting (dynamic
and static), postural tolerance, specific range of motion, coordination and strength, worker habits,
employability and financial status, as well as psychosocial aspects of competitive employment may be
evaluated. Components of this evaluation may include: (a) musculoskeletal screen; (b) cardiovascular
profile/aerobic capacity; (c) coordination; (d) lift/carrying analysis; (e) job-specific activity tolerance; (f)
maximum voluntary effort; (g) pain assessment/psychological screening; and (h) non-material and
material handling activities.
(1) Frequency: Can be used initially to determine baseline status. Additional evaluations can be
performed to monitor and assess progress and aid in determining the endpoint for treatment.
c. Jobsite Evaluation
Jobsite evaluation is a comprehensive analysis of the physical, mental and sensory components of a
specific job. These components may include, but are not limited to: (a) postural tolerance (static and
dynamic); (b) aerobic requirements; (c) range of motion; (d) torque/force; (e) lifting/carrying; (f) cognitive
demands; (g) social interactions; (h) visual perceptual; (i) environmental requirements of a job; (j)
repetitiveness; and (k) essential functions of a job. Job descriptions provided by the employer are helpful
but should not be used as a substitute for direct observation.
(1) Frequency: One time with additional visits as needed for follow-up per job site.
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 should not be delayed solely due to lack of attainment of a
vocational assessment.
(1) Frequency: One time with additional visits as needed for follow-up.
e. Work Tolerance Screening
Work tolerance screening is a determination of an individual's tolerance for performing a specific job as
based on a job activity or task. It may include a test or procedure to specifically identify and quantify workrelevant cardiovascular, physical fitness and postural tolerance. It may also address ergonomic issues
affecting the patient's return-to-work potential. May be used when a full Functional Capacity Evaluation is
not indicated.
(1) Frequency: One time for evaluation. May monitor improvements in strength every 3 to 4 weeks up to
a total of 6 evaluations.
E. THERAPEUTIC PROCEDURES — NON-OPERATIVE
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 selfmanagement of symptoms.
Lastly, formal psychological or psychosocial screening should be performed on patients not making
expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate
with objective signs and tests.
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.
Non-operative treatment procedures for low back pain can be divided into two groups: conservative care
and rehabilitation. Conservative care is treatment applied to a problem in which spontaneous
improvement is expected in 90% of the cases within three months. It is usually provided during the tissuehealing phase and lasts no more than six months, and often considerably less. Rehabilitation is treatment
applied to a more chronic and complex problem in a patient with deconditioning and disability. It is
provided during the period after tissue healing to obtain maximal medical recovery. Treatment modalities
may be utilized sequentially or concomitantly depending on chronicity and complexity of the problem, and
treatment plans should always be based on a diagnosis utilizing appropriate diagnostic procedures.
The following procedures are listed in alphabetical order.
1. Acupuncture
Acupuncture is an accepted and widely used procedure for the relief of pain and inflammation and there is
some scientific evidence to support its use. The exact mode of action is only partially understood.
Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the
brain, promotes deep relaxation, and affects the release of neurotransmitters. Acupuncture is commonly
used as an alternative or in addition to traditional Western pharmaceuticals. While it is commonly used
when pain medication is reduced or not tolerated, it may be used as an adjunct to physical rehabilitation
and/or surgical intervention to hasten the return of functional activity. Acupuncture should be performed by
credentialed practitioners.
a. Acupuncture
Acupuncture is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points).
Needles may be inserted, manipulated and retained for a period of time. Acupuncture can be used to
reduce pain, reduce inflammation, increase blood flow, increase range of motion, decrease the side effect
of medication-induced nausea, promote relaxation in an anxious patient, and reduce muscle spasm.
Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical
pain relief, muscle spasm, and scar tissue pain.
(1) Time to produce effect: 3 to 6 treatments
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 1 to 2 months
(4) Maximum duration: 14 treatments
b. Acupuncture with Electrical Stimulation
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.
(1) Time to produce effect: 3 to 6 treatments
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 1 to 2 months
(4) Maximum duration: 14 treatments
c. Other Acupuncture Modalities
Acupuncture treatment is based on individual patient needs and therefore treatment may include a
combination of procedures to enhance treatment effect. Other procedures may include the use of heat,
soft tissue manipulation/massage, and exercise. Refer to Active Therapy (Therapeutic Exercise) and
Passive Therapy sections (Massage and Superficial Heat and Cold Therapy) for a description of these
adjunctive acupuncture modalities.
(1) Time to produce effect: 3 to 6 treatments
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 1 to 2 months
(4) Maximum 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 treatments must be documented with respect to need and ability to facilitate
positive symptomatic or functional gains. Such care should be re-evaluated and documented with each
series of treatments.
2. Biofeedback
Biofeedback 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.
(1) Time to produce effect: 3 to 4 sessions
(2) Frequency: 1 to 2 times per week
(3) Optimum duration: 5 to 6 sessions
(4) 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.
3. Injections — Therapeutic
a. Therapeutic Spinal Injections
Description — Therapeutic spinal injections, which include epidural steroid and facet injections, are
generally accepted, well-established procedures. They may be used after initial conservative treatment,
such as physical and occupational therapy, medication, manual therapy, exercise, acupuncture etc., has
been undertaken. Therapeutic injections should be used only after pathology has been demonstrated.
Injections are invasive procedures that can cause serious complications thus clinical indications and
contraindications should be closely adhered to. It is recommended that all patients have an appropriate
exercise program that may include a functionally directed rehabilitation program.
Special Considerations — For all injections (excluding trigger point) fluoroscopic, arthrographic and/or CT
guidance during procedures is recommended to document technique and needle placement, and should
be performed by a physician experienced in the procedure. The subspecialty disciplines of the physicians
may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry. The
practitioner should participation in ongoing injection training workshops such as those sponsored by
International Society for Injection Studies (ISIS) and be knowledgeable in radiation safety. In addition,
practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments
of Radiology, as applicable.
Complications — General complications of spinal injections may include (a) transient neurapraxia, local
pain, nerve injury, infection, headache, urinary retention and vasovagal effects; (b) epidural hematoma,
permanent neuralgic damage, dural perforation and CSF leakage, spinal meningeal abscess; and or (c)
suppression of the hypothalamic pituitary adrenal axis, which may be steroid dose dependent. Permanent
paresis, anaphylaxis and arachnoiditis have been rarely reported with the use of epidural steroids.
Contraindications — Absolute contraindications of diagnostic injections include: (a) bacterial infectionsystemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d)
possible pregnancy. Relative contraindications of diagnostic injections may include: (a) allergy to contrast,
(b) poorly controlled Diabetes Mellitus or hypertension, (c) ASA/antiplatelet therapy (drug may be held for
3 days prior to injection), (d) shellfish allergy, if contrast to be used.
1) Epidural Steroid Injection (ESI)
(a) Description — Epidural steroid injections are injections of corticosteroid into the epidural space. The
purpose of ESI is to reduce pain and inflammation, restoring range of motion and thereby
facilitating progress in more active treatment programs. ESI use three approaches: transforminal,
translaminar (midline), and caudal. There is good evidence to support a preference for a
transforaminal approach. The evidence also suggests that the transforaminal approach can
deliver medication to the target tissue with few complications and is therefore used to identify the
specific site of pathology. This is also the preferred approach for post-surgical patients.
(b) Needle Placement — Spinal imaging is required for all transforaminal epidural steroid injections.
Since injections performed without radiographic guidance result in an increased risk of incorrect
needle placement, spinal imaging is recommended for caudal and translaminar injections if
available within 30 miles of the patient's home. Contrast epidurograms allow one to verify the flow
of medication into the epidural space.
(c) Indications — There is some evidence that epidural steroid injections are effective for patients with
radicular pain or radiculopathy (sensory or motor loss in a specific dermatome or myotome).
Although there is no evidence regarding the effectiveness of ESI for non-radicular pain, it is a
generally accepted intervention. Selected cases of vertebral compression fracture may be helped
by ESI.
(1) Time to produce effect: Local anesthetic, approximately 30 minutes; corticosteroid, 48 to 72
hours for 80% of patients and 2 weeks for 20%.
(2) Frequency: One or more divided levels can be injected in one session. Whether injections are
repeated depends upon the patient's response to the previous injection session.
Subsequent injection sessions may occur after 1 to 2 weeks if patient response has been
favorable. Injections can be repeated after a hiatus of three months if the patient has
demonstrated functional gain and pain returns or worsens. If ESIs are repeated in the
future, there should be increasing duration of relief and continued functional gain.
(3) Optimum duration: Usually 1 to 3 sessions of injection(s), depending upon each patient's
response and functional gain.
(4) Maximum duration: Up to 3 to 4 sessions of injections may be done as per the patient's
response to pain and function. Patients should be reassessed after each injection
session.
2) Zygoapophyseal (Facet) Injection
(a) Description — Intra-articular or pericapsular injection of local anesthetic and corticosteroid. Medial
branch nerve blocks are diagnostic only. There is conflicting evidence to support a long-term
therapeutic effect using facet injections.
(b) Indications — Facet injections may be considered in those patients whose history and examination
are suggestive of a facet pain generator. Lumbar facet injections are primarily of diagnostic value.
The therapeutic value of facet injections provides short-term pain relief for patients to progress
through a functionally directed rehabilitation program. These injections are useful when used in
conjunction with Manipulation Under Joint Anesthesia (MUJA). Facet injections determine level(s)
of lumbar facet involvement and the degree of pain coming from the posterior elements. Facet
injections may help determine the best therapeutic exercise approach (i.e., lumbar stabilization
vs. sacroiliac stabilization).
(1) Time to produce effect: Approximately 30 minutes for local anesthetic; 48 to 72 hours for
corticosteroid.
(2) Frequency: 1 to 3 sessions for each joint.
(3) Optimum duration: 1 to 3 sessions of injections for each joint.
(4) Maximum duration: 3 intra-synovial or medial branch nerve injections per joint can be done
for facilitating a therapeutic exercise program.
b. Facet Rhizotomy (Radio Frequency Medial Branch Neurotomy)
(a) Description — A procedure designed to denervate the facet joint by ablating the periarticular facet
nerve branches. Percutaneous radiofrequency is the method generally used. There is good
evidence to support this procedure in the cervical spine but benefits beyond one year are not yet
established. Evidence in the lumbar spine is conflicting, however, the procedure is generally
accepted.
(b) Indications — Pain of well-documented facet origin, unresponsive to active and/or passive therapy,
unresponsive to manual therapy, and in which a psychosocial evaluation has been performed.
This procedure is commonly used to provide a window of pain relief allowing for participation in
active therapy. All patients must have a successful response to diagnostic medial nerve branch
blocks. A successful response is considered to be a 90 percent or greater relief of pain for the
length of time appropriate to the local anesthetic used (i.e., bupivacaine greater than lidocaine).
Radio-frequency rhizotomy is the procedure of choice over alcohol, phenol, or cryoablation.
Precise positioning of the probe using fluoroscopic guidance is recommended since the maximum
effective radius of the device is 2 milimeters.
(c) Complications — Bleeding, infection, or neural injury. The clinician must be aware of the risk of
developing a deafferentation centralized pain syndrome as a complication of this and other
neuroablative procedures.
(d) Post-Procedure Therapy — Active active and/or passive therapy. Implementation of a gentle aerobic
reconditioning program (e.g., walking) and back education within the first post-procedure week,
barring complications. Instruction and participation in a long-term home-based program of ROM,
strengthening, endurance and stability exercises should be done 3 to 4 weeks post-procedure.
c. Sacroiliac Joint Injection
(a) Description — Injection of local anesthetic in an intra-articular fashion into the sacroiliac joint under
radiographic guidance. May include the use of corticosteroids. Long-term therapeutic effect has
not yet been established.
(b) Indications — Primarily diagnostic to rule out sacroiliac joint dysfunction vs. other pain generators.
Intra-articular injection can be of value in diagnosing the pain generator. There should be
documented relief from previously painful maneuvers (e.g., Patrick's test) on post-injection
physical exam. Therapeutic response varies. Sacroiliac joint blocks may facilitate functionally
directed rehabilitation program.
(1) Time to produce effect: Approximately 30 minutes for local anesthetic; 48 to 72 hours for
corticosteroid.
(2) Frequency: 1 to 3 sessions of injections.
(3) Optimum duration: 1 to 3 sessions.
(4) Maximum duration: 3 sessions of injections. Once diagnosis has been documented by
intrajoint injection, posterior ligament block may be as effective as intra-joint injection for
therapeutic value unless the primary pain is coming from an anterior capsular pain
generator.
d. Trigger Point Injections
(a) Description — Trigger point injection consists of dry needling or injection of local anesthetic with or
without corticosteroid into highly localized, extremely sensitive bands of skeletal muscle fibers
that produce local and referred pain when activated. Medication is injected in a four-quadrant
manner in the area of maximum tenderness. Injection efficacy can be enhanced if injections are
immediately followed by myofascial therapeutic interventions, such as vapo-coolant spray and
stretch, ischemic pressure massage (myotherapy), specific soft tissue mobilization and physical
modalities. The effectiveness of trigger point injection is uncertain, in part due to the difficulty of
demonstrating advantages of active medication over injection of saline. Needling alone may be
responsible for some of the therapeutic response.
(b) Indications — Trigger point injections may be used to relieve myofascial pain and facilitate active
therapy and stretching of the affected areas. They are to be used as an adjunctive treatment in
combination with other treatment modalities such as functional restoration programs. Trigger point
injections should be utilized primarily for the purpose of facilitating functional progress. Patients
should continue in an aggressive aerobic and stretching therapeutic exercise program as
tolerated throughout the time period they are undergoing intensive myofascial interventions.
Myofascial pain is often associated with other underlying structural problems and any
abnormalities need to be ruled out prior to injection.
Trigger point injections are indicated in those patients where well circumscribed trigger points
have been consistently observed, demonstrating a local twitch response characteristic radiation
of pain pattern and local autonomic reaction, such as persistent hyperemia following palpation.
Generally, these injections are not necessary unless consistently observed trigger points are not
responding to specific, noninvasive, myofascial interventions within approximately a 6 week time
frame. However, trigger point injections may be occasionally effective when utilized in the patient
with immediate, acute onset of low back pain.
(c) Complications — Potential but rare complications of trigger point injections include infection,
pneumothorax, anaphylaxis, penetration of viscera, neurapraxia and neuropathy. If corticosteroids
are injected in addition to local anesthetic, there is a risk of local myopathy developing. Severe
pain on injection suggests the possibility of an intraneural injection, and the needle should be
immediately repositioned.
(1) Time to produce effect: Local anesthetic 30 minutes; 24 to 48 hours for no anesthesia.
(2) Frequency: Weekly. Suggest no more than 4 injection sites per session per week to avoid
significant post-injection soreness.
(3) Optimum duration: 4 Weeks.
(4) Maximum duration: 8 weeks. Occasional patients may require 2 to 4 repetitions of trigger
point injection series over a 1 to 2 year period.
e. Prolotherapy
Prolotherapy, also known as sclerotherapy, consists of a series of injections of hypertonic dextrose, with
or without glycerine and phenol, into the ligamentous structures of the low back. Its proponents claim that
the inflammatory response to the injections will recruit cytokine growth factors involved in the proliferation
of connective tissue, stabilizing the ligaments of the low back when these structures have been damaged
by mechanical insults.
There are conflicting studies concerning the effectiveness of prolotherapy in the low back. Lasting
functional improvement has not been shown. The injections are invasive, may be painful to the patient,
are not generally accepted or widely used. Therefore, the use of prolotherapy for low back pain is not
recommended.
f. Sympathetic Injections
Refer to Division Rule XVII, Exhibit D, Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome
Medical Treatment Guideline for specific information regarding the use of these injections.
4. Medications
Medication use in the treatment of low back injuries is appropriate for controlling acute and chronic pain
and inflammation. Use of medications will vary widely due to the spectrum of injuries from simple strains
to post-surgical healing. All drugs should be used according to patient needs. A thorough medication
history, including use of alternative and over the counter medications, should be performed at the time of
the initial visit and updated periodically.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are useful in the treatment of
inflammation. These same medications can be used for pain control.
Narcotic medications should be prescribed with strict time, quantity and duration guidelines, and with
definitive cessation parameters. Pain is subjective in nature and should be evaluated using a scale to rate
effectiveness of the narcotic prescribed. Other medications, including antidepressants, may be useful in
selected patients with chronic pain. Tramadol, a centrally acting non-narcotic, can be useful to provide
pain relief. Other medications, including antidepressants, may be useful in selected patients with chronic
pain.
Topical agents may be beneficial in the management of localized low back pain.
The following are listed in alphabetical order:
a. Acetaminophen
Acetaminophen is an effective analgesic with antipyretic but not anti-inflammatory activity. Acetaminophen
is generally well tolerated, causes little or no gastrointestinal irritation and is not associated with ulcer
formation. Acetaminophen has been associated with liver toxicity in overdose situations or in chronic
alcohol use.
(1) Optimum duration: 7 to 10 days.
(2) Maximum duration: Chronic use as indicated on a case-by-case basis.
b. Minor Tranquilizer/Muscle Relaxants
Minor tranquilizer/muscle relaxants are appropriate for muscle spasm, mild pain and sleep disorders.
(1) Optimum duration: 1 week.
(2) Maximum duration: 4 weeks.
c. Narcotics
Narcotics should be primarily reserved for the treatment of severe low back pain. There are
circumstances where prolonged use of narcotics is justified based upon specific diagnosis, and in these
cases, it should be documented and justified. In mild to moderate cases of low back pain, narcotic
medication should be used cautiously on a case-by-case basis. Adverse effects include respiratory
depression, the development of physical and psychological dependence, and impaired alertness.
(1) Optimum duration: 3 to 7 days.
(2) Maximum duration: 2 weeks. Use beyond two weeks is acceptable in appropriate cases.
d. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs are useful for pain and inflammation. In mild cases, they may be the only drugs required for
analgesia. There are several classes of NSAIDs, and the response of the individual injured worker to a
specific medication is unpredictable. For this reason, a range of NSAIDs may be tried in each case with
the most effective preparation being continued. Patients should be closely monitored for adverse
reactions. Intervals for metabolic screening are dependent upon the patient's age, general health status
and should be within parameters listed for each specific medication. Liver and renal function should be
monitored at least every six months in patients on chronic NSAIDs.
1) Selective Nonsteroidal Anti-Inflammatory Drugs
Includes Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and acetylsalicylic acid (aspirin). Serious GI
toxicity, such as bleeding, perforation, and ulceration can occur at any time, with or without warning
symptoms in patients treated with traditional NSAIDs. Physicians should inform patients about the signs
and/or symptoms of serious gastrointestinal toxicity and what steps to take if they occur. Anaphylactoid
reactions may occur in patients taking NSAIDs. NSAIDs may interfere with platelet function. Fluid
retention and edema have been observed in some patients taking NSAIDs.
Due to the cross-reactivity between aspirin and NSAIDs, NSAIDs should not be used in aspirin-sensitive
patients, and should be used with caution in all asthma patients. NSAIDs are associated with abnormal
renal function, including renal failure, as well as abnormal liver function. Certain NSAIDs may have
interactions with various other medications. Individuals may have adverse events not listed above.
(1) Optimal duration: 1 week
(2) Maximum duration: 1 year
2) Selective Cyclo-oxygenase-2 (COX-2) Inhibitors
Selective cyclo-oxygenase-2 (COX-2) inhibitors are more recent NSAIDs and differ in adverse side effect
profiles from the traditional NSAIDs. The major advantages of selective COX-2 inhibitors over traditional
NSAIDs are that they have less gastrointestinal toxicity and no platelet effect. COX-2 inhibitors can
worsen renal function in patients with renal insufficiency, thus renal function may need monitoring.
COX-2 inhibitors should not be first-line for low risk patients who will be using an NSAID short term but
are indicated in select patients whom traditional NSAIDs are not tolerated or in certain high-risk patients.
Patients most at risk of having a complication from traditional NSAIDs include patients with a prior history
of peptic ulcer disease, gastrointestinal bleeding, gastrointestinal perforation, or hemophilia, as well as
patients with thrombocytopenia or systemic anticoagulation. Celecoxib is FDA approved for osteoarthritis
and rheumatoid arthritis. Rofecoxib is FDA approved for acute pain and osteoarthritis. Celecoxib is
contraindicated in sulfonamide allergic patients.
(1) Optimal duration: 7 to 10 days
(2) Maximum duration: Chronic use is appropriate in individual cases.
e. Oral Steroids
Oral steroids have limited use but are accepted in cases requiring potent anti-inflammatory drug effect.
They have no proven benefit for patients with low back pain with or without radiculopathy and are not
recommended unless spinal cord compression is suspected. The risks of permanent neurological damage
from acute spinal cord compression generally outweigh the risks of pharmacologic side effects of steroids
in an emergent situation.
f. Psychotropic/Anti-anxiety/Hypnotic Agents
Psychotropic/anti-anxiety/hypnotic agents may be useful for treatment of mild and chronic pain,
dysesthesias, sleep disorders, and depression. Antidepressant medications, such as tricyclics and
Selective Serotonin Reuptake Inhibitors (SSRIs), are useful for affective disorder and chronic pain
management. Tricyclic antidepressant agents, in low dose, are useful for chronic pain but have more
frequent side effects.
Anti-anxiety medications are best used for short-term treatment (i.e., less than 6 months). Accompanying
sleep disorders are best treated with sedating antidepressants prior to bedtime. Frequently, combinations
of the above agents are useful. As a general rule, physicians should access the patient's prior history of
substance abuse or depression prior to prescribing any of these agents.
(1) Optimum duration: 1 to 6 months.
(2) Maximum duration: 6 to 12 months, with monitoring.
g. Tramadol
Tramadol is useful in relief of low back pain and has been shown to provide pain relief equivalent to that
of commonly prescribed NSAIDs. Although Tramadol may cause impaired alertness, it is generally well
tolerated, does not cause gastrointestinal ulceration, or exacerbate hypertension or congestive heart
failure. Tramadol should be used cautiously in patients who have a history of seizures or who are taking
medication that may lower the seizure threshold, such as MAO inhibiters, SSRIs, and tricyclic
antidepressants. This medication has physically addictive properties and withdrawal may follow abrupt
discontinuation and is not recommended for those with prior opoid addiction.
(1) Optimum duration: 3 to 7 days.
(2) Maximum duration: 2 weeks. Use beyond 2 weeks is acceptable in appropriate cases.
h. Topical Drug Delivery
Topical drug delivery may be an alternative treatment for localized musculoskeletal disorders and is an
acceptable form of treatment in selected patients although there is no scientific evidence to support its
use in low back pain. It is necessary that all topical agents be used with strict instructions for application
as well as maximum number of applications per day to obtain the desired benefit and avoid potential
toxicity. As with all medications, patient selection must be rigorous to select those patients with the
highest probability of compliance. Refer to “Iontophoresis” in the Passive Therapy section for information
regarding topical iontophoretic agents.
5. Occupational Rehabilitation Programs
a. 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.
1) Work Conditioning
These programs are usually initiated once reconditioning has been completed but may be offered at any
time throughout the recovery phase. It 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.
(1) Length of visit: 1 to 2 hours per day.
(2) Frequency: 2 to 5 visits per week
(3) Optimum duration: 2 to 4 weeks
(4) Maximum duration: 6 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.
2) Work Simulation
Work simulation is a program where an individual completes specific work-related tasks for a particular
job and return to work. Use of this program is appropriate when modified duty can only be partially
accommodated in the work place, when modified duty in the work place is unavailable, or when the
patient requires more structured supervision. The need for work place simulation should be based upon
the results of a Functional Capacity Evaluation and or Jobsite Analysis.
(1) Length of visit: 2 to 6 hours per day.
(2) Frequency: 2 to 5 visits per week
(3) Optimum duration: 2 to 4 weeks
(4) Maximum duration: 6 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.
b. Interdisciplinary
Interdisciplinary programs are characterized by a variety of disciplines that participate in the assessment,
planning, and/or implementation of an injured workers program with the goal for patients to gain full or
optimal function and return to work. There should be close interaction and integration among the
disciplines to ensure that all members of the team interact to achieve team goals. These programs are for
patients with greater levels of perceived disability, dysfunction, deconditioning and psychological
involvement. For patients with chronic pain, refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder
Medical Treatment Guideline.
1) Work Hardening
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,
psychological, behavioral, physical, functional, and vocational components of employability and return-towork.
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 therapy, physical therapy, case manager,
and psychologist. As appropriate, the team may also include: chiropractor, RN, or vocational specialist.
(1) Length of visit: Up to 8 hours/day.
(2) Frequency: 2 to 5 visits per week
(3) Optimum duration: 2 to 4 weeks
(4) Maximum duration: 6 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.
2) Spinal Cord Programs
Spinal Cord Systems of Care provide coordinated, case-managed, and integrated service for people with
spinal cord dysfunction, whether due to trauma or disease. The system includes an inpatient component
in an organization licensed as a hospital and an outpatient component. Each component endorses the
active participation and choice of the persons served throughout the entire program. The Spinal Cord
System of Care also provides or formally links with key components of care that address the lifelong
needs of the persons served.
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 and trained in rehabilitation, a case manager, occupational therapy,
physical therapy, psychologist, rehabilitation RN and MD, and therapeutic recreation specialist. As
appropriate, the team may also include: rehabilitation counselor, respiratory therapist, social worker, or
speech-language pathologist.
Timeframe durations for any spinal cord program should be determined based upon the extent of the
patient's injury and at the discretion of the rehabilitation physician in charge.
6. Orthotics
a. Foot Orthoses
Orthotics and inserts are a recognized and accepted intervention for spinal disorders that are due to
aggravated mechanical abnormalities, such as leg length discrepancy, scoliosis, or lower extremity
misalignment. Shoe insoles or inserts may be effective for patients with acute low back problems who
stand for prolonged periods of time.
b. Lumbosacral Bracing
Rigid Bracing Devices are well accepted and commonly used for post fusion, scoliosis, and vertebral
fractures.
Lumbar Support Devices include backrests for chairs and car seats. Lumbar supports may provide
symptomatic relief of pain and movement reduction in cases of chronic low back problems.
Lumbar Corsets and Back Belts may be useful in some cases. They are an accepted treatment with
limited application yet there is insufficient evidence to support the effectiveness of their use. The injured
worker should be advised of the potential harm from using a lumbar support for a period of time greater
than that which is prescribed. Harmful effects include deconditioning of the trunk musculature, skin
irritation and general discomfort.
7. Patient Education
No treatment plan is complete without addressing issues of individual and/or group patient 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 be encouraged to take an active role in the
establishment of function outcome goals. They should be educated on their specific injury, assessment
findings, and plan of treatment. Instruction on proper body mechanics and posture, positions to avoid,
self-care for exacerbation of symptoms, and home exercise should also be addressed.
(1) Time to produce effect: Varies with individual patient.
(2) Frequency: Should occur at every visit.
8. Personalitv/Psychological/Psychosocial Intervention
Psychosocial Psychosocial treatment is generally accepted, widely used and well established
intervention. This group of therapeutic and diagnostic modalities includes, but is not limited to, individual
counseling, group therapy, stress management, psychosocial crises intervention, hypnosis and
meditation. Any screening or diagnostic workup should clarify and distinguish between preexisting versus
aggravated versus purely causative psychological conditions. Psychosocial intervention is recommended
as an important component in the total management program that should be implemented as soon as the
problem is identified. This can be used alone or in conjunction with other treatment modalities. Providers
treating patients with chronic pain should refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder
Medical Treatment Guideline.
(1) Time to produce effect: 2 to 4 weeks.
(2) Frequency: 1 to 3 times weekly for the first 4 weeks (excluding hospitalization, if required), decreasing
to 1 to 2 times per week for the second month. Thereafter, 2 to 4 times monthly.
(3) Optimum duration: 6 weeks to 3 months
(4) Maximum duration: 3 to 12 months. Counseling is not intended to delay but to enhance functional
recovery. For select patients, longer supervised treatment may required, and if further counseling
beyond 3 months is indicated, documentation addressing which pertinent issues are preexisting
versus aggravated versus causative, as well as projecting a realistic functional prognosis, should
be provided by the authorized treating provider every 4 to 6 weeks during treatment.
9. Restriction of Activities
Continuation of normal daily activities is the recommendation for acute and chronic low back pain without
neurologic symptoms. There is good evidence against the use of bed rest in cases without neurologic
symptoms. Bed rest may lead to deconditioning and impair rehabilitation. Complete work cessation
should be avoided, if possible, since it often further aggravates the pain presentation. Modified return-towork is almost always more efficacious and rarely contraindicated in the vast majority of injured workers
with low back pain.
10. Return-to-Work
Early return-to-work should be a prime goal in treating occupational injuries given the poor return-to-work
prognosis for an injured worker who has been out of work for more than six months. It is imperative that
the patient be educated regarding the benefits of return-to-work, restrictions, and follow-up if problems
arise. When attempting to return a patient to work after a specific injury, clear objective restrictions of
activity level should be made. An accurate job description may be necessary to assist the physician in
making return-to-work recommendations.
Return-to-work is defined as any work or duty that the patient is able to perform safely, and it may not be
the patient's regular work. Due to the large spectrum of injuries of varying severity and varying physical
demands in the work place, it is not possible to make specific return-to-work guidelines for each injury.
Therefore, the Division recommends the following:
a. Establishment of a Return-To-Work Status
Ascertaining a return-to-work status is part of medical care, should be included in the treatment and
rehabilitation plan, and addressed at every visit. A description of daily activity limitations is part of any
treatment plan and should be the basis for restriction of work activities. In most non-surgical cases, the
patient should be able to return to work in some capacity or in an alternate position consistent with
medical treatment within several days unless there are extenuating circumstances. Injuries requiring more
than two weeks off work should be thoroughly documented.
b. Establishment of Activity Level Restrictions
Communication is essential between the patient, employer and provider to determine appropriate
restrictions and return-to-work dates. It is the responsibility of the physician to provide clear concise
restrictions, and it the employer's responsibility to determine if temporary duties can be provided within
the restrictions. For low back pain injuries, the following should be addressed when describing the
patient's activity level:
1) Lower body postures such as squatting, kneeling, crawling, stooping, or climbing should include
duration and frequency.
2) Ambulatory level for distance, frequency and terrain should be specified.
3) Standing duration and frequency with regard to balance issues.
4) Use of adaptive devices or equipment for proper office ergonomics to enhance capacities can be
included.
c. Compliance with Activity Restrictions.
In some cases, compliance with restriction of activity levels may require a complete jobsite evaluation, a
functional capacity evaluation (FCE), or other special testing. Refer to the “Special Tests” section of this
guideline.
11. Therapy — Active
The following active therapies have some evidence to support their use and are widely used and
accepted methods of care for a variety of work-related injuries. They are based on the philosophy that
therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function,
range of motion, and can alleviate discomfort. Active therapy requires an internal effort by the individual to
complete a specific exercise or task. This form of therapy requires supervision from a therapist or medical
provider such as verbal, visual and/or tactile instruction(s). At times, the provider may help stabilize the
patient or guide the movement pattern but the energy required to complete the task is predominately
executed by the patient.
Patients should be instructed to continue active therapies at home as an extension of the treatment
process in order to maintain improvement levels. Home exercise can include exercise with or without
mechanical assistance or resistance and functional activities with assistive devices.
The following active therapies are listed in alphabetical order:
a. Activities of Daily Living (ADL)
Activities of daily living are instruction, active-assisted training and/or adaptation of activities or equipment
to improve a person's capacity in normal daily activities such as self-care, work re-integration training,
homemaking and driving.
(1) Time to produce effect: 4 to 5 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 weeks
b. Aquatic Therapy
Aquatic therapy is 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 affect allows the patient to have a mechanical advantage and more likely have a
successful trial of therapeutic exercise. Aquatic vests or belts can be used to provide stability and balance
in the water. Indications are for individuals who cannot tolerate active land-based or full-weight bearing
therapeutic procedures. The pool should be large enough to allow full extremity range of motion and fully
erect posture. Aquatic vests, belts and other devices and be used to provide stability, balance, buoyancy,
and resistance.
(1) Time to produce effect: 4 to 5 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 weeks
c. Functional Activities
Functional activities are the use of therapeutic activity to enhance mobility, body mechanics,
employability, coordination, and sensory motor integration.
(1) Time to produce effect: 4 to 5 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 weeks
d. Functional Electrical Stimulation
Functional electrical stimulation is the application of electrical current to elicit involuntary or assisted
contractions of atrophied and/or impaired muscles. Indications include muscle atrophy, weakness, and
sluggish muscle contraction secondary to pain, injury, neuromuscular dysfunction, peripheral nerve lesion,
or radicular symptoms.
(1) Time to produce effect: 2 to 6 treatments
(2) Frequency: 3 times per week
(3) Optimum duration: 8 weeks.
(4) Maximum duration: 8 weeks. If beneficial, provide with home unit.
e. Lumbar Stabilization
Lumbar stabilization is a therapeutic program whose goal is to strengthen the spine in its neural and
anatomic position. The stabilization is dynamic which allows whole body movements while maintaining a
stabilized spine. It is the ability to move and function normally through postures and activities without
creating undue vertebral stress.
(1) Time to produce effect: 4 to 8 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 4 to 8 weeks
(4) Maximum duration: 8 weeks
f. Neuromuscular Re-Education
Neuromuscular 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.
(1) Time to produce effect: 2 to 6 treatments
(2) Frequency: 3 times per week
(3) Optimum duration: 4 to 8 weeks
(4) Maximum duration: 8 weeks
g. Therapeutic Exercise
Therapeutic exercise, with or without mechanical assistance or resistance, may include isoinertial,
isotonic, isometric and isokinetic types of exercises. Indications include the need for cardiovascular
fitness, reduced edema, improved muscle strength, improved connective tissue strength and integrity,
increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle
recruitment, increased range-of-motion and are used to promote normal movement patterns. Can also
include complementary/alternative exercise movement therapy.
(1) Time to produce effect: 2 to 6 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 4 to 8 weeks
(4) Maximum duration: 8 weeks
12. Therapy — Passive
Most of the following passive therapies and modalities are generally accepted methods of care for a
variety of work-related injuries. Passive therapy includes those treatment modalities that do not require
energy expenditure on the part of the patient. They are principally effective during the early phases of
treatment and are directed at controlling symptoms such as pain, inflammation and swelling and to
improve the rate of healing soft tissue injuries. They should be use adjunctively 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.
While protocols for specific diagnoses and post-surgical conditions may warrant durations of treatment
beyond those listed as “maximum,” factors such as exacerbation of symptoms, re-injury, interrupted
continuity of care, and comorbidities may extend durations of care. Having specific goals with objectively
measured functional improvement during treatment can support extended durations of care. It is
recommended that if after 6 to 8 visits no treatment effect is observed, alternative treatment interventions,
further diagnostic studies or further consultations should be pursued.
The following passive therapies are listed in alphabetical order:
a. Electrical Stimulation (Unattended)
Electrical stimulation, once applied, requires minimal on-site supervision by the physical or nonphysical
provider. Indications include pain, inflammation, muscle spasm, atrophy, decreased circulation, and the
need for osteogenic stimulation.
(1) Time to produce effect: 2 to 4 treatments
(2) Frequency: Varies, depending upon indication, between 2 to 3 times/day to 1 time/week. Provide
home unit if frequent use.
(3) Optimum duration: 1 to 3 months
(4) Maximum duration: 3 months
b. Infrared Therapy
Infrared therapy is a radiant form of heat application. Indications include the need to elevate the pain
threshold before exercise and to alleviate muscle spasm to promote increased movement.
(1) Time to produce effect: 2 to 4 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 3 weeks as primary, or intermittently as an adjunct to other therapeutic procedures
up to 2 months.
(4) Maximum duration: 2 months
c. Iontophoresis
Iontophoresis 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).
(1) Time to produce effect: 1 to 4 treatments
(2) Frequency: 3 times per week with at least 48 hours between treatments
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 weeks
d. Manipulation
Manipulation is a generally accepted, well-established and widely used therapeutic intervention for low
back pain. Manipulation can include high velocity, low amplitude (HVLA) technique, chiropractic
manipulation, osteopathic manipulation, muscle energy techniques and non-force techniques. It is
performed by taking a joint to its end range of motion and moving the articulation into the zone of
accessory joint movement, well within the limits of anatomical integrity.
There is good scientific evidence to suggest that manipulation can be helpful for patients with acute low
back pain problems without radiculopathy when used within the first 4 to 6 weeks of symptoms. Although
the evidence for sub-acute and chronic low back pain and low back pain with radiculopathy is less
convincing, it is a generally accepted and well established intervention for these conditions. Indications for
manipulation include joint pain, decreased joint motion and joint adhesions. Contraindications include joint
instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthridites,
aortic aneurysm, and signs of progressive neurologic deficits.
(1) Time to produce effect: 1 to 6 treatments.
(2) Frequency: 1 to 5 times per week for the first 2 weeks as indicated by the severity of involvement and
the desired effect, then 2 to 3 treatments per week for the next 4 weeks, then 1 to 2 treatments
per week for the next 6 weeks.
(3) Optimum duration: 8 to 12 weeks
(4) Maximum duration: 3 months. 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. Care beyond 3 months is indicated for certain chronic
syndromes in which manipulation is helpful in improving function, decreasing pain and improving
quality of life. Such care should be re-evaluated and documented on a monthly basis. Treatment
may include visits 2 times a month through the 7th month postinjury, then on a monthly basis
thereafter through the 10th month post-injury. Care beyond the 10th month should be reviewed and
allowed on a case-by-case basis according to the unique needs of the patient with chronic and/or
permanent injury.
e. Massage — 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
practitioners hands. Indications include edema (peripheral or hard and non-pliable edema), muscle
spasm, adhesions, the need to improve peripheral circulation and range-of-motion, or to increase muscle
relaxation and flexibility prior to exercise.
(1) Time to produce effect: Immediate.
(2) Frequency: 1 to 2 times per week
(3) Optimum duration: 6 weeks
(4) Maximum duration: 2 months
f. Mobilization (Joint)
Mobilization is passive movement involving oscillatory motions to the vertebral segment(s). The passive
mobility is performed in a graded manner (I, II, III, IV, or V), which depicts the speed of the maneuver. It
may include skilled manual joint tissue stretching. Indications include the need to improve joint play,
segmental alignment, improve intracapsular arthrokinematics, or reduce pain associated with tissue
impingement. Contraindications include joint instability, fractures, severe osteoporosis, infection,
metastatic cancer, active inflammatory arthridities, aortic aneurysm, and signs of progressive neurologic
deficits.
(1) Time to produce effect: 6 to 9 treatments
(2) Frequency: 3 times per week
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 weeks
g. Mobilization (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.
(1) Time to produce effect: 2 to 3 weeks
(2) Frequency: 2 to 3 times per week
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 weeks
h. Superficial Heat and Cold Therapy
Superficial heat and cold 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.
(1) Time to produce effect: Immediate
(2) Frequency: 2 to 5 times per week
(3) Optimum duration: 3 weeks as primary or intermittently as an adjunct to other therapeutic procedures
up to 2 months
(4) Maximum duration: 2 months
i. Short-Wave Diathermy
Short-wave diathermy involves the use of equipment that exposes soft tissue to a magnetic or electrical
field. Indications include enhanced collagen extensibility before stretching, reduced muscle guarding,
reduced inflammatory response and enhanced reabsorption of hemorrhage/hematoma or edema.
(1) Time to produce effect: 2 to 4 treatments
(2) Frequency: 2 to 3 times per week up to 3 weeks
(3) Optimum duration: 3 to 5 weeks
(4) Maximum duration: 5 weeks
j. Traction — Manual
Manual traction is an integral part of manual manipulation or joint mobilization. Indications include
decreased joint space, muscle spasm around joints, and the need for increased synovial nutrition and
response. Manual traction is contraindicated in patients with tumor, infection, fracture, or fracture
dislocation.
(1) Time to produce effect: 1 to 3 sessions
(2) Frequency: 2 to 3 times per week
(3) Optimum duration: 30 days
(4) Maximum duration: 1 month
k. Traction — Mechanical
Mechanical traction is indicated for decreased joint space, muscle spasm around joints, and the need for
increased synovial nutrition and response. Traction modalities are contraindicated in patients with tumor,
infections, fracture or fracture dislocation. Nonoscillating inversion traction methods are contraindicated in
patients with glaucoma or hypertension. A home lumbar traction unit can be purchased if therapy proves
effective.
(1) Time to produce effect: 1 to 3 sessions up to 30 minutes. If response is negative after 3 treatments,
discontinue this modality.
(2) Frequency: 2 to 3 times per week
(3) Optimum duration: 4 week
(4) Maximum duration: 1 month
l. Transcutaneous Electrical Nerve Stimulation (TENS)
TENS should include least one instructional session for proper application and use. Indications include
muscle spasm, atrophy, and decreased circulation and pain control. Minimal TENS unit parameters
should include pulse rate, pulse width and amplitude modulation.
(1) Time to produce effect: Immedicate.
(2) Frequency: Variable.
(3) Optimum duration: 3 sessions
(4) Maximum duration: 3 sessions. If beneficial, provide with home unit or purchase if effective.
m. Ultrasound
Ultrasound 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 the
need to extend muscle tissue or accelerate the soft tissue healing. Ultrasound with electrical stimulation is
concurrent delivery of electrical energy that involves dispersive electrode placement. Indications include
muscle spasm, scar tissue, pain modulation and muscle facilitation. Phonophoresis is the transfer of
medication to the target tissue to control inflammation and pain through the use of sonic generators.
These topical medications include, but are not limited to, steroidal antiinflammatory and anesthetics.
(1) Time to produce effect: 6 to 15 treatments
(2) Frequency: 3 times per week
(3) Optimum duration: 4 to 8 weeks
(4) Maximum duration: 2 months
n. Vertebral Axial Decompression (VAX-D)
VAX-D, a registered trademark for a motorized traction table used to stretch the lower back, is an
acronym for vertebral axial decompression. The patient lies prone on the table in a pelvic harness for 30
to 45 minutes while alternating cycles of stretching and relaxation are applied. The table has FDA
approval as a traction device, but no studies have shown any advantage of vertebral axial decompression
over ordinary manual therapy for low back pain and it has not been shown to treat conditions associated
with herniated discs.
The evidence in support of vertebral axial decompression is insufficient to support its use in low back
injuries. Proponents of this therapy may submit supporting evidence to the Division if they believe that
claims of its effectiveness can be supported by well-designed studies. Vertebral axial decompression for
treatment of low back injuries is not recommended.
o. Whirlpool/Hubbard Tank
The whirlpool/Hubbard Tank is conductive exposure to water at temperatures that best elicits the desired
effect (cold vs. heat). It generally includes massage by water propelled by a turbine or Jacuzzi jet system
and has the same thermal effects as hot packs if higher than tissue temperature. It has the same thermal
effects as cold application if comparable temperature water used. Indications include the need for
analgesia, relaxing muscle spasm, reducing joint stiffness, and facilitating and preparing for exercise.
(1) Time to produce effect: 2 to 4 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 3 weeks as primary, or intermittently as an adjunct to other therapeutic procedures
up to 2 months.
(4) Maximum duration: 2 months
13. Vocational Rehabilitation
Vocational rehabilitation is a generally accepted intervention, but Colorado limits its use as a result of
Senate Bill 87-79. Initiation of vocational rehabilitation requires adequate evaluation of patients for
quantification 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.
F. THERAPEUTIC PROCEDURES — OPERATIVE
All operative interventions must be based upon positive correlation of clinical findings, clinical course and
diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with
positive identification of pathologic condition(s). It is imperative to rule out non-physiologic modifiers of
pain presentation or non-operative conditions mimicking radiculopathy or instability (e.g., peripheral
neuropathy, piriformis syndrome, myofascial pain, scleratogenous or sympathetically mediated pain
syndromes, sacroiliac dysfunction, psychological conditions, etc.) prior to consideration of elective
surgical intervention.
In addition, operative treatment is indicated when the natural history of surgically treated lesions is better
than the natural history for non-operatively treated lesions. All patients being considered for surgical
intervention should first undergo a comprehensive neuromusculoskeletal examination to identify
mechanical pain generators that may respond to non-surgical techniques or may be refractory to surgical
intervention.
While sufficient time allowances for non-operative treatment are required to determine the natural cause
and response to non-operative treatment of low back pain disorders, timely decision making for operative
intervention is critical to avoid deconditioning and increased disability (exclusive of “emergent” or urgent
pathology such as cauda equina syndrome or associated rapidly progressive neurologic loss).
In general, if the program of non-operative treatment fails, operative treatment is indicated when:
1. Improvement of the symptoms has plateaued and the residual symptoms of pain and functional
disability are unacceptable at the end of 6 to 12 weeks of treatment, or at the end of longer
duration of non-operative programs for debilitated patients with complex problems; and/or
2. Frequent recurrences of symptoms cause serious functional limitations even if a non-operative
treatment program provides satisfactory relief of symptoms and restoration of function on each
recurrence. Mere passage of time with poorly guided treatment is not considered an active
treatment program.
Surgical workup and implementation for simple decompression of patients with herniated nucleus
pulposus and sciatica should occur within 6 to 12 weeks after injury at the latest, within the above stated
contingencies. For patients with true, refractory mechanical low back pain in whom fusion is being
considered, it is recommended that a decisive commitment to surgical or non-surgical interventions occur
within 5 months following injury, at the latest.
Re-operation is indicated only when the functional outcome following the reoperation is expected to be
better, within a reasonable degree of certainty, than the outcome of other non-invasive or less invasive
treatment procedures. “Functional outcomes” refers to the patient's ability to improve functional tolerances
such as sitting, standing, walking, strength, endurance, and/or vocational status. While timely surgical
decision-making is critical to avoid deconditioning and increased disability, a time limited trial of
reconditioning should be tried prior to re-operation. Re-operation has a high rate of complications and
failure and may lead to disproportionately increased disability.
Structured rehabilitation interventions should be strongly considered post-operative in any patient not
making expected functional progress within three weeks post-operative.
Return to work restriction should be specific according to the recommendation in the section “Return to
Work” under Therapeutic Procedures – Non-Operative. Most non-fusion surgical patient can return to a
limited level of duty between 3 to 6 weeks. Full activity is generally achieved between 6 weeks to 6
months depending on the procedure and healing of the individual.
1. Discectomy
a. Description — To enter into and partially remove the disc.
b. Complications — Includes, but are not limited to, nerve damage, wrong level operation, spinal fluid
leakage, infection and hemorrhage.
c. Surgical Indications — To include all of the following: Primary radicular symptoms, radiculopathy on
exam, correlating imaging study, and failure of non-surgical care. There is limited evidence that
surgery provides initial improvement in symptoms although most lumbar discs resolve naturally
with time.
d. Operative Treatment — Laminotomy, partial discectomy, and root decompression.
e. Post-Operative Therapy — Active and/or passive therapy. Implementation of a gentle aerobic
reconditioning program (e.g., walking) and back education within the first post-operative week,
barring complications. Instruction and participation in a long-term home-based program of ROM,
strengthening, endurance and stability exercises should be considered 3 to 4 weeks post-op.
2. Chemonucleolysis
a. Description — Injection of a proteolytic enzyme into the disc to obtain an enzymatic degradation of the
nucleus pulposus.
b. Complications — Includes, but are not limited to, severe adverse reaction, neurologic complications
including transverse myelitis, infection and back muscle spasm.
c. Surgical Indications — To include all of the following: Primary radicular symptoms, radiculopathy on
exam, correlating imaging study, and failure of non-surgical care. There is some evidence to
support the use of chemonucleolysis over no treatment. However, more patients require second
surgeries after this procedure than after a discectomy. The failure rate of chemonucleolysis is
higher than the failure rate of discectomy.
d. Operative Treatment — Injection of a proteolytic enzyme into the disc to obtain an enzymatic
degradation of the nucleus pulposus. Physicians trained in chemonucleolysis and with extensive
experience performing the procedure should only perform chemonucleolysis.
e. Post-Operative Therapy — Active and/or passive therapy. Instruction and participation in a long-term
home-based program of ROM, strengthening, endurance and stability exercises should be
considered 3 to 4 weeks post-op.
3. Percutaneous Discectomy (Nuclectomy) or Laser Discectomy
a. Description — An invasive operative procedure to accomplish partial removal of the disc through a
trocar under imaging control.
b. Complications — Include, but are not limited to, injuries to the nerve or vessel, infection and
hematoma.
c. Surgical Indications — Percutaneous discetomy is indicated in cases with suspected septic discitis in
order to obtain diagnostic tissue. These procedures may be used in the presence of septic discitis
for the following: Primary radicular symptoms, radiculopathy on exam, correlating imaging study,
and failure of non-surgical care. The procedure has limited application for non-septic cases due to
lack of evidence to support long-term improvement.
d. Operative Treatment — Partial discectomy & root decompression. If unsuccessful, open laminectomy
should be strongly considered within 2 weeks post-discectomy.
e. Post-Operative Therapy — Active and/or passive therapy. Implementation of a gentle aerobic
reconditioning program (e.g., walking) and back education within the first post-operative week,
barring complications. Instruction and participation in a long-term home-based program of ROM,
strengthening, endurance and stability exercises should be considered 3 to 4 weeks post-op.
4. Laminotomy/Laminectomy/Foramenotomy/Facetectomy
a. Description — They provide access to produce neural decompression by partial or total removal of
various parts of vertebral bone.
b. Complications — Include, but are not limited to, nerve injury, post-surgical instability, CSF leakage and
infection.
c. Surgical Indications — To include all of the following: Primary radicular symptoms, radiculopathy on
exam, correlating imaging study, and failure of non-surgical care.
d. Operative Treatment — Laminotomy, partial discectomy & root decompression.
e. Post-Operative Therapy — Active and/or passive therapy. Implementation of a gentle aerobic
reconditioning program (e.g., walking) and back education within the first post-operative week,
barring complications. Instruction and participation in a long-term home-based program of ROM,
strengthening, endurance and stability exercises should be considered 3 to 4 weeks post-op.
5. Spinal Fusion
a. Description — Use of bone grafts, sometimes combined with metal devices, to produce a rigid
connection between two or more adjacent vertebrae.
b. Complications — Instrumentation failure, bone graft donor site pain, in-hospital mortality, deep wound
infection, superficial infection, graft extrusion.
c. Surgical Indications — A timely decision-making process is recommended when considering patients
for possible fusion. There is no good evidence from controlled trials that spinal fusion alone is
effective for treatment of any type of acute low back problem, in the absence of spinal fracture or
dislocation. For chronic low back problems, fusion should not be considered within the first 3
months of symptoms, except for fracture or dislocation. Indications for spinal fusion may include:
1) Neural arch defect – Spondylolytic spondylolisthesis, congenital unilateral neural arch
hypoplasia.
2) Segmental Instability - Excessive motion, as in degenerative spondylolisthesis, surgically
induced segmental instability.
3) Primary Mechanical Back Pain/ Functional Spinal Unit Failure - Multiple pain generators
objectively involving two or more of the following: (a) Internal disc disruption (poor
success rate if more than one disc involved), (b) Painful motion segment, as in annular
tears, (c) Disc resorption, (d) Facet syndrome, and or (e) Ligamentous tear.
4) Revision surgery for failed previous operation(s) if significant functional gains are anticipated.
Revision surgery for purposes of pain relief must be approached with extreme caution
due to the less than 50% success rate reported in medical literature.
5) Infection, tumor, or deformity of the lumbosacral spine that cause intractable pain, neurological
deficit and/or functional disability.
d. Pre-Operative Surgical Indications — Required pre-operative clinical surgical indications for spinal
fusion include all of the following:
1) All pain generators are identified and treated; and
2) All physical medicine and manual therapy interventions are completed; and
3) X-ray, MRI, or CT/Discography demonstrating disc pathology or spinal instability; and
4) Spine pathology limited to two levels; and
5) Psychosocial screen with confounding issues addressed.
6) For any potential fusion surgery, it is recommended that the injured worker refrain from
smoking for at least six weeks prior to surgery and during the period of fusion healing.
e. Operative Therapy — Operative procedures may include: a) Intertransverse Fusion; b) Anterior Fusion
– generally used for component of discogenic pain where there is no significant radicular
component requiring decompression; c) Posterior Interbody Fusion – generally used for
componen: of discogenic pain where posterior decompression for radicular symptoms also
performed; or d) Anterior/posterior (360°;) Fusion – most commonly seen in unstable or
potentially unstable situations or non-union of a previous fusion.
f. Post-Operative Therapy — Active and/or passive therapy. Implementation of a gentle aerobic
reconditioning program (e.g., walking) and back education within the first post-operative week,
barring complications. Instruction and participation in a long-term home-based program of ROM,
strengthening, endurance and stability exercises should be done once fusion is solid (generally 6
weeks to 6 months post-op).
g. Return to Work — Barring complications, patients responding favorably to spinal fusion may be able to
return to sedentary-to-light work within 6 to 12 weeks post-operatively, light-to-medium work
within 6 to 9 months post-operatively and medium-to-medium/heavy work within 6 to 12 months
post-operatively. Patients requiring fusion whose previous occupation involved heavy-to-veryheavy labor should be considered for vocational assessment as soon as reasonable restrictions
can be predicted. As previously noted, the practitioner must release the patient with specific
physical restrictions and should obtain a clear job description from the employer, if necessary.
Once an injured worker is off work greater than 6 months, the functional prognosis with or without
fusion becomes guarded for that individual.
6. Sacroiliac Joint Fusion
a. Description — Use of bone grafts, sometimes combined with metal devices, to produce a rigid
connection between two or more adjacent vertebrae providing symptomatic instability as a part of
major pelvic ring disruption.
b. Complications — Instrumentation failure, bone graft donor site pain, in-hospital mortality, deep
infection, superficial infection, graft extrusion.
c. Surgical Indications — This procedure has limited use in minor trauma and would be considered only
on an individual case-by-case basis. In patients with typical mechanical low back pain, this
procedure is considered to be under investigation in Colorado. Until the efficacy of this procedure
for mechanical low back pain is determined by an independent valid prospective outcome study,
this procedure is not recommended for mechanical low back pain.
7. Implantable Spinal Cord Stimulators
Implantable spinal cord stimulators are reserved for those low back pain patients with pain of greater than
6 months duration who have not responded to the standard non-operative or operative interventions
previously discussed within this document. Refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder
Medical Treatment Guideline.
8. Intradiscal Electrothermal Annuloplasty (IDEA)
a. Description — An outpatient non-operative procedure. A wire is guided into the identified painful disc
using fluoroscopy. The wire is then heated within the disc. The goal of the procedure is to burn
the nerves and to tighten the injured tissue within the disc. Physicians performing this procedure
must have been trained in the procedure and have performed at least 25 prior discograms. Prior
authorization is required for IDEA.
b. Complications — Complications include, but are not limited to, discitis, nerve damage, pain
exacerbation and anaphylaxis.
c. Surgical Indications — Failure of conservative therapy including physical therapy, medication
management, or therapeutic injections. Indications may include those with chronic low back pain,
disc related back pain, or pain lasting greater than 6 months. There is some evidence to support
this procedure. It continues to be investigational and cannot be generally recommended.
Controlled trials are currently in progress, but results will not be published in the immediate future
so functional benefit beyond 12 months is unknown. Only patients who meet the following should
be considered, including:
1) All pain generators are identified and treated; and
2) All physical medicine and manual therapy interventions are completed; and
3) X-ray, MRI, or CT/Discography demonstrating disc pathology; and
4) Spine pathology limited to two levels; and
5) Psychosocial screen with confounding issues addressed.
6) For any potential surgery, it is recommended that the injured worker refrain from smoking for
at least six weeks prior to surgery and during the period of healing.
Additionally, the candidate must meet the following criteria:
1) Age not above 60 or under 18; and
2) Normal neurological exam; and
3) No evidence of nerve root compression on MRI; and
4) Concordant pain reproduction with provocative discography at less than 1ml dye volume (low
pressure); and
5) Functionally limiting low back for at least 6 months; and
6) No evidence of inflammatory arthritis, spinal conditions mimicking low back pain, moderate to
severe spinal stenosis, spinal instability, disc herniation, or medical or metabolic diseases
precluding follow-up rehabilitation; and
7) The height of the disc must be sufficient to permit maneuvering of the thermal wire; and
8) Previous IDEA within the last 6 months.
d. Operative Treatment — A wire is guided into the identified painful disc using fluoroscopy and then the
wire is heated within the disc.
e. Post-Procedure Therapy — Active and/or passive therapy. Some cases may require epidural injection
after the procedure has been performed. Rehabilitation may take as long as 6 months and
include stretching during the first month, floor exercises in the second month, 3 to 5 consecutive
months of progressive exercise program, and sport activities in the 5 th and 6th months as
tolerated.
f. Return to Work — Barring complications, may be able to return to limited duty after one week. Zero to
10 pounds lifting for first 6 weeks post-procedure. May return to medium work category (20 to 50
pounds per DOT standards) at 3 months or more.
RULE XVII, EXHIBIT B Upper Extremity Medical Treatment Guidelines 1995 (Revised March 15,
1998)
presented by:
State of Colorado Department of Labor and Employment DIVISION OF WORKERS'
COMPENSATION
TABLE OF CONTENTS
SECTION
I
DESCRIPTION
INTRODUCTION
GENERAL GUIDELINE PRINCIPLES
A.
Application of Guidelines
B.
Education
C.
Treatment Parameter
Duration
D.
Active Interventions
E.
Active Therapeutic
Exercise Program
F.
Positive Patient Response
G.
Re-Evaluate Treatment
Every 3-4 Weeks
H.
Surgical Intervention
I.
Six-Month Time Frame
J.
Return-to-Work
K.
Delayed Recovery
OCCUPATIONAL CARPAL TUNNEL SYNDROME
THORACIC OUTLET SYNDROME
SHOULDER INJURY
CUMULATIVE TRAUMA DISORDER
II
III
IV
V
INTRODUCTION
This document has been prepared by the Colorado Department of Labor and Employment, Division of
Workers' Compensation (Division) and should be interpreted within the context of guidelines for
physicians/providers treating individuals qualifying under Colorado's Workers' Compensation Act as
injured workers with upper extremity involvement.
Although the primary purpose of this text is educational, these guidelines are enforceable under the
Workers' Compensation Rules of Procedure, 7 CCR 1101-3. The Division recognizes that acceptable
medical practice may include deviations from these guidelines. Therefore, these guidelines are not
relevant as evidence of a provider's legal standard of professional care.
To properly utilize this document, the reader should not skip nor overlook any sections.
J. RETURN-TO-WORK:
Even if there is residual chronic pain, return-to-work is not necessarily contraindicated. Return-to-work
may be therapeutic, assuming the work is not likely to aggravate the basic problem or increase long-term
pain. The practitioner must write detailed restrictions when returning a patient to limited duty. The
following functions 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. The patient should never be released to “sedentary or light duty”
without specific physical limitations. The practitioner must understand all of the physical, demands of the
patient's job position before returning the patient to full duty and should request clarification of the
patient's job duties. Clarification should be obtained from the employer or, if necessary, including, but not
limited to, an occupational health nurse, occupational therapist, vocational rehabilitation specialist, or an
industrial hygienist.
K. DELAYED RECOVERY:
Strongly consider a psychological evaluation, if not previously provided, as well as initiating interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to make
expected progress 6-12 weeks after an injury. The Division recognizes that 3-10% of all industrially
injured patients will not recover within the timelines outlined in this document despite optimal care. Such
individuals may require treatment beyond the limits discussed within this document, but such treatment
will require clear documentation by the authorized treating practitioner focusing on objective functional
gains afforded by further treatment and impact upon prognosis.
The remainder of this document should be interpreted within the parameters of these guideline principles
which will hopefully lead to more optimal medical and functional outcomes for injured workers.
I. GENERAL GUIDELINE PRINCIPLES
The principles summarized in this section are key to the intended implementation of these guidelines and
critical to the reader's application of the guidelines in this document.
A. APPLICATION OF GUIDELINES:
The Division provides procedures to implement medical treatment guidelines and to foster communication
to resolve disputes among the provider, payer and patient through the Workers' Compensation Rules of
Procedure, Rule XVII and Rule VIII. In lieu of more costly litigation, parties may wish to seek
administrative dispute resolution services through the Division.
B. EDUCATION:
Education of the patient and family, as well as the employer, insurer, policy makers and the community
should be the primary emphasis in the treatment of lower extremity pain and disability. Currently,
practitioners often think of education last, after medications, manual therapy and surgery. Practitioners
must develop and implement an effective strategy and skills to educate patients, employers, insurance
systems, policy makers and the community as a whole. An education-based paradigm should always start
with inexpensive communication providing reassuring information to the patient. More in-depth education
currently exists within a treatment regime employing functional restorative and innovative programs of
prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or
group patient education as a means of facilitating self-management of symptoms and prevention.
C. TREATMENT PARAMETER DURATION:
Time frames for specific interventions commence once treatments have been initiated, not on the date of
injury. Obviously, duration will be impacted by patient compliance, as well as availability of services.
Clinical judgement may substantiate the need to accelerate or decelerate the time frames discussed in
this document.
D. ACTIVE INTERVENTIONS:
Interventions emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment,
are generally emphasized over passive modalities, especially as treatment progresses. Generally,
passive and palliative interventions are viewed as a means to facilitate progress in an active rehabilitation
program with concomitant attainment of objective functional gains.
E. ACTIVE THERAPEUTIC EXERCISE PROGRAM:
Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and
education. This includes functional application in vocational or community settings.
F. POSITIVE PATIENT RESPONSE:
Positive results are defined primarily as functional gains which can be objectively measured. Objective
functional gains include, but are not limited to, positional tolerances, range-of-motion, strength,
endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures
which can be quantified. Subjective reports of pain and function should be considered and given relative
weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on
objective findings.
G. RE-EVALUATE TREATMENT EVERY 3-4 WEEKS:
If a given treatment or modality is not producing positive results within 3-4 weeks, the treatment should be
either modified or discontinued. Reconsideration of diagnosis should also occur in the event of poor
response to a seemingly rational intervention.
H. SURGICAL INTERVENTIONS:
Surgery should be contemplated within the context of expected functional outcome and not purely for the
purpose of pain relief. The concept of “cure” with respect to surgical treatment by itself is generally a
misnomer. All operative interventions must be based upon positive correlation of clinical findings, clinical
course and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific
diagnosis with positive identification of pathologic condition(s).
I. SIX-MONTH TIME FRAME:
Since the prognosis drops precipitously for returning an injured worker to work once he/she has been
temporarily totally disabled for more than six months. The emphasis within these guidelines is to move
patients along a continuum of care and return-to-work within a six-month time frame, whenever possible.
It is important to note that time frames may not be pertinent to injuries which do not involve work-time loss
or are not occupationally related.
RULE XVII, EXHIBIT B-II Carpal Tunnel Syndrome (CTS) Medical Treatment Guidelines July 30,
2003
(Previously Adopted March 2, 1995 and Revised December 30, 1996 and March 15, 1998)
Presented By:
State of Colorado Department of Labor and Employment DIVISION OF WORKERS'
COMPENSATION
TABLE OF CONTENTS
A. INTRODUCTION
B. GENERAL GUIDELINE PRINCIPLES
1. APPLICATION OF GUIDELINES
2. EDUCATION
3. TREATMENT PARAMATER DURATION
4. ACTIVE INTERVENTIONS
5. ACTIVE THERAPEUTIC EXERCISE PROGRAM
6. POSITIVE PATIENT RESPONSE
7. RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS
8. SURGICAL INTERVENTIONS
9. SIX-MONTH TIME FRAME
10. RETURN-TO-WORK
11. DELAYED RECOVERY
12. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE
13. CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI)
C. DEFINITION
D. INITIAL DIAGNOSTIC PROCEDURES
1. INTRODUCTION
2. HISTORY
a. Description of symptoms - should address at least the following:
b. Identification of Occupational Risk Factors
c. Demographics
d. Past Medical History and Review of Systems
e. Activities of Daily Living (ADLs)
f. Avocational Activities
g. Social History
3. PHYSICAL EXAMINATION
4. RISK FACTORS
5. LABORATORY TESTS
E. FOLLOW-UP DIAGNOSTIC TESTING PROCEDURES
1. ELECTRODIAGNOSTIC (EDX) STUDIES
2. IMAGING STUDIES:
a. Radiographic Imaging
b. MRI
c. Sonography
3. ADJUNCTIVE TESTING
a. Electromyography
b. Electroneurometer
c. Portable Automated Electrodiagnostic Device
d. Quantitative Sensory Testing (QST)
e. Pinch And Grip Strength Measurements
f. Laboratory Tests
4. SPECIAL TESTS
a. Personality/Psychological/Psychosocial Evaluations
b. Jobsite Evaluation
c. Functional Capacity Evaluation
d. Vocational Assessment
e. Work Tolerance Screening
F. THERAPEUTIC PROCEDURES – NON-OPERATIVE
1. ACUPUNCTURE
a. Definition
b. Acupuncture with Electrical Stimulation
c. Other Acupuncture Modalities
2. BIOFEEDBACK
3. INJECTIONS – THERAPEUTIC
4. JOB SITE ALTERATION
a. Ergonomic changes
b. Interventions
c. Seating Description
d. Job Hazard Checklist
5. MEDICATIONS
a. Vitamin B6
b. Oral Steroids
6. OCCUPATIONAL REHABILITATION PROGRAMS
a. Non-Interdisciplinary
b. Interdisciplinary
7. ORTHOTICS/IMMOBILIZATION WITH SPLINTING
8. PATIENT EDUCATION
9. PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION
10. RESTRICTION OF ACTIVITIES
11. RETURN TO WORK
a. Establishment of Return-To-Work
b. Establishment of Activity Level Restrictions
c. Compliance with Activity Level Restrictions
12. THERAPY - ACTIVE
a. Nerve Gliding
b. Instruction in Therapeutic Exercise
c. Proper Work Techniques
13. THERAPY - PASSIVE
a. Manual Therapy Techniques
b. Ultrasound
c. Microcurrent TENS
d. Other Passive Therapy
14. VOCATIONAL REHABILITATION
G. THERAPEUTIC PROCEDURES – OPERATIVE
1. SURGICAL DECOMPRESSION
2. NEUROLYSIS
3. TENOSYNOVECTOMY
4. CONSIDERATIONS FOR REPEAT SURGERY
5. POST-OPERATIVE TREATMENT
a. Immobilization
b. Home Program
c. Supervised Therapy Program
A. INTRODUCTION
This document has been prepared by the Colorado Department of Labor and Employment, Division of
Workers' Compensation (Division) and should be interpreted within the context of guidelines for
physicians/providers treating individuals qualifying under Colorado's Workers' Compensation Act as
injured workers with CTS.
Although the primary purpose of this document is advisory and educational, these guidelines are
enforceable under the Workers' Compensation rules of Procedure, 7 CCR 1101-3. The Division
recognizes that acceptable medical practice may include deviations from these guidelines, as individual
cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of
professional care.
To properly utilize this document, the reader should not skip nor overlook any sections.
B. GENERAL GUIDELINE PRINCIPLES
The principles summarized in this section are key to the intended implementation of all Division of
Workers' Compensation guidelines and critical to the reader's application of the guidelines in this
document.
1. Application of Guidelines
The Division provides procedures to implement medical treatment guidelines and to foster communication
to resolve disputes among the provider, payer and patient through the Worker's Compensation Rules of
Procedure, Rule XVII and Rule VIII. In lieu of more costly litigation, parties may wish to seek
administrative dispute resolution services through the Division.
2. Education
Education of the patient and family, as well as the employer, insurer, policy makers and the community
should be the primary emphasis in the treatment of CTS and disability. Currently, practitioners often think
of education last, after medications, manual therapy and surgery. Practitioners must develop and
implement an effective strategy and skills to educate patients, employers, insurance systems, policy
makers and the community as a whole. An education-based paradigm should always start with
inexpensive communication providing reassuring information to the patient. More in-depth education
currently exists within a treatment regime employing functional restorative and innovative programs of
prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or
group patient education as a means of facilitating self-management of symptoms and prevention.
3. Treatment Paramater Duration
Time frames for specific interventions commence once treatments have been initiated, not on the date of
injury. Obviously, duration will be impacted by patient compliance, as well as availability of services.
Clinical judgment may substantiate the need to accelerate or decelerate the time frames discussed in this
document.
4. Active Interventions
Interventions emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment,
are generally emphasized over passive modalities, especially as treatment progresses. Generally,
passive interventions are viewed as a means to facilitate progress in an active rehabilitation program with
concomitant attainment of objective functional gains.
5. Active Therapeutic Exercise Program
Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and
education. This includes functional application in vocational or community settings.
6. Positive Patient Response
Positive results are defined primarily as functional gains that can be objectively measured. Objective
functional gains include, but are not limited to, positional tolerances, range-of-motion, strength,
endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures
that can be quantified. Subjective reports of pain and function should be considered and given relative
weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on
objective findings.
7. Re-Evaluate Treatment Every 3 to 4 Weeks
If a given treatment or modality is not producing positive results within 3 to 4 weeks, the treatment should
be either modified or discontinued. Reconsideration of diagnosis should also occur in the event of poor
response to a seemingly rational intervention.
8. Surgical Interventions
Surgery should be contemplated within the context of expected functional outcome and not purely for the
purpose of pain relief. The concept of “cure” with respect to surgical treatment by itself is generally a
misnomer. All operative interventions must be based upon positive correlation of clinical findings, clinical
course and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific
diagnosis with positive identification of pathologic conditions.
9. Six-Month Time Frame
The prognosis drops precipitously for returning an injured worker to work once he/she has been
temporarily totally disabled for more than six months. The emphasis within these guidelines is to move
patients along a continuum of care and return-to-work within a six-month time frame, whenever possible.
It is important to note that time frames may not be pertinent to injuries that do not involve work-time loss
or are not occupationally related.
10. Return-to-Work
Return-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 and the patient should never be
released to “sedentary” or “light duty.” The following physical limitations should be considered and
modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, bending at the waist,
awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data
entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors. Even if there is
residual chronic pain, return-to-work is not necessarily contraindicated.
The practitioner should understand all of the physical demands of the patient's job position before
returning the patient to full duty and should request clarification of the patient's job duties. Clarification
should be obtained from the employer or, if necessary, including, but not limited to, an occupational health
nurse, occupational therapist, vocational rehabilitation specialist, or an industrial hygienist.
11. Delayed Recovery
Strongly consider a psychological evaluation, if not previously provided, as well as initiating
interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to
make expected progress 6 to 12 weeks after an injury. The Division recognizes that 3 to 10% of all
industrially injured patients will not recover within the timelines outlined in this document despite optimal
care. Such individuals may require treatments beyond the limits discussed within this document, but such
treatment will require clear documentation by the authorized treating practitioner focusing on objective
functional gains afforded by further treatment and impact upon prognosis.
12. Guideline Recommendations and Inclusion of Medical Evidence
Guidelines are recommendations based on available evidence and/or consensus recommendations.
When possible, guideline recommendations will note the level of evidence supporting the treatment
recommendation. When interpreting medical evidence statements in the guideline, the following apply:
Consensus means the opinion of experienced professionals based on general medical principles.
Consensus recommendations are designated in the guideline as “generally well accepted,”
“generally accepted,” “acceptable,” or “well established.”
“Some” means the recommendation considered at least one adequate scientific study, which
reported that a treatment was effective.
“Good” means the recommendation considered the availability of multiple adequate scientific
studies or at least one relevant high-quality scientific study, which reported that a treatment was
effective.
“Strong” means the recommendation considered the availability of multiple relevant and high
quality scientific studies, which arrived at similar conclusions about the effectiveness of a
treatment.
All recommendations in the guideline are considered to represent reasonable care in appropriately
selected cases, regardless of the level of evidence or consensus statement attached to it. Those
procedures considered inappropriate, unreasonable, or unnecessary are designated in the guideline as
being “not recommended.”
13. Care Beyond Maximum Medical Improvement (MMI)
MMI should be declared when a patient's condition has plateaued to the point where the authorized
treating physician no longer believes further medical intervention is likely to result in improved function.
However, some patients may require treatment after MMI has been declared in order to maintain their
functional state. The recommendations in this guideline are for pre-MMI care and are not intended to limit
post-MMI treatment.
The remainder of this document should be interpreted within the parameters of these guideline principles
that may lead to more optimal medical and functional outcomes for injured workers.
C. DEFINITION
Carpal tunnel syndrome (CTS) is one of the most common mononeuropathies (a disorder involving only a
single nerve). The median nerve is extremely vulnerable to compression and injury in the region of the
wrist and palm. In this area, the nerve is bounded by the wrist bones and the transverse carpal ligament.
The most common site of compression is at the proximal edge of the flexor retinaculum (an area near the
crease of the wrist). There is often a myofascial component in the patient's presentation. This should be
considered when proceeding with the diagnostic workup and therapeutic intervention.
Studies have repeatedly confirmed that the diagnosis cannot be made based on any single historical
factor or physical examination finding. Electrodiagnostic tests may be negative in surgically confirmed
cases. Conversely, electrodiagnostic testing may be positive in asymptomatic individuals. The diagnosis
of CTS, therefore, remains a clinical diagnosis based on a preponderance of supportive findings.
Classic findings of CTS include subjective numbness or dysesthesias confined to the median nerve
distribution, worsening of symptoms at night, and positive exam findings. When the diagnosis is in
question, steroid injection into the carpal tunnel is a strongly supportive test if it is followed by significant
relief of symptoms.
Please refer to other appropriate upper extremity guidelines contained in this document (Exhibit B –
Upper Extremity Medical Treatment Guidelines).
D. INITIAL DIAGNOSTIC PROCEDURES
1. Introduction
The two standard procedures that are to be utilized when initially evaluating a work-related carpal tunnel
complaint are History Taking, and Physical Examination.
History-taking and Physical Examination are generally accepted, well-established, and widely used
procedures which establish the foundation/basis for and dictate all ensuing stages of diagnostic and
therapeutic procedures. When findings of clinical evaluation and those of other diagnostic procedures do
not complement each other, the objective clinical findings should have preference.
2. History
a. Description of symptoms - should address at least the following:
1) Numbness, tingling, and/or burning of the hand involving the distal median nerve distribution; however,
distribution of the sensory symptoms may vary considerably between individuals. Although the
classic median nerve distribution is to the palmar aspect of the thumb, the index finger, the middle
finger and radial half of the ring finger, patients may report symptoms in any or all of the fingers.
The Katz Hand diagram (see Fig. 1, page 7) may be useful in documenting the distribution of
symptoms; the classic pattern of carpal tunnel affects at least two of the first three digits and does
not involve dorsal and palmar aspects of the hand. A probable pattern involves the palmar but not
dorsal aspect of the hand (excluding digits).
2) Nocturnal symptoms frequently disrupt sleep and consist of paresthesias and/or pain in the hand
and/or arm.
3) Pain in the wrist occurs frequently and may even occur in the forearm, elbow or shoulder. While
proximal pain is not uncommon, its presence warrants evaluation for other pathology in the
cervical spine, shoulder and upper extremity.
4) The “flick sign,” or shaking the symptomatic hand to relieve symptoms may be reported.
5) Clumsiness of the hand or dropping objects is often reported, but may not be present early in the
course.
Used with permission. JAMA 2000; 283 (23): 3110-17. Copyrighted 2000, American Medical Association.
b. Identification of Occupational Risk Factors
Job title alone is not sufficient information. The clinician is responsible for documenting specific
information regarding repetition, force and other risk factors, as listed in the CTS Associations/Exposures
Table. A job site evaluation may be required.
c. Demographics
Age, hand dominance, gender, etc.
d. Past Medical History and Review of Systems
A study of CTS patients showed a 33% prevalence of related disease. Risk factors for CTS include
female gender; obesity; Native American, Hispanic, or Black heritage, and certain medical conditions:
1) Pregnancy,
2) Arthropathies including connective tissue disorders, rheumatoid arthritis, systemic lupus
erythematosus, gout, osteoarthritis and spondyloarthropathy,
3) Colles' fracture or other acute trauma,
4) Amyloidosis,
5) Hypothyroidism, especially in older females,
6) Diabetes mellitus, including family history or gestational diabetes,
7) Acromegaly,
8) Use of corticosteroids or estrogens,
9) Vitamin B6 deficiency
e. Activities of Daily Living (ADLs)
ADLs include such activities as self care and personal hygiene, communication, ambulation, attaining all
normal living postures, travel, non-specialized hand activities, sexual function, sleep, and social and
recreational activities. Specific movements in this category include pinching or grasping keys/pens/other
small objects, grasping telephone receivers or cups or other similar-sized objects, and opening jars. The
quality of these activities is judged by their independence, appropriateness, and effectiveness. Assess not
simply the number of restricted activities but the overall degree of restriction or combination of restrictions.
f. Avocational Activities
Information must be obtained regarding sports, recreational, and other avocational activities that might
contribute to or be impacted by CTD development. Activities such as hand-operated video games,
crocheting/needlepoint, home computer operation, golf, racquet sports, bowling, and gardening are
included in this category.
g. Social History
Exercise habits, alcohol consumption, and psychosocial factors.
3. Physical Examination
Please refer to Table 1 for respective sensitivities and specificities for findings used to diagnose CTS (a-f).
a. Sensory loss to pinprick, light touch, two-point discrimination or Semmes-Weinstein Monofilament
tests in a median nerve distribution may occur
b. Thenar atrophy may appear, but usually late in the course
c. Weakness of the abductor pollicis brevis may be present
d. Phalen's sign may be positive
e. Tinel's sign over the carpal tunnel may be positive
f. Closed Fist test – holding fist closed for 60 seconds reproduces median nerve paresthesia
g. Evaluation of the contralateral wrist is recommended due to the frequency of bilateral involvement
h. Evaluation of the proximal upper extremity and cervical spine for other disorders including cervical
radiculopathy, thoracic outlet syndrome, other peripheral neuropathies, and other musculoskeletal
disorders
i. Signs of underlying medical disorders associated with CTS, e.g., diabetes mellitus, arthropathy, and
hypothyroidism
j. Myofascial findings requiring treatment may present in soft tissue areas near other CTD pathology, and
should be documented. Refer to Rule XVII, Exhibit B, Cumulative Trauma Disorder
Table 1: Sensitivities and Specificities and Evidence Level for Physical Examination findings
Procedure
1.
2.
3.
4.
5.
6.
7.
Sensory testing
Hypesthesia
Katz Hand Diagram
Two-point discrimination
Semmes-Weinstein
Vibration
Phalen's
Tinel's
Carpal tunnel
compression
Thenar atrophy
Abductor pollicis brevis
weakness
Closed fist test
Tourniquet test
Sensitivity (%)
Specificity (%)
15-51
62-89
22-33
52-91
20-61
51-88
25-73
28-87
85-93
73-88
81-100
59-80
71-81
32-86
55-94
33-95
3-28
63-66
82-100
62-66
61
16-65
92
36-87
4. Risk Factors
A critical review of epidemiologic literature identified a number of physical exposures associated with
CTS. For example, trauma and fractures of the hand and wrist may result in CTS. Other physical
exposures considered risk factors include: repetition, force, vibration, pinching and gripping, and cold
environment. When workers are exposed to several risk factors simultaneously, there is an increased
likelihood of CTS. Not all risk factors have been extensively studied. Exposure to cold environment, for
example, was not examined independently; however, there is good evidence that combined with other risk
factors, cold environment increases the likelihood of a CTS. The table at the end of this section entitled,
“Risk Factors Associated CTS,” summarizes the results of currently available literature.
No single epidemiologic study will fulfill all criteria for causality. The clinician must recognize that currently
available epidemiologic data is based on population results, and that individual variability lies outside the
scope of these studies. Many published studies are limited in design and methodology, and, thus,
preclude conclusive results. Most studies' limitations tend to attenuate, rather than inflate, associations
between workplace exposures and CTS.
These guidelines are based on current epidemiologic knowledge. As with any scientific work, the
guidelines are expected to change with advancing knowledge. The clinician should remain flexible and
incorporate new information revealed in future studies.
Table 2: Risk Factors Associated with Carpal Tunnel Syndrome
Diagnosis
Strong evidence
Good evidence
Some evidence
Carpal Tunnel Syndrome
Combination of high
exertional force (Varied
from > 6 kg) and high
repetition (work
cycles<30 sec or >50% of
cycle time performing
same task, length of
shortest task <10 sec).
Repetition or force
independen tly, use of
vibration hand tools.
Wrist ulnar deviation
extension.
5. Laboratory Tests
Laboratory tests are generally accepted, well established and widely used procedures. Patients should be
carefully screened at the initial exam for signs or symptoms of diabetes, hypothyroidism, arthritis, and
related inflammatory diseases. The presence of concurrent disease does not negate work-relatedness of
any specific case. When a patient's history and physical examination suggest infection, metabolic or
endocrinologic disorders, tumorous conditions, systemic musculoskeletal disorders (e.g., rheumatoid
arthritis), or potential problems related to prescription of medication (e.g., renal disease and nonsteroidal
anti-inflammatory medications), then laboratory tests, including, but not limited to, the following can
provide useful diagnostic information:
a. Serum rheumatoid factor and ANA for rheumatoid work-up;
b. TSH for hypothyroidism;
c. Fasting glucose - recommended for obese men and women over 40 years of age, patients with a
history of family diabetes, those from high-risk ethnic groups, and with a previous history of
impaired glucose tolerance. A fasting blood glucose >125mg/dl is diagnostic for diabetes. Urine
dipstick positive for glucose is a specific but not sensitive screening test. Quantitative urine
glucose is sensitive and specific in high-risk populations;
d. Serum protein electrophoresis;
e. Sedimentation rate, nonspecific, but elevated in infection, neoplastic conditions and rheumatoid
arthritis;
f. Serum calcium, phosphorus, uric acid, alkaline and acid phosphatase for metabolic, endocrine and
neoplastic conditions;
g. CBC, liver and kidney function profiles for metabolic or endocrine disorders or for adverse effects of
various medications;
h. Bacteriological (microorganism) work-up for wound, blood and tissue
i. Serum B6 – routine screening is not recommended due to the fact that vitamin B6 supplementation has
not been proven to affect the course of carpal tunnel syndrome. However, it may be appropriate
for patients on medications that interfere with the effects of vitamin B6, or for those with
significant nutritional problems.
The Division recommends the above 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.
E. FOLLOW-UP DIAGNOSTIC TESTING PROCEDURES
1. Electrodiagnostic (EDX) Studies
Electrodiagnostic (EDX) studies are well established and widely accepted for evaluation of patients
suspected of having CTS. The results are highly sensitive and specific for the diagnosis. Studies may
confirm the diagnosis or direct the examiner to alternative disorders. Studies require clinical correlation
due to the occurrence of false positive and false negative results. Symptoms of CTS may occur with
normal EDX studies, especially early in the clinical course.
EDX findings in CTS reflect slowing of median motor and sensory conduction across the carpal tunnel
region due to demyelination. Axonal loss, when present, is demonstrated by needle electromyography in
median nerve-supplied thenar muscles. Findings include fibrillations, fasciculations, neurogenic
recruitment and polyphasic units (reinnervation).
a. Needle electromyography of a sample of muscles innervated by the C5 to T1 spinal roots, including a
thenar muscle innervated by the median nerve of the symptomatic limb, is frequently required.
b. The following EDX studies are not recommended to confirm a clinical diagnosis of CTS:
1) Low sensitivity and specificity compared to other EDX studies: multiple median F wave
parameters, median motor nerve residual latency, and sympathetic skin response
2) Investigational studies: evaluation of the effect on median NCS of limb ischemia, dynamic
hand exercises, and brief or sustained wrist positioning
c. To assure accurate testing, temperature should be maintained at 30-34C preferably recorded from the
hand/digits. For temperature below 30C the hand should be warmed.
d. All studies must include normative values for their laboratories.
e. Positive Findings – Any of these nerve conduction study findings must be accompanied by median
nerve symptoms to establish the diagnosis.
1) Slowing of median distal sensory and/or motor conduction through the carpal tunnel region
2) Electromyographic changes in the median thenar muscles in the absence of proximal
abnormalities
3) Suggested guidelines for the upper limits of normal latencies:
e. Because laboratories establish their own norms, a degree of variability from the suggested guideline
values is acceptable.
f. In all cases, normative values are to be provided with the neurodiagnostic evaluation.
g. Suggested grading scheme by electrodiagnostic criteria for writing a consultation or report may be:
1) Mild CTS-prolonged (relative or absolute) median sensory or mixed action potential distal
latency (orthodromic, antidromic, or palmar).
2) Moderate CTS-abnormal median sensory latencies as above, and prolongation (relative or
absolute) of median motor distal latency.
3) Severe CTS-prolonged median motor and sensory distal latencies, with either absent or
sensory or palmar potential, or low amplitude or absent thenar motor action potential.
Needle examination reveals evidence of acute and chronic denervation with axonal loss.
h. Frequency of Studies/Maximum Number of Studies:
1) Indications for Initial Testing:
(a) Patients who do not improve symptomatically or functionally with conservative
measures for carpal tunnel syndrome over a 3-4 week period
(b) Patients in whom the diagnosis is in question
(c) Patients for whom surgery is contemplated
(d) To rule out other nerve entrapments or a radiculopathy
2) Repeated studies may be performed:
(a) To determine disease progression. 8-12 weeks is most useful when the initial studies
were normal and CTS is still suspected
(b) For inadequate improvement with non-surgical treatment for 8-12 weeks
(c) For persistent or recurrent symptoms following carpal tunnel release, post-op 3-6
months, unless an earlier evaluation is required by the surgeon
2. Imaging Studies:
a. Radiographic Imaging
Not generally required for most CTS diagnoses. However, it may be necessary to rule out other pathology
in the cervical spine, shoulder, elbow, wrist or hand. Wrist and elbow radiographs would detect
degenerative joint disease, particularly scapholunate dissociation and thumb carpometacarpal
abnormalities which occasionally occur with CTS.
b. MRI
Considered experimental and not recommended for diagnosis of Carpal Tunnel Syndrome. Trained
neuroradiologists have not identified a single MRI parameter that is highly sensitive and specific. MRI is
less accurate than standard electrodiagnostic testing, and its use as a diagnostic tool is not
recommended.
c. Sonography
This tool has not been sufficiently studied to define its diagnostic performance relative to electrodiagnostic
studies. It is not a widely applied test. Sonography may detect synovial thickening in CTS caused by
rheumatoid arthritis. It may be useful if space-occupying lesions, such as, lipomas, hemangiomas,
fibromas, and ganglion cysts, are suspected. Its routine use in CTS is not recommended.
3. Adjunctive Testing
Clinical indications for the use of tests and measurements are predicated on the history and systems
review findings, signs observed on physical examination, and information derived from other sources and
records. They are not designed to be the definitive indicator of dysfunction.
a. Electromyography
Electromyography is a generally accepted, well-established procedure. It is indicated when acute and/or
chronic neurogenic changes in the thenar eminence are associated with the conduction abnormalities
discussed above.
b. Electroneurometer
Not recommended as a diagnostic tool because it requires patient participation, cannot distinguish
between proximal and distal lesions, and does not have well-validated reference values.
c. Portable Automated Electrodiagnostic Device
Measures distal median nerve motor latency and F-wave latency at the wrist and has been tested in one
research setting. It performed well in this setting following extensive calibration of the device. Motor nerve
latency compared favorably with conventional electrodiagnostic testing, but F-wave latency added little to
diagnostic accuracy. It remains an investigational instrument whose performance in a primary care setting
is as yet not established, and is not recommended as a substitute for conventional electrodiagnostic
testing in clinical decision-making.
d. Quantitative Sensory Testing (QST)
May be used as a screening tool in clinical settings pre- and post-operatively. Results of tests and
measurements of sensory integrity are integrated with the history and systems review findings and the
results of other tests and measures. QST has been divided into two types of testing:
1) Threshold tests measure topognosis, the ability to exactly localize a cutaneous sensation, and
pallesthesia, the ability to sense mechanical using vibration discrimination testing (quickly
adapting fibers); Semmes-Wienstein monofilament testing (slowly adapting fibers);
2) Density Tests also measure topognosis and pallesthesia using static two-point discrimination (slowly
adapting fibers); moving two-point discrimination (quickly adapting fibers)
e. Pinch And Grip Strength Measurements
Not generally accepted as a diagnostic tool for CTS. Strength is defined as the muscle force exerted by a
muscle or group of muscles to overcome a resistance under a specific set of circumstances. Pain, the
perception of pain secondary to abnormal sensory feedback, and/or the presence of abnormal sensory
feedback affecting the sensation of the power used in grip/pinch may cause a decrease in the force
exerted and thereby not be a true indicator of strength. When all five handle settings of the dynamometer
are used, a bell-shaped curve, reflecting maximum strength at the most comfortable handle setting,
should be present. These measures provide a method for quantifying strength that can be used to follow
a patient's progress and to assess response to therapy. In the absence of a bell-shaped curve, clinical
reassessment is indicated.
f. Laboratory Tests
In one study of carpal tunnel patients seen by specialists, 9% of patients were diagnosed with diabetes,
7% with hypothyroidism, and 15% with chronic inflammatory disease including spondyloarthropathy,
arthritis, and systemic lupus erythematosis. Up to two thirds of the patients were not aware of their
concurrent disease. Estimates of the prevalence of hypothyroidism in the general population vary widely,
but data collected from the Colorado Thyroid Disease Prevalence Study revealed subclinical
hypothyroidism in 8.5% of participants not taking thyroid medication. The prevalence of chronic joint
symptoms in the Behavioral Risk Factor Surveillance System (BRFSS) from the Centers for Disease
Control was 12.3%. If after 2-3 weeks, the patient is not improving, the physician should strongly consider
the following laboratory studies: thyroid function studies, rheumatoid screens, chemical panels, and
others, if clinically indicated.
Laboratory testing may be required periodically to monitor patients on chronic medications.
4. Special Tests
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 physical work demand classifications
and tolerance
a. Personality/ Psychological/Psychosocial Evaluations
Personality/psychological/psychosocial evaluations are generally accepted and well-established
diagnostic procedures with selective use in the CTS population, but have more widespread use in subacute and chronic pain populations.
Diagnostic testing procedures may be useful for patients with symptoms of depression, delayed recovery,
chronic pain, recurrent painful conditions, disability problems, and for pre-operative evaluation as well as
a possible predictive value for post-operative response. Psychological testing should provide
differentiation between pre-existing depression versus injury-caused depression, as well as posttraumatic stress disorder.
Formal psychological or psychosocial evaluation should be performed on patients not making expected
progress within 6-12 weeks following injury and whose subjective symptoms do not correlate with
objective signs and tests. In addition to the customary initial exam, the evaluation of the injured worker
should specifically address the following areas:
1) Employment history;
2) Interpersonal relationships — both social and work;
3) Leisure activities;
4) Current perception of the medical system;
5) Results of current treatment;
6) Perceived locus of control; and
7) Childhood history, including abuse and family history of disability
Results should provide clinicians with a better understanding of the patient, thus allowing for more
effective rehabilitation. The evaluation will determine the need for further psychosocial interventions, and
in those cases, a DSM IV diagnosis should be determined and documented. An individual with a PhD,
PsyD, or Psychiatric MD/DO credentials may perform initial evaluations, which are generally completed
within one to two hours. When issues of chronic pain are identified, the evaluation should be more
extensive and follow testing procedures as outlined in Division Rule XVII, Exhibit F, Chronic Pain Disorder
Medical Treatment Guideline.
Frequency: One time visit for evaluation. If psychometric testing is indicated as a portion of the initial
evaluation, time for such testing should not exceed an additional two hours of professional time.
b. Jobsite Evaluation
Jobsite evaluation is a comprehensive analysis of the physical, mental and sensory components of a
specific job. These components may include, but are not limited to: (a) postural tolerance (static and
dynamic); (b) aerobic requirements; (c) range of motion; (d) torque/force; (e) lifting/carrying; (f) cognitive
demands; (g) social interactions; (h) visual perceptual; (i) environmental requirements of a job; (j)
repetitiveness; and (k) essential functions of a job. Job descriptions provided by the employer are helpful
but should not be used as a substitute for direct observation.
Frequency: One time with additional visits as needed for follow-up per job site.
c. Functional Capacity Evaluation
Functional capacity evaluation is a comprehensive or modified evaluation of the various aspects of
function as they relate to the worker's ability to return to work. Areas such as endurance, lifting (dynamic
and static), postural tolerance, specific range of motion, coordination and strength, worker habits,
employability and financial status, as well as psychosocial aspects of competitive employment may be
evaluated. Components of this evaluation may include: (a) musculoskeletal screen; (b) cardiovascular
profile/aerobic capacity; (c) coordination; (d) lift/carrying analysis; (e) job-specific activity tolerance; (f)
maximum voluntary effort; (g) pain assessment/psychological screening; and (h) non-material and
material handling activities.
Frequency: Can be used initially to determine baseline status. Additional evaluations can be performed to
monitor and assess progress and aid in determining the endpoint for treatment.
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 should not be delayed solely due to lack of attainment of a
vocational assessment.
Frequency: One time with additional visits as needed for follow-up.
e. Work Tolerance Screening
Work tolerance screening is a determination of an individual's tolerance for performing a specific job as
based on a job activity or task. It may include a test or procedure to specifically identify and quantify workrelevant cardiovascular, physical fitness and postural tolerance. It may also address ergonomic issues
affecting the patient's return-to-work potential. May be used when a full Functional Capacity Evaluation is
not indicated.
Frequency: One time for evaluation. May monitor improvements in strength every 3 to 4 weeks up to a
total of 6 evaluations.
F. THERAPEUTIC PROCEDURES – NON-OPERATIVE
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 selfmanagement of symptoms.
Lastly, formal psychological or psychosocial screening should be performed on patients not making
expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate
with objective signs and tests.
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.
Non-operative treatment procedures for CTS can be divided into two groups: conservative care and
rehabilitation. Conservative care is treatment applied to a problem in which spontaneous improvement is
expected in 90% of the cases within three months. It is usually provided during the tissue-healing phase
and lasts no more than six months, and often considerably less. Rehabilitation is treatment applied to a
more chronic and complex problem in a patient with deconditioning and disability. It is provided during the
period after tissue healing to obtain maximal medical recovery. Treatment modalities may be utilized
sequentially or concomitantly depending on chronicity and complexity of the problem, and treatment plans
should always be based on a diagnosis utilizing appropriate diagnostic procedures.
The following procedures are listed in alphabetical order.
1. Acupuncture
Acupuncture is an accepted and widely used procedure for the relief of pain and inflammation and there is
some scientific evidence to support its use. The exact mode of action is only partially understood.
Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the
brain, promotes deep relaxation, and affects the release of neurotransmitters. Acupuncture is commonly
used as an alternative or in addition to traditional Western pharmaceuticals. While it is commonly used
when pain medication is reduced or not tolerated, it may be used as an adjunct to physical rehabilitation
and/or surgical intervention to hasten the return of functional activity. Acupuncture should be performed by
licensed practitioners.
a. Definition
Acupuncture is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points).
Needles may be inserted, manipulated and retained for a period of time. Acupuncture can be used to
reduce pain, reduce inflammation, increase blood flow, increase range of motion, decrease the side effect
of medication-induced nausea, promote relaxation in an anxious patient, and reduce muscle spasm.
Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical
pain relief, muscle spasm, and scar tissue pain.
1) Time to produce effect: 3 to 6 treatments
2) Frequency: 1 to 3 times per week
3) Optimum duration: 1 to 2 months
4) Maximum duration: 14 treatments
b. Acupuncture with Electrical Stimulation
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.
1) Time to produce effect: 3 to 6 treatments
2) Frequency: 1 to 3 times per week
3) Optimum duration: 1 to 2 months
4) Maximum duration: 14 treatments
c. Other Acupuncture Modalities
Acupuncture treatment is based on individual patient needs and therefore treatment may include a
combination of procedures to enhance treatment effect. Other procedures may include the use of heat,
soft tissue manipulation/massage, and exercise. Refer to Active Therapy and Passive Therapy sections
for a description of these adjunctive acupuncture modalities.
1) Time to produce effect: 3 to 6 treatments
2) Frequency: 1 to 3 times per week
3) Optimum duration: 1 to 2 months
4) Maximum 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 treatments must be documented with respect to need and ability to facilitate
positive symptomatic or functional gains. Such care should be re-evaluated and documented with each
series of treatments.
2. Biofeedback
Biofeedback 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.
1) Time to produce effect: 3 to 4 sessions
2) Frequency: 1 to 2 times per week
3) Optimum duration: 5 to 6 sessions
4) 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.
3. Injections — Therapeutic
Steroids Injections — Beneficial effects of injections are well established, but generally considered to be
temporary. Recurrence of symptoms is frequent. It is not clear whether or not injections slow progression
of electrodiagnostic changes. Therefore, although symptoms may be temporarily improved, nerve
damage may be progressing. When motor changes are present, surgery is preferred over injections.
1) Time to produce effect: 2-5 days
2) Frequency: every 6-8 weeks
3) Optimum number: 2 injections
4) Maximum number: 3 injections in 6 months
If, following the first injection, symptomatic relief is followed by recurrent symptoms, the decision to
perform a second injection must be weighed against alternative treatments such as surgery. Surgery may
give more definitive relief of symptoms.
4. Job 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 work site
evaluation. Some evidence supports alteration of the work site in the early treatment of Carpal Tunnel
Syndrome (CTS). There is no single factor or combination of factors that is proven to prevent or
ameliorate CTS, but a combination of ergonomic and psychosocial factors is 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 carpal tunnel. Psychosocial
factors to be considered include pacing, degree of control over job duties, perception of job stress, and
supervisory support.
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.
a. Ergonomic changes
Ergonomic changes should be made to modify the hazards identified. In addition workers should be
counseled to vary tasks throughout the day whenever possible. OSHA suggests that workers who perform
repetitive tasks, including keyboarding, take 15-30 second breaks every 10 to 20 minutes, or 5-minute
breaks every hour. Mini breaks should include stretching exercises.
b. Interventions
Interventions should consider engineering controls, e.g., mechanizing the task, changing the tool used, or
adjusting the work site, or administrative controls, e.g., adjusting the time an individual performs the task.
c. Seating Description
The following description may aid in evaluating seated work positions: The head should incline only
slightly forward, and if a monitor is used, there should be 18-24 inches of viewing distance with no glare.
Arms should rest naturally, with forearms parallel to the floor, elbows at the sides, and wrists straight or
minimally extended. The back must be properly supported by a chair, which allows change in position and
backrest adjustment. There must be good knee and legroom, with the feet resting comfortably on the floor
or footrest. Tools should be within easy reach, and twisting or bending should be avoided.
d. Job Hazard Checklist
The following Table 3 is adopted from Washington State's job hazard checklist, and may be used as a
generally accepted guide for identifying job duties which may pose ergonomic hazards. The fact that an
ergonomic hazard exists at a specific job, or is suggested in the table, does not establish a causal
relationship between the job and the individual with a musculoskeletal injury. However, when an individual
has a work-related injury and ergonomic hazards exist that affect the injury, appropriate job modifications
should be made. Proper correction of hazards may prevent future injuries to others, as well as aid in the
recovery of the injured worker.
Table 3: Identifying Job Duties Which May Pose Ergonomic Hazards
Type of Job Duty
Pinching an unsupported
object(s) weighing 2 lbs
or more per hand or
pinching with a force of 4
lbs or more per hand
(comparable to pinching a
half a ream of paper):
1. Highly repetitive
motion
2. Palmar flexion >30
degrees, dorsiflexion >45
degrees, or radial
deviation >30 degrees
____________________
____________________
__________
3. No other risk factors
Gripping an unsupported
object(s) weighing 10 lbs
or more/hand, or gripping
with a force of 10 lbs or
more/hand (comparable
to clamping light duty
automotive jumper cables
onto a battery): *Handles
should be rounded and
soft, with at least 1-2.5”
in diameter grips at least
5” long.
1. Highly repetitive
motion
2. Palmar flexion >30
degrees, dorsiflexion >45
degrees, or radial
deviation > 30 degrees
____________________
____________________
__________
3. No other risk factors
Hours per Day
More than 3 hours
total/day
_____________________
_____________________
________
More than 4 hours
total/day
More than 3 hours
total/day
_____________________
_____________________
________
More than 4 hours
total/day
Repetitive Motion (using
the same motion with
little or no variation every
few seconds, excluding
keying activities:
1. High, forceful
exertions with the hands,
with palmar flexion >30
degrees, dorsiflexion >45
degrees, or radial
deviation > 30 degrees
____________________
____________________
__________
2. No other risk factors
Intensive Keying:
1. Palmar flexion >30
degrees, dorsiflexion >45
degrees, or radial
deviation > 30 degrees
____________________
____________________
__________
2. No other risk factors
Repeated Impact:
1. Using the hand
(heel/base of palm) as a
hammer more than
once/minute
Vibration:
Two determinants of the
tolerability of segmental
vibration of the hand are
the frequency and the
acceleration of the motion
of the vibrating tool, with
lower frequencies being
more poorly tolerated at a
given level of imposed
acceleration, expressed
below in multiples of the
acceleration due to
More than 2 hours
total/day
_____________________
_____________________
________
More than 6 hours
total/day
More than 4 hours
total/day
_____________________
_____________________
________
More than 7 hours
total/day
More than 2 hours
total/day
More than 30 minutes at
a time
gravity (10m/sec/sec).
1. Frequency range 8-15
Hz and acceleration 6 g
2. Frequency range 80 Hz
and acceleration 40 g
3. Frequency range 250
Hz and acceleration 250 g
____________________
____________________
__________
4. Frequency range 8-15
Hz and acceleration 1.5 g
5. Frequency range 80 Hz
and acceleration 6 g
6. Frequency range 250
Hz and acceleration 20 g
_____________________
_____________________
________
More than 4 hours at a
time
5. Medications
Medications including nonsteroidal anti-inflammatory medications, oral steroids, diuretics and pyridoxine
(Vitamin B6) have not been shown to have significant long-term beneficial effect in treating Carpal Tunnel
Syndrome. Although NSAIDS are not curative, they and other analgesics may provide symptomatic relief.
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.
a. Vitamin B6
Randomized trials have demonstrated conflicting results. Higher doses may result in development of a
toxic peripheral neuropathy. In the absence of definitive literature showing a beneficial effect, use of
Vitamin B6 cannot be recommended.
b. Oral Steroids
Oral steroids have been shown to have short-term symptomatic benefit but no longterm functional benefit
and are not recommended due to possible side effects.
6. Occupational Rehabilitation Programs
a. 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.
1) Work Conditioning — These programs are usually initiated once reconditioning has been completed
but may be offered at any time throughout the recovery phase. It 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.
(a) Length of visit: 1 to 2 hours per day
(b) Frequency: 2 to 5 visits per week
(c) Optimum duration: 2 to 4 weeks
(d) Maximum duration: 6 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.
2) Work Simulation — Work simulation is a program where an individual completes specific work-related
tasks for a particular job and return to work. Use of this program is appropriate when modified
duty can only be partially accommodated in the work place, when modified duty in the work place
is unavailable, or when the patient requires more structured supervision. The need for work place
simulation should be based upon the results of a Functional Capacity Evaluation and or Jobsite
Analysis.
(a) Length of visit: 2 to 6 hours per day
(b) Frequency: 2 to 5 visits per week
(c) Optimum duration: 2 to 4 weeks
(d) Maximum duration: 6 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.
b. Interdisciplinary
Interdisciplinary programs are characterized by a variety of disciplines that participate in the assessment,
planning, and/or implementation of an injured workers program with the goal for patients to gain full or
optimal function and return to work. There should be close interaction and integration among the
disciplines to ensure that all members of the team interact to achieve team goals. These programs are for
patients with greater levels of perceived disability, dysfunction, deconditioning and psychological
involvement. For patients with chronic pain, refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder
Medical Treatment Guideline.
1) Work Hardening — 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, psychological, 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 therapy, physical
therapy, case manager, and psychologist. As appropriate, the team may also include:
chiropractor, RN, or vocational specialist.
(a) Length of visit: Up to 8 hours/day
(b) Frequency: 2 to 5 visits per week
(c) Optimum duration: 2 to 4 weeks
(d) Maximum duration: 6 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.
7. Orthotics/Immobilization With Splinting
Immobilization with splinting is a generally accepted, well-established and widely used therapeutic
procedure. There is some evidence that splinting leads to more improvement in symptoms and hand
function than watchful waiting alone. Because of limited patient compliance with day and night splinting in
published studies, evidence of effectiveness is limited to nocturnal splinting alone. Splints should be loose
and soft enough to maintain comfort while supporting the wrist in a relatively neutral position. This can be
accomplished using a soft or rigid splint with a metal or plastic support. 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. Most
studies show that full time night splinting for a total of 4 to 6 weeks is the most effective protocol.
Depending on job activities, intermittent daytime splinting can also be helpful. Splint use is rarely
mandatory. Providers should be aware that over-usage is counterproductive, and should counsel patients
to minimize daytime splint use in order avoid detrimental effects such as stiffness and dependency over
time.
Splinting is generally effective for milder cases of CTS. Long-term benefit has not been established. An
effect should be seen in 2-4 weeks.
1) Time to produce effect: 1-4 weeks. If, after 4 weeks, the patient has partial improvement, continue to
follow since neuropathy may worsen, even in the face of diminished symptoms.
2) Frequency: Nightly. Daytime intermittent, depending on symptoms and activities
3) Optimum duration: 4 to 8 weeks
4) Maximum duration: 2 to 4 months. If symptoms persist, consideration should be given to either
repeating electrodiagnostic studies or to more aggressive treatment.
8. Patient Education
No treatment plan is complete without addressing issues of individual and/or group patient 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 be encouraged to take an active role in the
establishment of function outcome goals. They should be educated on their specific injury, assessment
findings, and plan of treatment. Instruction on proper body mechanics and posture, positions to avoid,
self-care for exacerbation of symptoms, and home exercise should also be addressed.
1) Time to produce effect: Varies with individual patient
2) Frequency: Should occur at every visit
9. Personality/Psychological/Psychosocial Intervention
Personality/Psychological/Psychosocial Intervention is generally accepted, widely used and well
established. This group of therapeutic and diagnostic modalities includes, but is not limited to, individual
counseling, group therapy, stress management, psychosocial crises intervention, hypnosis and
meditation. Any screening or diagnostic workup should clarify and distinguish between preexisting versus
aggravated versus purely causative psychological conditions. Psychosocial intervention is recommended
as an important component in the total management program that should be implemented as soon as the
problem is identified. This can be used alone or in conjunction with other treatment modalities. Providers
treating patients with chronic pain should refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder
Medical Treatment Guideline.
1) Time to produce effect: 2 to 4 weeks
2) Frequency: 1 to 3 times weekly for the first 4 weeks (excluding hospitalization, if required), decreasing
to 1 to 2 times per week for the second month. Thereafter, 2 to 4 times monthly.
3) Optimum duration: 6 weeks to 3 months
4) Maximum duration: 3 to 12 months. Counseling is not intended to delay but to enhance functional
recovery. For select patients, longer supervised treatment may required, and if further counseling
beyond 3 months is indicated, documentation addressing which pertinent issues are preexisting
versus aggravated versus causative, as well as projecting a realistic functional prognosis, should
be provided by the authorized treating provider every 4 to 6 weeks during treatment.
10. Restriction of Activities
Continuation of normal daily activities is the recommendation for acute and chronic pain without
neurologic symptoms. There is good evidence against the use of bed rest in cases without neurologic
symptoms. Bed rest may lead to deconditioning and impair rehabilitation. Complete work cessation
should be avoided, if possible, since it often further aggravates the pain presentation. Modified return-towork is almost always more efficacious and rarely contraindicated in the vast majority of injured workers
with Carpal Tunnel Syndrome.
Medication use in the treatment of Carpal Tunnel Syndrome is appropriate for controlling acute and
chronic pain and inflammation. Use of medications will vary widely due to the spectrum of injuries from
simple strains to post-surgical healing. All drugs should be used according to patient needs. A thorough
medication history, including use of alternative and over the counter medications, should be performed at
the time of the initial visit and updated periodically.
11. Return to Work
Early return-to-work should be a prime goal in treating Carpal Tunnel Syndrome (CTS) given the poor
prognosis for the injured employee who is out of work for more than six months. The employee and
employer should be educated in the benefits of early return-to-work. When attempting to return an
employee with CTS to the workplace, clear, objective physical restrictions that apply to both work and
non-work related activities should be specified by the provider. Good communication between the
provider, employee, and employer is essential.
Return-to-work is any work or duty that the employee can safely perform, which may not be the worker's
regular job activities. Due to the large variety of jobs and the spectrum of severity of CTS, it is not
possible for the Division to make specific return-to-work guidelines, but the following general approach is
recommended:
a. Establishment of Return-To-Work
Ascertainment of return-to-work status is part of the medical treatment and rehabilitation plan, and should
be addressed at every visit. Limitations in activities of daily living (ADLs) should also be reviewed at every
encounter, and help to provide the basis for work restrictions provided they are consistent with objective
findings. The Division recognizes that employers vary in their ability to accommodate restricted duty, but
encourages employers to be active participants and advocates for early return-to-work. In most cases, the
patient can be returned to work in some capacity, either at a modified job or alternate position,
immediately unless there are extenuating circumstances, which should be thoroughly documented and
communicated to the employer. Return-to-work status should be periodically reevaluated, at intervals
generally not to exceed three weeks, and should show steady progression towards full activities and full
duty.
b. Establishment of Activity Level Restrictions
It is the responsibility of the physician/provider to provide both the employee and employer clear, concise,
and specific restrictions that apply to both work and non-work related activities. The employer is
responsible to determine whether modified duty can be provided within the medically determined
restrictions. The Division's WC M164 form can be used as a guide to document and communicate the
activity level restrictions. Refer to the “Job Site Alteration” section for specific activity and ergonomic
factors to be considered when establishing work restrictions for an employee with CTS.
c. Compliance with Activity Level Restrictions
The employee's compliance with the activity level restrictions is an important part of the treatment plan
and should be reviewed at each visit. In some cases, a job site analysis, a functional capacity evaluation,
or other special testing may be required to facilitate return-to-work and document compliance. Refer to
the “Job Site Alteration” and “Work Tolerance Screening” sections.
12. Therapy — Active
Active therapies are based on the philosophy that therapeutic exercises and/or activities 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 to continue after discharge. This
form of therapy requires supervision from a therapist or medical provider such as verbal, visual and/or
tactile instructions(s). 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 assistance 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.
a. Nerve Gliding
Nerve gliding exercises consist of a series of flexion and extension movements of the hand and wrist 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. Randomized trials have been lacking or have suffered
from design flaws that preclude sound conclusions of the effectiveness of these exercises, but these flaws
have tended to underestimate rather than overestimate the usefulness of nerve gliding. The exercises are
simple to perform and can be done by the patient after brief instruction. It is considered accepted therapy
for CTS.
1) Time to Produce Effect: 2-4 weeks
2) Frequency: Up to 5 times per day by patient (patient-initiated)
3) Optimum Duration: 2 sessions
4) Maximum Duration: 3 sessions
b. Instruction in Therapeutic Exercise
Instruction should focus on alleviating associated myofascial symptoms. Please refer to the Cumulative
Trauma Disorder (CTD) guideline for information on therapeutic exercise techniques.
c. Proper Work Techniques
Please refer to the “Job Site Evaluation” and “Job Site Alteration” sections of this guideline.
13. Therapy — Passive
Passive therapy includes those treatment modalities that do not require energy expenditure on the part of
the patient. They are principally effective during the early phases of treatment and are directed at
controlling symptoms such as pain, inflammation and swelling and to improve the rate of healing soft
tissue injuries. They should be used in adjunct with active therapies. They may be used intermittently as a
therapist deems appropriate or regularly if there are specific goals with objectively measured functional
improvements during treatment. Diathermies have not been shown to be beneficial to patients with CTS
and may interfere with nerve conduction.
a. Manual Therapy Techniques
Manual 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 noncontractile 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.
Soft tissue mobilization/ manipulation techniques are generally accepted and widely used adjunctive
treatment modalities in the treatment of myofascial symptoms related to carpal tunnel syndrome.
Mobilization and manipulation can include myofascial release therapy, muscle energy techniques, neural
gliding, high velocity, low amplitude (HVLA) technique, osteopathic manipulation, and non-force
techniques.
1) Time to produce effect: 2-6 treatments
2) Frequency: 1-3 times/week, decreasing over time
3) Optimum duration: 4-6 weeks
4) Maximum duration: 8-10 weeks
b. Ultrasound
There is some evidence that ultrasound may be effective in symptom relief and in improving nerve
conduction in mild to moderate cases of CTS. No studies have demonstrated long-term functional benefit.
It may be used in conjunction with an active therapy program for non-surgical patients who do not
improve with splinting and activity modification. It is not known if there are any long-term deleterious
neurological effects from ultrasound.
c. Microcurrent TENS
There is some evidence that concurrent application of microamperage TENS applied to distinct
acupuncture points and low-level laser treatment may be useful in treatment of mild to moderate CTS.
This treatment may be useful for patients not responding to initial conservative treatment or who wish to
avoid surgery. Patient selection criteria should include absence of denervation on EMG and motor
latencies not exceeding 7 ms. The effects of microamperage TENS and low-level laser have not been
differentiated; there is no evidence to suggest whether only one component is effective or the combination
of both is required.
1) Time to produce effect: 1 week
2) Frequency: 3 sessions per week
3) Optimum duration: 3 weeks
4) Maximum duration: 4 weeks
d. Other Passive Therapy
For associated myofascial symptoms, please refer to the Cumulative Trauma Disorder (CTD) guideline.
14. Vocational Rehabilitation
Vocational rehabilitation is a generally accepted intervention, but Colorado limits its use as a result of
Senate Bill 87-79. 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.
G. THERAPEUTIC PROCEDURES — OPERATIVE
1. Surgical Decompression
Surgical decompression is well-established, generally accepted and widely used and includes open and
endoscopic techniques. There is good evidence that surgery is more effective than splinting in producing
long-term symptom relief and normalization of median nerve conduction velocity.
a. Endoscopic techniques have had a higher incidence of serious complications (up to 5%) compared to
open techniques (<1%). The most commonly seen serious complications are incomplete
transection of the transverse carpal ligament and inadvertent nerve or vessel injuries. The
incidence of complications may be lower for surgeons who have extensive experience and
familiarity with certain endoscopic techniques. Choice of technique should be left to the discretion
of the surgeon.
b. Indications for surgery include positive history, abnormal electrodiagnostic studies and/or failure of
conservative management. Job modification should be considered prior to surgery. Please refer
to the “Job Site Alteration” section for additional information on job modification.
c. Surgery should be considered as an initial therapy in situations where:
1) Median nerve trauma has occurred; “acute carpal tunnel syndrome”, or
2) Electrodiagnostic evidence of moderate to severe neuropathy. EMG findings showing
evidence of acute or chronic motor denervation suggest the possibility that irreversible
damage may be occurring.
d. Surgery may be considered in cases where electrodiagnostic testing is normal. A second opinion from
a hand surgeon is strongly recommended. The following criteria should be considered in deciding
whether to proceed with surgery:
1) The patient experiences significant temporary relief following steroid injection into the carpal
tunnel; or
2) The patient has failed 3-6 months of conservative treatment including work site change; and
3) Psychosocial factors have been addressed through psychological screening requirements as
defined “Adjunctive Testing” in this Section; and
4) The patient's signs and symptoms are specific for carpal tunnel syndrome
e. Suggested parameters for return-to-work are:
Timeframe
2 days
2 - 3 weeks
4-6 weeks
6-12 weeks
Activity Level
Return to work with
restrictions on utilizing
the affected extremity
Sedentary and nonrepetitive work
Case-by-case basis
Heavy labor, forceful and
repetitive
Note: All return-to-work decisions are based upon clinical outcome.
2. Neurolysis
Neurolysis has not been proven advantageous for carpal tunnel syndrome. Internal neurolysis should
never be done. Very few indications exist for external neurolysis.
3. Tenosynovectomy
Tenosynovectomy has not proven to be of benefit in carpal tunnel syndrome.
4. Considerations for Repeat Surgery
The single most important factor in predicting symptomatic improvement following carpal tunnel release is
the severity of preoperative neuropathy. Patients with moderate electrodiagnostic abnormalities have
better results than those with either very severe or no abnormalities. Incomplete cutting of the transverse
carpal ligament or iatrogenic injury to the median nerve are rare.
If median nerve symptoms do not improve following initial surgery or symptoms improve initially and then
recur, but are unresponsive to non-operative therapy (see Section II.D., Therapeutic Procedures, NonOperative) consider the following:
a. Recurrent synovitis;
b. Repetitive work activities may be causing “dynamic” CTS;
c. Scarring;
d. Work-up of systemic diseases
A second opinion by a hand surgeon is required if repeat surgery is contemplated. The decision to
undertake repeat surgery must factor in all of the above possibilities. Results of surgery for recurrent
carpal tunnel syndrome vary widely depending on the etiology of recurrent symptoms.
5. Post-Operative Treatment
Considerations for post-operative therapy are:
a. Immobilization
There is some evidence showing that immediate mobilization of the wrist following surgery is associated
with less scar pain and faster return to work. Final decisions regarding the need for splinting postoperatively should be left to the discretion of the treating physician based upon his/her understanding of
the surgical technique used and the specific conditions of the patient.
b. Home Program
It is generally accepted that all patients should receive a home therapy protocol involving stretching,
ROM, scar care, and resistive exercises. Patients should be encouraged to use the hand as much as
possible for daily activities, allowing pain to guide their activities.
c. Supervised Therapy Program
Supervised Therapy Programs may be helpful in patients who do not show functional improvements postoperatively or in patients with heavy or repetitive job activities. The therapy program may include some of
the generally accepted elements of soft tissue healing and return to function:
1) Soft tissue healing/remodeling:
May be used after the incision has healed. It may include all of the following: evaluation,
whirlpool, electrical stimulation, soft tissue mobilization, scar compression pad, heat/cold
application, splinting or edema control may be used as indicated. Following wound healing,
ultrasound and iontophoresis with Sodium Chloride (NaCl) may be considered for soft tissue
remodeling. Diathermy is a non-acceptable adjunct.
2) Return to function:
Range-of-motion and stretching exercises, strengthening, activity of daily living adaptations, joint
protection instruction, posture/body mechanics education; worksite modifications may be
indicated.
(a) Time to produce effect: 2-4 weeks
(b) Frequency: 2-3 times/week
(c) Optimum duration: 4-6 weeks
(d) Maximum duration: 8 weeks
III. THORACIC OUTLET SYNDROME
TABLE OF CONTENTS
SECTION
DESCRIPTION
III
THORACIC OUTLET SYNDROME
A.
Definition
B.
Initial Diagnostic Procedures
1.
History Taking and
Physical Examinatio
(Hx & PE)
C.
Follow-up Diagnostic Imaging and Testing Procedu
1.
Cervical CT or MRI
2.
Electrodiagnostic Stu
3.
Vascular Studies
4.
Thermography
5.
Scalene Muscle Bloc
6.
Personality/Psycholo
/Psychosocial Evalua
D.
Therapeutic Procedures
1.
Nonoperative Treatm
Procedures
2.
Operative Treatment
Procedures
3.
Post-Operative Treat
A. DEFINITION:
Thoracic Outlet Syndrome (TOS) is felt to be a neurovascular disorder affecting the upper extremity
which, on rare occasions, is caused by workplace factors, such as jobs that require repetitive activities of
the upper extremities. It should be emphasized that occupational TOS is a relatively uncommon disorder
and other disorders with similar symptomatology need to be ruled out.
Because of the frequency of TOS being diagnosed in the workplace in Colorado and the clinical and
financial factors that result, these guides are to be used in the evaluation and treatment of occupational
TOS. The most commonly associated history before the development of TOS is acute trauma where
hyperextension of the neck occurs, usually the result of a motor vehicle accident (MVA) and a resultant
“whiplash” injury. Since approximately 19% of occupational spinal cord injuries are from MVA's, this may
also be a common cause of TOS from a work-related injury.
The majority of occupations resulting in TOS are probably related to tasks requiring repetitive activities
and awkward postures. Although little published literature exists regarding TOS as an occupational
disorder, at-risk occupations include workers on assembly lines with repetitive head motions and
keyboard work (e.g. typewriter, computer, adding machine). A common factor in the development of TOS
in these occupations is that the workers' hands are fixed to a keyboard or machine. When attempting to
talk to others in the work area or talk on the telephone, or when looking from copy to monitor to keyboard,
in a suboptimal ergonomic worksite. The worker must extend his/her neck in various directions in order to
keep the hands in a fixed position. When working on an assembly line, the worker must look up or down
for the next item. The result probably is small neck traumata which eventually lead to scalene muscle
stretching, fibrosis, and nerve compression, since the nerves of the brachial plexus are normally in
contact with these muscle fibers.
B. INITIAL DIAGNOSTIC PROCEDURES:
1. History Taking and Physical Examination (Hx & PE)
are generally accepted, well-established and widely used procedures which establish the foundation/basis
for and dictate all other following 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.
a. History Taking:
1) Occupational relationship: activities requiring fixed upper extremity positions and extension of
the neck should be documented.
2) History of nonoccupational injury and avocational pursuits needs to be specifically
documented.
3) Symptoms Positive to TOS:
a) Neck pain: often first symptom within few days of injury.
b) Occipital headaches: also an early symptom
c) Arm pain.
d) Numbness and paresthesia in arm, hand and fingers:
1 - all 5 fingers: most common pattern
2 - 4th and 5th digits: next most common pattern
3 - 1st, 2nd and 3rd digits: may occur, but must rule out carpal tunnel syndrome
e) Upper extremity weakness: arm and/or hand; “dropping things” is a common
complaint
f) Exacerbating factor: elevating arms; common complaints are trouble combing hair,
driving car, etc.
g) Intermittent symptoms: if constant symptoms, consider diagnosis of brachial plexus
injury, “true neurogenic” TOS
b. Physical Findings:
1) Physical Examination Signs Positive in TOS:
a) Tenderness over scalene muscles in supraclavicular area
b) Pressure in supraclavicular area elicits symptoms in arm/hand
c) Tinel's sign over brachial plexus is positive
d) 90°; AER test*: While the radial pulse may or may not disappear, this is not important.
Duplication of the patient's symptoms of pain and paresthesia in hand and arm
are characteristic. (* The 90°; AER test is a modified Adson's position test, with
the test performed with the arm abducted 90°; and in external rotation. There are
other test positions which purport to evaluate neurovascular compromise. The
best known position is the Adson's, however, many patients with TOS do not
have alteration of their radial pulse with any of these maneuvers and many
normals will have reduced pulses with positional testing. Neurovascular testing is
not felt to be reliable in establishing the diagnosis of TOS.)
e) Head Tilting: lateral flexion of the neck (ear to shoulder) causes radiating pain and
paraesthesia in the contralateral shoulder and sometimes in the arm and hand.
f) Neurologic Examination: usually normal, but may be abnormal
(1) Sensory exam: may show decreased sensation to light touch, pin and
temperature in lower brachial plexus distribution.
(2) Motor exam: weakness and/or muscle atrophy in either upper or lower trunk
distributions including, but, not limited to, valid dynamometer readings
indicative of relative weakness in the affected limb.
2) Clinical Prognosis: if the patient has unilateral symptoms, positive physical findings on the
ipsilateral side strongly support the diagnosis of TOS. In patients with bilateral symptoms,
positive scalene muscle tenderness and a positive response to 90°; in abduction and
external rotation can still support the diagnosis, but, it is not as strong as in the unilateral
situation.
3) Physical findings suggest other disorders to consider:
a) Neck rotation may or may not be restricted; present in many conditions.
b) Rotator cuff/acromioclavicular (AC) joint tenderness; suggests rotator cuff or biceps
tendinitis or AC joint disease.
c) Trapezius muscle, shoulder girdle muscles or paraspinal muscle tenderness suggests
myofascial component.
d) Tinel's sign and/or Phalen's sign at wrist suggests carpal tunnel syndrome.
e) Tinel's sign at elbow (over ulnar groove) suggests ulnar nerve entrapment.
f) Tinel's sign over pronator or radial tunnel, when positive, suggests nerve compression.
c. Cervical Spine X-ray is a generally accepted, wellestablished procedure indicated to rule out cervical
spine disease, fracture, cervical rib or rudimentary first rib when clinical findings suggest these
diagnoses. Cervical spine x-rays should also be considered when there is asymmetric diminished
pulse in an arm that is symptomatic. Routine roentgenographic evaluation of the cervical spine in
the primary care setting provides little significant information.
C. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES:
1. Cervical CT or MRI
are a generally accepted, wellestablished procedures indicated to rule out cervical disc or other cervical
spine disorders when clinical findings suggest these diagnoses. MRI is the preferred test over a CT
unless a fracture is suspected, then CT may be superior to MRI. CT/MRI is not indicated early unless
there is a neurological deficit. Either CT or MRI should be done, not both. Repeat cervical CT/MRI is
never indicated. If cervical spine injury is confirmed, refer to Division Rule XVII, Exhibit E., Cervical Spine
Injury Medical Treatment Guidelines. If a cervical spine disorder is not suspected, conservative therapy as
indicated in this Section III., Therapeutic Procedures, should be done for at least 8–12 weeks, prior to
ordering an MRI for persistent symptoms.
2. Electrodiagnostic Studies:
a) Electromyography/Nerve Conduction Studies (EMG/NCV) is a generally accepted, well-established
procedure. EMG/NCV is primarily indicated to rule out other nerve entrapment syndromes such
as carpal tunnel or cubital tunnel syndrome when indicated by clinical examination. Most cases of
TOS have normal electrodiagnostic studies, but EMG/NCV should be considered when
symptoms have been present for approximately 3 months or failed 8 weeks of conservative
therapy. EMG/NCV may also be performed to rule out other disorders. Criteria for Neurogenic
TOS:
1) Reduction of the ulnar sensory nerve action potential to digits; or
2) Reduction of the median M-wave amplitude; or
3) Prolongation of ulnar F-wave latencies; or
4) Needle EMG examination reveals neurogenic changes in intrinsic hand muscles.
b) Ouantitative Sensory Testing (OST) is not generally accepted and has limited use. Research is not
currently available on the use of QST in the evaluation of TOS, but the use of QST may be useful
in ruling out other nerve entrapments of the upper extremity. Studies in peripheral neuropathy and
carpal tunnel syndrome show these studies to be more sensitive than EMG/NCV in detecting
subtle nerve injuries; however, these studies are not as localizing as EMG/NCV). QST may be
considered when all other studies are negative. Types of QST are
1) Vibration Perception Thresholds
2) Thermal Perception Thresholds
3) Current Perception Thresholds
QST is not essential in the evaluation of TOS, but may be a useful, cost-effective method of screening for
nerve injuries of the upper extremities or in those cases where conventional EMG/NCV is normal.
3. Vascular Studies:
Noninvasive vascular testing, such as pulse-volume recording in different positions, is not indicated in
cases of neurogenic TOS. Since the presence or absence of a pulse cutoff on physical examination is not
helpful in establishing a diagnosis of TOS, the recording of finer degrees of positional pulse alteration will
not add much to the diagnosis. Procedures that include vascular laboratory studies, duplex scanning,
Doppler studies and arteriography are not cost effective in cases of neurogenic TOS. These studies are
only indicated in patients who have arterial occlusive symptoms.
4. Thermography
is not generally accepted or widely used for TOS. In experienced evaluators, “stress” thermography, done
while having a patient perform the 90°; AER test, may be a useful tool in evaluating some cases of TOS if
surgery is being considered. It may be used if differential diagnosis includes RSD; in such cases refer to
Division Rule XVII, Exhibit D., Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome Medical
Treatment Guidelines.
5. Scalene Muscle Blocks
are useful only for diagnosis, not for treatment.
a. Time to produce effect: 2–5 minutes
b. Duration or effect: 20–30 minutes
c. Frequency: 1
The interscalene block, sometimes used to treat TOS, is a brachial plexus block and is not indicated to
treat or diagnose neurogenic TOS. Repeated blocks are not indicated for therapy.
6. Personality/Psychological/Psychosocial Evaluations
are generally accepted and well-established diagnostic procedures with selected use in the acute TOS
population, but have more widespread use in the subacute and chronic TOS population. These
procedures may be useful for patients with delayed recovery, chronic pain, recurrent painful conditions,
suspected concomitant closed head injury, disability problems and pre-operative evaluation, as well as a
possible predictive value for post-operative response. Results may provide clinicians with a better
understanding of the patient, thus allowing for more effective rehabilitation. Formal psychological or
psychosocial screening should be performed on patients not making expected progress within 6–12
weeks following injury and whose subjective symptoms do not correlate with clinical signs and tests as
outlined in this Section III., Initial Diagnostic Procedures. This testing will determine the need for further
psychosocial interventions. Evaluations should be performed by an individual with PH.D., PSY.D., L.S.W.
or Psychiatric M.D./D.O. credentials. Initial psychological screening is generally completed within one
hour. If psychometric testing is indicated as a portion of the initial screening process, the time for such
testing should not exceed an additional two hours of professional time.
D. THERAPEUTIC PROCEDURES:
1. Nonoperative Treatment Procedures:
Worksite analysis should be done early in all cases. Most cases are treated conservatively first for a
minimum of 3 months.
a. Physical Medicine and Rehabilitation: It is understood that patients undergoing therapeutic procedures
may return to modified or restricted duty during their rehabilitation, at the earliest appropriate
time. It is also understood that 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.
1) Worksite Analysis should be performed by a qualified individual in all cases of suspected
occupational TOS unless previously performed. Postural risk factors should be identified
and awkward postures of overhead reach, hyperextension or rotation of the neck,
shoulder drooped or forward-flexed and head-chin forward postures should be
eliminated. Unless combined with one of the above postures, repetitiveness is not by
itself a risk factor. Work activities need to be modified early in treatment to avoid exposing
the patient to these ergonomic risk factors while trying to treat symptoms.
2) Neck and Thoracic Stretching Exercises are primarily a daily home program developed and
supervised by an appropriately trained professional. Stretching exercises should include
the following muscle groups: scalene, pectoralis minor, trapezius and levator scapulae. A
patient should attend therapy for up to 4 weeks, then be seen once a week thereafter.
Most patients will need to continue to be monitored and progressed in their activities for
another 4–8 weeks or until they are able to return to the same level of duties or activities
prior to symptom onset.
a) Time to produce effect: 2–3 weeks
b) Frequency: 3 times/week for first 2 weeks; 2 times/week for second two weeks; 1
time/week for weeks 4–6
c) Optimum duration: 6–8 weeks
d) Maximum duration: 3 months under supervision to assure compliance, then
indefinitely on an independent home program as long as symptoms persist.
3) Exercise: Unless confined to the lower extremities, do not do endurance or strengthening early
in the course of therapy and do not exacerbate cervical or upper extremity symptoms.
Endurance and strengthening activities may be contraindicated early on. If the patient
becomes asymptomatic for 2 weeks, standard endurance and strengthening exercises
may begin.
a) Time to produce effect: 2–4 weeks
b) Frequency: 3–4 times/week
c) Optimum duration: 4–6 weeks
d) Maximum duration: 3 months
4) Abdominal Breathing, Postural Exercises (Reeducation) are part of an overall therapy program
and should be primarily a home program supervised by qualified therapist.
a) Time to produce effect: 2–4 weeks
b) Frequency: 3–4 times/week
c) Optimum duration: 4–6 weeks
d) Maximum duration: 3 months under supervision to assure compliance, then
indefinitely on an independent home program as long as symptoms persist.
5) Biofeedback is the use of physiological monitoring equipment to:
a) Improve the patient's awareness to, and control of muscle activity (to include a variety
of muscle placements that are related to the symptoms and/or areas of
entrapment);
b) Reinforce the release of muscle tension that is being obtained from stretches,
exercises, and abdominal breathing for the purpose of decreasing sympathetic
arousal that is associated with stress;
c) Improve the patient's ability to feel like they can effect their physical responses and
symptoms;
d) Assist in avoiding re-injury through the individual returning to repetitive movement and
bracing patterns; or
e) Prepare for surgery.
Treatment time may or may not overlap return-to-work or maximum medical improvement (MMI).
a) Time to produce effect: 3–4 sessions
b) Frequency: 1–2 times/week
c) Optimum duration: 5–6 sessions
d) Maximum duration: 10–12 sessions
6) Medications usually include narcotics, minor tranquilizers/muscle relaxants, nonsteroidal antiinflammatory drugs (NSAIDs), non-narcotic analgesics, and hypnotic/sedatives, including
antidepressants (refer to Section II., Occupational Carpal Tunnel Syndrome, for details on
medication recommendations).
7) Education in correct body mechanics, sleep postures, activities-of-daily-living and work-station
design is important to prevent reinjury.
8) Injections:
a) Scalene blocks have no role in the treatment of TOS; use as a diagnostic tool only as
indicated in Section III., Follow-up Diagnostic Imaging and Testing Procedures.
b) Trigger point injections are generally accepted well-established procedures and of
value in treating a co-existing myofascial pain syndrome, which may be
contributing to some of the symptoms that the patient is experiencing. Trigger
point injections are indicated in those patients where well circumscribed trigger
points have been consistently observed, demonstrating a local twitch response
characteristic radiation of pain pattern and local autonomic reaction, such as
persistent hyperemia following palpation. Generally, these injections are not
necessary unless consistently observed trigger points are not responding to
specific, noninvasive, myofascial interventions within a six-week time frame.
However, trigger point injections may occasionally be effective when utilized in
the patient with immediate, acute onset of upper extremity complaints. Injection
efficacy can be enhanced if injections are immediately followed by myofascial
therapeutic interventions, such as vapocoolant spray and stretch, ischemic
pressure massage (myotherapy), specific soft tissue mobilization and hot packs.
Potential, but rare, complications of trigger point injections include infection,
anaphylaxis, neuroapraxia and neuropathy. As with the therapeutic blocks
discussed above, trigger point injections should be utilized primarily for the
purpose of facilitating functional progress. Muscles requiring injection should not
be aggressively exercised until post-injection soreness resolves and/or the trial of
injections has been completed. However, patients should continue in an
aggressive aerobic and stretching therapeutic exercise program as tolerated
throughout the time period they are undergoing intensive myofascial
interventions.
1) Frequency: weekly, suggest no more than 4 injection sites per session per
week to avoid significant post-injection soreness
2) Optimum duration: 4 weeks
3) Maximum duration: 8 weeks; occasional patient may require 2–4 repetitions of
trigger point injection series over a 1–2 year period
9) Manual Therapy Techniques, such as soft tissue and vertebral mobilization/manipulation
techniques, may be used as adjunctive therapy to improve thoracic mobility and relieve
pain.
a) Time to produce effect: 2–3 visits
b) Frequency: 1–3 times/week
c) Optimum duration: 6–12 weeks
d) Maximum duration: 12 weeks
10) Work Restrictions are prescribed to get the patient back to work with modified activities which
will not aggravate the conditions. It is important to note that these work restrictions would
also be applicable during the time that the patient is undergoing conservative treatment.
Patients with occupational TOS seldom miss any work time, since most patients will
respond with the restrictions below, ergonomic adaptation, and ongoing therapy including
an independent home program. It is also important to reemphasize that TOS is an
uncommon occupational disorder. Suggested work restrictions include:
a) No repetitive reaching
b) No reaching above shoulder level or into hyperextension
c) No lifting more than 10–15 pounds
d) No repetitive or postural cervical hyperextension
e) No shoulder drooped or head forward postures, e.g., looking into a monitor positioned
too low, etc.
f) Frequent changes in activities
2. Operative Treatment Procedures:
a. Diagnostic Criteria for Surgical Procedures:
1) Definite TOS:
a) Clinical: at least two consistent clinical sign plus symptoms consistent with TOS (see
discussion in Section III., Initial Diagnostic Procedures).
b) Neurophysiologic meets criteria for neurogenic TOS (refer to Section III., Follow-up
Diagnostic Imaging and Testing Procedures).
2) Probable TOS:
a) Clinical: at least four consistent clinical signs plus symptoms consistent with TOS,
refer to discussion in Section III., Initial Diagnostic Procedures.
b) Neurophysiologic: may have normal EMG/NCV studies.
3) Possible TOS:
a) Clinical: inconsistent clinical signs plus symptoms of TOS for more than 3 months.
b) Neurophysiologic: may have normal EMG/NCV studies.
b. Surgical Procedures Used:
1) First rib resection
2) Anterior and middle scalenectomy
3) Anterior scalenectomy
4) Combined first rib resection and scalenectomy Since the success rates for the various surgical
procedures are similar, the Division suggests that the surgeon performing the procedure
use the technique with which the surgeon has the most experience. Complications are
felt to be slightly higher for first rib resection than for scalenectomy, RSD is a potential
complication of any TOS surgery. No good research is available to establish numbers.
c. Surgical Indications:
1) Early surgical intervention should only be performed if there is:
a) Documented EMG/NCV evidence of nerve compression with sensory loss, weakness
(with or without muscle atrophy) or
b) Acute subclavian vein thrombosis or arterial thrombosis.
2) After failed conservative therapy, the following criteria must be fulfilled:
a) For definite or probable TOS see the preceding subsection, and
b) Failed 3 months of conservative therapy, and
c) Disabling symptoms interfering with work, recreation, normal daily activities, sleep,
and
d) Pre-surgical psychiatric or psychological clearance has been obtained, demonstrating
motivation and long-term commitment without major issues of secondary gain
and with an expectation that surgical relief of pain probably would improve the
patient's functioning.
3) Even if return to their prior job is unlikely, an individual may need surgical intervention for both
increasing activities-of-daily-living and/or return to work in a different job.
4) It is critically important that all other pathology, especially shoulder disorders, be treated prior
to surgical intervention for TOS.
d. Return-to-Work Time:
1) Modified duty in 2 months.
2) Full duty with changes outlined previously in 6 months.
3. Post-Operative Treatment:
a. Physical Medicine and Rehabilitation:
1) Worksite Analysis should be performed by a qualified individual in all cases of suspected
occupational TOS unless previously performed. Postural risk factors should be identified
and awkward postures of overhead reach, hyperextension or rotation of the neck,
shoulder drooped or forward-flexed and head-chin forward postures should be
eliminated. Unless combined with one of the above postures, repetitiveness is not by
itself a risk factor. Work activities need to be modified prior to return-to-work to avoid
exposing the patient to these ergonomic risk factors.
2) Neck and Thoracic Stretching Exercises are primarily a daily home program developed and
supervised by an appropriately trained professional. Stretching exercises should include
the following muscle groups: scalene, pectoralis minor, upper trapezius and levator. A
patient should attend therapy for up to four weeks, then be seen once a week thereafter.
Most patients will need to continue to be monitored and progressed in their activities for
another 4–8 weeks or until they are able to return to the same level of duties or activities
prior to symptom onset.
a) Time to produce effect: 2–3 weeks
b) Frequency: 3 times/week for first 2 weeks; 2 times/week for second 2 weeks; 1
time/week for weeks 4–6
c) Optimum duration: 6–8 weeks
d) Maximum duration: 3 months to assure compliance
3) Exercise Unless confined to the lower extremities, do not do endurance or strengthening early
in the course of therapy and do not exacerbate cervical or upper extremity symptoms.
Endurance and strengthening activities may be contraindicated early on. If the patient
becomes asymptomatic for 2 weeks, standard endurance and strengthening exercises
may begin.
a) Time to produce effect: 2–4 weeks
b) Frequency: 3–4 times/week
c) Optimum duration: 4–6 weeks
d) Maximum duration: 3 months
4) Abdominal Breathing, Postural Exercises (Reeducation) are part of an overall therapy program
and should be primarily a home program supervised by qualified therapist.
a) Time to produce effect: 2–4 weeks
b) Frequency: 3–4 times/week
c) Optimum duration: 4–6 weeks
d) Maximum duration: 3 months
5) Home Program Instruction for Persistent Symptoms: Symptoms which persist without
improvement 3 weeks post-operatively may indicate referral to a therapy program which
includes home program instruction. The therapy program should include elements of soft
tissue healing and return to function as indicated:
a) Soft tissue healing/remodeling: Evaluation, electrical stimulation, soft tissue
mobilization, scar compression pad, heat/cold application, or edema control may
be used as indicated. Ultrasound may be considered after 6 weeks postoperative for soft tissue remodeling. Diathermy is a nonacceptable adjunct.
b) Return to function: Range-of-motion and stretching exercises, strengthening, activity
of daily living adaptations, joint protection instruction, posture/body mechanics
education, and worksite modifications may be as indicated:
(1) Time to produce effect: 2–4 weeks
(2) Frequency: 2–3 times/week
(3) Optimum duration: 4–6 weeks
(4) Maximum duration: 8 weeks
b. Biofeedback is the use of physiological monitoring equipment to:
1) Improve the patient's awareness and control of muscle activity to include a variety of muscle
placements that are related to the symptoms and/or areas of entrapment;
2) Reinforce the release of muscle tension that is being obtained from stretches, exercises, and
abdominal breathing;
3) Decrease sympathetic arousal that is associated with stress;
4) Improve the patient's ability to feel like they can effect their physical responses and symptoms;
and
5) Assist in avoiding re-injury through the individual returning to repetitive movement and bracing
patterns
Treatment time may or may not overlap return-to-work or MMI.
1) Time to produce effect: 3–4 sessions
2) Frequency: 1–2 time/week
3) Optimum duration: 5–6 sessions
4) Maximum duration: 10–12 sessions
c. Reactivation and Reconditioning are generally accepted, well-established and widely used modalities
which should be included in any standard therapeutic exercise program, see this guideline,
Section IV.D., Shoulder Injury, Physical Medicine and Rehabilitation:
1) Reactivation implies returning the patient to a higher level of activity than was previously
utilized during the disabling episode; conducted in the form of encouragement of activities
with limited supervised training (walking, stationary bicycle, etc.)
a) Time to produce effect: 2–4 visits
b) Frequency: Supervised 2–5 times/week for first 2 weeks, decreasing to 2–3
times/week
c) Optimum duration: 4–6 weeks
d) Maximum duration: 2 months
2) Supervised Reconditioning/Therapeutic Exercise is considered more specific therapeutic
exercise, involving activation, strength/stabilization training and endurance/agility training
of the injured body parts and used only in the presence of documented physical deficit. In
nonsurgical cases of upper extremity pain, the Division recommends initiation of a
supervised reconditioning program and implementation of a less-active treatment plan if:
a) The patient has not demonstrated objective carry over and benefit from an assigned
home exercise program; or
b) The patient has not objectively progressed within a preceding 3-week period; or
c) The patient has not been released to return to full duty or modified work within 3
weeks.
This does not preclude an earlier implementation of an active, supervised reconditioning program:
a) Time to produce effect: 2–6 weeks
b) Frequency: 2–6 times/week supervised for the first 3–4 weeks, decreasing to 2–4
times/week thereafter
c) Optimum duration: 4–6 weeks
d) Maximum duration: 2 months, exclusive of intervening medical complications
A self-monitored program with periodic monitoring is recommended thereafter.
d. Work Simulation modalities are generally accepted, well-established and widely used. They are
simulated activities-of-daily-living including those generally performed by disabled workers in the
work place. If placement at modified duty at the work place is unavailable, work simulation should
run concurrently or sequentially based upon analysis of physical capacity and job analysis:
1) Time to produce effect: 1–3 weeks
2) Frequency: 2–5 times/week
3) Optimum duration: 2–3 weeks
4) Maximum duration: 3–6 weeks
Work simulation is generally followed either by work hardening, return to work, or a combination thereof,
see this Section III., Work Hardening, for further discussion.
e. Psychosocial Intervention is generally accepted, widely used and well-established. This group of
therapeutic and diagnostic modalities includes, but is not limited to, individual counseling, group
therapy, stress management, psychosocial crisis intervention, biofeedback, hypnosis and
meditation. Any screening or diagnostic workup should clarify and distinguish between preexisting versus aggravated versus purely causative psychological conditions. Psychosocial
intervention is recommended as an important component in the total management program which
should be implemented as soon as the problem is identified. This could be used in conjunction
with other treatment modalities:
1) Time to produce effect: 2–4 weeks
2) Frequency: 1–3 time/week (excluding hospitalization, if required) for the first 4 weeks,
decreasing to 1–2 times/week for the second month
3) Optimum duration: 6–10 weeks
4) Maximum duration: 6–12 months
Occasionally, longer supervised treatment may be required, but if further counseling beyond 6 months
seems indicated, extensive documentation addressing which pertinent issues are pre-existing versus
aggravated versus causative, as well as projecting a realistic functional prognosis, should be provided by
the authorized treating practitioner every 4–6 weeks.
f. Vocational Rehabilitation is a generally accepted intervention, but Colorado limits its use by statute.
Initiation of vocational rehabilitation requires adequate evaluation of patients for quantification of
highest functional level, motivation and achievement of MMI. Vocational rehabilitation may be as
simple as returning to the original job or as complicated as being retrained for a new occupation.
g. 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, can reasonably
prognosticate final restrictions and date of MMI, implementation of a timely vocational
assessment can provide valuable guidance in the determination of future rehabilitation program
design. Clarification of rehabilitation goals optimize both patient motivation and utilization of
rehabilitation resources. Except in the most extenuating circumstances, this process should be
implemented within 3–12 months post-injury at the latest, if prognosis for return to former
occupation is determined to be guarded to poor. Declaration of MMI should not be delayed solely
due to lack of attainment of a vocational assessment.
h. Interdisciplinary Team Approach interventions are generally accepted, well-established and widely
used. This approach includes work hardening programs, functional restoration programs and pain
clinics. In general, these programs are more comprehensive, time consuming and costly and are,
therefore, appropriate for patients with greater levels of (perceived) disability, dysfunction,
deconditioning and psychological involvement. For upper extremity involvement, interdisciplinary
teams should include a physical therapist or an occupational therapist.
1) Work Hardening Programs are generally more comprehensive than the work simulation and
include education, reconditioning and specific work simulation with respect to task quality,
quantity and intensity (for further discussion, reference this Section III., Work Simulation).
Work Hardening involving repetitive use of the upper extremity should be pursued
cautiously for most TOS patients, as it may bring back symptoms (even postsurgically).
The Division recommends the Commission for the Accreditation of Rehabilitation
Facilities (CARF) eligibility and/or accreditation of work hardening programs for all
facilities treating injured workers to assure that such programs meet certain standards
involving program design and efficacy. Work hardening is generally initiated after
reconditioning or functional restoration has been completed if 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. As discussed in this Section III.,
Vocational Rehabilitation and Vocational Assessment, identification of realistic vocational
goals is essential for the successful completion of a work hardening program. Generally,
work hardening programs entail a progressive increase in the number of hours per day
that a patient completes work simulation tasks until the patient can tolerate a full work
day:
a) Time to produce effect: 2–4 weeks
b) Frequency: 2–5 times/week
c) Optimum duration: 4–6 weeks
d) Maximum duration: 2–3 months
2) Functional Restoration Programs are intended for patients with both physical deconditioning
and/or significant psychological and socioeconomic involvement. It encompasses work
hardening, quantification of function, disability management, adjustment counseling and
outcome review. The interdisciplinary team must consist of physicians and therapists
working in a structured environment. The Division recommends an interdisciplinary team
include physical therapy, occupational therapy and psychology or at least related
supervised personnel addressing the physiologic, psychologic and ergonomic factors
impacting a patient's upper extremity pain presentation. Regular, documented
interdisciplinary team meetings to discuss patient progress and upgrade rehabilitation
goals must be a part of any credible interdisciplinary approach. The Division recommends
programs which meet criteria consistent with those for work hardening established by
CARF. In nonsurgical upper extremity pain patients with evidence of delayed recovery,
the Division strongly recommends referral to an interdisciplinary/functional restoration
program within three months post-injury.
a) Time to produce effect: 4–6 weeks
b) Frequency: 2–6 times/week
c) Optimum duration: 6–12 weeks
d) Maximum duration: 4 months
3) Pain Clinics have been the traditional rehabilitation program for chronically disabled upper
extremity patients who have not responded to functional restoration interventions. In
general, pain clinics deal with irreversible, painful neurological disorders and
psychological issues, including drug dependence, high levels of stress and anxiety, failed
surgery and pre-existing or latent psychopathology. The Division recommends CARF
eligibility and/or accreditation of pain clinics treating injured workers to assure that such
programs meet certain standards involving program design and efficacy. The Division
also recommends consideration of referral to a pain clinic within 6 months post-injury in
those patients with delayed recovery unless surgical interventions or other medical
complications intervene. It may be useful in determining the appropriateness of referral to
a pain clinic to consider the Colorado Foundation for Medical Care's “Criteria for
Outpatient (or Inpatient) Management of Chronic Pain.”
a) Time to produce effect: 3–8 weeks
b) Frequency: 2–7 times/week for the first month, decreasing to 2–3 times/week
thereafter
c) Optimum duration: 6–12 weeks, including follow-up for outpatient pain clinics; 3–4
weeks for inpatient pain clinics
d) Maximum duration: 4 months, including follow-up
Periodic review and monitoring on an as-needed basis is thereafter founded upon the documented
maintenance of functional gains.
IV. SHOULDER INJURY
TABLE OF CONTENTS
SECTION
DESCRIPTION
IV
SHOULDER INJURY
A.
B.
C.
D.
History Taking and Physical Examination
1.
History Taking
2.
Physical Findings
Specific Diagnosis, Testing and Treatment Procedu
1.
Acromioclavicular Jo
Sprains/Dislocations
2.
Adhesive
Capsulation/Frozen
Shoulder Disorders
3.
Bicipital Tendon
Disorders
4.
Brachioplexus Injuri
5.
Bursitis of the Shoul
6.
Impingement Syndro
7.
Rotator Cuff Tear
8.
Rotator Cuff Tendini
9.
Shoulder Fractures
10.
Shoulder Instability
Medications
1.
Nonsteroidal AntiInflammatory Drugs
(NSAID)
2.
Aanalgesics
3.
Psychotropic Medica
4.
Hypnotics
5.
Narcotics
6.
Minor
Tranquilizers/Muscle
Relaxants.
Nonoperative Treatment Procedures
1.
Immobilization
2.
Relative Rest
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Therapeutic Exercise
Alteration of Occupa
and Work Station
Thermal Treatment
Transcutaneous Elec
Nerve Stimulation
(TENS)
Therapeutic Ultrasou
With or Without Elec
Stimulation
Electrical Therapeuti
Modality
Return-to-Work
Biofeedback
Physical Medicine an
Rehabilitation
Work Simulation
Personality/Psycholo
/Psychosocial Evalua
Vocational Rehabilita
Vocational Assessme
Interdisciplinary Tea
Approach
This section addresses the shoulder and the ten most common work-related injuries/syndromes/disorders
to or involving the shoulder complex. The following format was developed to reduce repetitive text:
● SUBSECTION A., HISTORY TAKING AND PHYSICAL EXAMINATION, provides information
common to all injuries through a discussion of provider procedures which should be applied to
each patient, regardless of the injury and diagnosis (this subsection is standard to all Division
medical treatment guidelines).
● SUBSECTION B., SPECIFIC DIAGNOSIS, TESTING AND TREATMENT PROCEDURES,
provides information unique to each of the following work-related injuries/syndromes/disorders:
1. Acromioclavicular (AC) Joint Sprains/Dislocations
2. Adhesive Capsulitis/Frozen Shoulder Disorders
3. Bicipital Tendon Disorders
4. Brachioplexus Injuries
a. Brachial Plexus
b. Axillary Nerve
c. Long Thoracic Nerve
d. Musculocutaneous Nerve
e. Spinal Accessory Nerve
f. Suprascapular Nerve
5. Bursitis of the Shoulder
6. Impingement Syndrome
7. Rotator Cuff Tears
8. Rotator Cuff Tendinitis
9. Shoulder Fractures
a. Clavicular Fracture
b. Proximal Humeral Fracture
c. Humeral Shaft Fracture
d. Scapular Fracture
e. Sternoclavicular Dislocation/Fracture
10. Shoulder Instability
Each diagnosis is presented in the following format:
1. A definition of the injury/disorder/syndrome;
2. Discussion of relevant physical findings;
3. Applicable testing and diagnostic procedures;
4. Diagnosis-based, nonoperative therapeutic treatment procedures;
5. Options for operative/surgical treatment; and
6. Options for post-operative rehabilitation/treatment procedures.
● SUBSECTION C., MEDICATION, provides information common to all injuries through detailed
discussions of referenced medications with indications for expected time to produce effect,
frequency, and optimum and maximum durations.
● SUBSECTION D., NONOPERATIVE TREATMENT PROCEDURES, provides information
common to all injuries through detailed discussions of referenced therapeutic procedures with
indications for expected time to produce effect, frequency, and optimum and maximum durations.
As shoulder injuries frequently involve a complex of problems, it is always necessary to consider the
possible interaction of the various parts of the shoulder mechanism when proceeding with a diagnostic
workup and a therapeutic treatment plan. Injuries to the shoulder may require the provider to reference
and/or use the other Division medical treatment guidelines (i.e., Rule XVII, Exhibit B., Section III, Thoracic
Outlet Syndrome and Section V., Cumulative Trauma Disorder, and/or Exhibit D., Reflex Sympathetic
Dystrophy/Complex Regional Pain Syndrome).
A. HISTORY TAKING AND PHYSICAL EXAMINATION (Hx & PE):
There are two standard procedures that should be utilized when initially diagnosing work-related shoulder
instability. These procedures are generally accepted, well-established and widely used procedures which
establish the foundation/basis for and dictate all other following 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.
1. History Taking
should address at least the following for each shoulder injury diagnosis:
a. Occupational relationship, and
b. History of nonoccupational injury and avocational pursuits need to be specifically documented.
2. Physical Findings
are specific to and addressed within each shoulder injury diagnosis noted in this section. Given the
complexity of the shoulder mechanism, an evaluation for concomitant injury should be considered.
B. SPECIFIC DIAGNOSIS, TESTING AND TREATMENT PROCEDURES:
1. Acromioclavicular Joint Sprains/Dislocations:
An acute acromioclavicular (AC) joint injury is frequently referred to as a shoulder separation. There are
six classifications of an AC joint separation which are based upon the extent of ligament damage and
bony displacement:
Type I Partial disruption of the AC ligament and capsule.
Type II Sprains consisting of a ruptured AC ligament and capsule with incomplete injury to the
coracoclavicular ligament, resulting in minimal AC joint subluxation.
Type III Separation or complete tearing of the AC ligament and/or coracoclavicular ligaments, possible
deltoid trapezius fascial injury, and dislocation of the AC joint.
Type IV Dislocation consisting of a displaced clavicle that penetrates posteriorly through or into the
trapezius muscle.
Type V Dislocation consisting of complete separation of the AC and CC ligaments and dislocation of the
acromioclavicular joint with a large coracoclavicular interval.
Type VI Dislocation consisting of a displaced clavicle that penetrates inferior to the coracoid.
Types I–III are common, while Types IV–VI are not and, when found, require surgical consultation. For AC
joint degeneration from repetitive motion that is found to be work-related, see this Section IV.B.6.,
Impingement Syndrome.
a. History and Initial Diagnostic Procedures (AC Joint Sprains/Dislocations)
1) Occupational Relationship - generally, workers sustain an AC joint injury when they land on
the point of the shoulder, driving the acromion downward, or fall on an outstretched hand
or elbow, creating a backward and outward force on the shoulder. It is important to rule
out other sources of shoulder pain from an acute injury, including rotator cuff tear, fracture
and nerve injury.
b. Physical Findings (AC Joint Sprains/Dislocations) may include
1) Tenderness at the AC joint with, at times, contusions and/or abrasions at the joint area;
prominence/asymmetry of the shoulder can be seen; and/or
2) One finds decreased shoulder motion and with palpation, the distal end of the clavicle is
painful; there may be increased clavicular translation; cross-body adduction can cause
exquisite pain.
c. Laboratory Tests (AC Joint Sprains/Dislocations) are not indicated unless a systemic illness or disease
is suspected.
d. Testing Procedures (AC Joint Sprains/Dislocations)
1) Plain x-rays may include
a) AP view;
b) AP radiograph of the shoulder with the beam angled 10°; cephalad (Zanca view);
c) Axillary lateral views; and
d) Stress view; side-to-side comparison with 10–15 lbs. of weight in each hand.
e. Nonoperative Treatment Procedures (AC Joint Sprains/Dislocations) may include
1) Procedures outlined in this Section IV.D., such as thermal therapy and immobilization (up-to-6
weeks for Type I–III AC joint separations). Immobilization treatments for Type III injuries
are controversial and may range from a sling to surgery.
2) Medication, such as nonsteroidal anti-inflammatories and analgesics, would be indicated;
narcotics are not normally indicated. In the face of chronic acromioclavicular joint pain, a
series of injections with or without cortisone, may be injected 6–8 times per year.
3) Physical medicine interventions, as outlined in this Section IV.D., should emphasize a
progressive increase in range-of-motion without exacerbation of the AC joint injury. With
increasing motion and pain control, a strengthening program should be instituted and
return to modified/limited duty would be considered at this time. By 8–11 weeks, with
restoration of full motion, return to full duty should be anticipated.
f. Operative Procedures (AC Joint Sprains/Dislocations)
1) With a Type III AC joint injury, an appropriate orthopedic consultation could be considered
initially, but should be considered when conservative care fails to increase function.
2) With a Type IV–VI AC joint injury, an orthopedic surgical consultation is recommended.
g. Post-Operative Procedures (AC Joint Sprains/Dislocations) should be coordinated by the orthopedic
and the primary care physician working with the interdisciplinary team. Keeping with the
therapeutic and rehabilitation procedures found in this Section IV.D., the patient could be
immobilized for 2–3 weeks, restricted in activities, both workrelated and avocational for 6–8
weeks while undergoing rehabilitation, and be expected to progress to return to full duty based
upon the his/her response to rehabilitation and the demands of the job.
2. Adhesive Capsulitis/Frozen Shoulder Disorders:
Adhesive capsulitis of the shoulder, also known as frozen shoulder disorder, is a soft tissue lesion of the
glenohumeral joint resulting in restrictions of passive and active range-of-motion. Occupational adhesive
capsulitis arises secondarily to any chest or upper extremity trauma. Primary adhesive capsulitis is rarely
occupational in origin. The disorder goes through stages, specifically:
Stage 1 Consists of acute pain with some limitation in range-of-motion; generally lasting 2–9 months.
Stage 2 Characterized by progressive stiffness, loss of range-of-motion, and muscular atrophy; it may
last an additional 4–12 months beyond Stage 1.
Stage 3 Characterized by partial or complete resolution of symptoms and restoration of range-of-motion
and strength; it usually takes an additional 6–9 months beyond Stage 2.
a. History and Initial Diagnostic Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder)
1) Occupational Relationship - There should be some history of work-related injury. Often
adhesive capsulitis is seen with impingement syndrome or other shoulder disorders; refer
to appropriate subsection of this guideline.
2) Patient will usually complain of pain in the subdeltoid region, but occasionally over the long
head of the biceps or radiating down the lateral aspect of the arm to the forearm. Pain is
often worse at night with difficulty sleeping on the involved side. Motion is restricted and
painful.
b. Physical Findings (Adhesive Capsulitis/Frozen Shoulder Disorder) may include
1) Restricted active and passive glenohumeral range-of-motion is the primary physical finding. It
may be useful for the examiner to inject the glenohumeral joint with lidocaine and then
repeat range-of-motion to rule out other shoulder pathology; lack of range-of-motion
confirms the diagnosis. Postural changes and secondary trigger points along with atrophy
of the deltoid and supraspinatus muscles may be seen.
c. Laboratory Tests (Adhesive Capsulitis/Frozen Shoulder Disorder) are not indicated unless systemic
illness or disease is suspected.
d. Testing Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder)
1) Plain x-rays are generally not helpful except to rule out concomitant pathology.
2) Arthrography may be helpful in ruling out other pathology. Arthrography can also be
therapeutic as steroids and/or anesthetics may be injected and a brisement or distension
arthrogram can be done at the same time (refer to the next subsection on nonoperative
treatment procedures for further discussion).
e. Nonoperative Treatment Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder) address the goal
to restore and maintain function and may include:
1) Physical medicine interventions are the main-stay of treatment and may include thermal
treatment, ultrasound, TENS, manual therapy, and passive and active range-of-motion
exercises; as the patient progresses, strengthening exercises should be included in the
exercise regimen; refer to this Section IV.D.
2) Medications, such as NSAIDs and analgesics, may be helpful; rarely, the use of oral steroids
are helpful to decrease acute inflammation; narcotics are indicated only for postmanipulation or post-operative cases; refer to this Section IV.C.
3) Occasionally, subacromial bursal and/or glenohumeral steroid injections can decrease
inflammation and allow the therapist to pro-gress functional exercise and range-ofmotion. Injections should be limited to two injections to any one site, given at least one
month apart.
4) In cases that are refractory to conservative therapy lasting at least 3–6 months and in whom
range-of-motion remains significantly restricted (abduction less than. 90°;), the following
more aggressive treatment may be considered:
(a) Distension arthrography or “brisement” in which saline, an anesthetic and usually a
sterold are forcefully injected into the shoulder joint causing disruption of the
capsule. Early and aggressive physical medicine to maintain range-of-motion and
restore strength and function should follow distension arthrography or
manipulation under anesthesia; return-to-work with restrictions should be
expected within one week of the procedure; return to full duty is expected within
4–6 weeks.
f. Operative Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder)
For cases failing conservative therapy of at least 3–6 months duration and which are significantly limited
in range-of-motion (abduction less than 90°;), the following operative procedures may be considered:
1) Manipulation under anesthesia which may be done in combination with steroid injection or
distension arthrography; and
2) In rare cases, refractory to conservative treatment and in which manipulation under
anesthesia is contraindicated, an open capsular release or arthroscopy with resection of
the coracohumeral and/or coracoacromial ligaments may be done; other disorders, such
as impingement syndrome, may also be treated at the same time.
g. Post-Operative Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder) would include an
individualized rehabilitation program based upon communication between the surgeon and the
therapist.
1) Early and aggressive physical medicine interventions are recommended to maintain range-ofmotion and progress strengthening; return-to-work with restrictions after surgery should
be discussed with the treating provider; patient should be approaching MMI within 8–12
weeks post-operative, however, coexistence of other pathology should be taken into
consideration.
3. Bicipital Tendon Disorders:
Disorders may include 1) primary bicipital tendinitis which is exceedingly rare; 2) secondary bicipital
tendinitis which is generally associated with rotator cuff tendinitis or impingement syndrome (see
appropriate diagnosis subsections); 3) subluxation of the biceps tendon which occurs with dysfunction of
the transverse intertubercular ligament and massive rotator cuff tears; and 4) acute disruption of the
tendon which can result from an acute distractive force or transection of the tendon from direct trauma.
a. History and Initial Diagnostic Procedures (Bicipital Tendon Disorders)
1) Occupational Relationship - bicipital tendon disorders may include symptoms of pain and/or
achiness that occur after repetitive use of the shoulder and/or blunt trauma to the
shoulder. Secondary bicipital tendinitis may be associated with prolonged above-theshoulder activities, and/or repeated shoulder flexion, external rotation and abduction.
Acute trauma to the biceps tendon of the shoulder girdle may also give rise to
occupational injury of the biceps tendon.
2) Occupational disorders of the biceps tendon may accompany scapulothoracic dyskinesis,
rotator cuff injury, AC joint separation, subdeltoid bursitis, shoulder instability or other
shoulder pathology. Symptoms should be exacerbated or provoked by work that activated
the biceps muscle. Symptoms may be exacerbated by other activities that are not
necessarily work related.
3) Symptoms may include aching, burning and/or stabbing pain in the shoulder, usually involving
the anterior medial portion of the shoulder girdle. The symptoms are exacerbated with
above-the-shoulder activities and those specifically engaging the biceps (flexion at the
shoulder, flexion at the elbow and supination of the forearm). Relief occurs with rest.
Patient may report nocturnal symptoms which interfere with sleep during the acute stages
of inflammation; pain and weakness in shoulder during activities; repeated snapping
phenomenon with a subluxing tendon; immediate sharp pain and tenderness along the
course of the long head of the biceps following a sudden trauma which would raise
suspicions of acute disruption of the tendon; and/or with predominant pain at the shoulder
referral patterns which may extend pain into the cervical or distal structures, including the
arm, elbow, forearm and wrist.
b. Physical Findings (Bicipital Tendon Disorders) may include
1) If continuity of the tendon has been lost (biceps tendon rupture), inspection of the shoulder
would reveal deformity (biceps bunching);
2) Palpation demonstrates tenderness along the course of the bicipital tendon;
3) Pain at end range of flexion and abduction as well as biceps tendon activation; and/or
4) Provocative testing may include
a) Yeagerson's sign – pain with resisted supination of forearm;
b) Speed's Test – pain with resisted flexion of the shoulder (elbow extended and forearm
supinated); or
c) Ludington's Test – pain with contraction of the biceps (hands are placed behind the
head placing the shoulders in abduction and external rotation).
c. Laboratory Tests (Bicipital Tendon Disorders) are not indicated unless a systemic illness or disease is
suspected.
d. Testing Procedures (Bicipital Tendon Disorders)
1) Plain x-rays include
a) AP view visualizes elevation of the humeral head, indicative of absence of the rotator
cuff due to a tear;
b) Lateral view in the plane of the scapula or an axillary view determines if there is
anterior or posterior dislocation or the presence of a defect in the humeral head
(a Hill-Sachs lesion);
c) 30°; caudally angulated AP view determines if there is a spur on the anterior/interior
surface of the acromion and/or the far end of the clavicle; and
d) Outlet view determines if there is a downwardly tipped acromion.
2) Adjunctive testing, such as sonography, MRI or arthrography, should be considered when
shoulder pain is refractory to 4-6 weeks of nonoperative conservative treatment and the
diagnosis is not readily identified by standard radiographic techniques.
e. Nonoperative Treatment Procedures (Bicipital Tendon Disorders)
1) Benefit may be achieved through procedures outlined in this Section IV.D., such as thermal
therapy, immobilization, alteration of occupation and/or work station, manual therapy and
biofeedback.
2) Medication, such as nonsteroidal anti-inflam-matories and analgesics, would be indicated;
narcotics are not normally indicated. Refer to this Section IV.C. for further discussions.
3) Physical medicine and rehabilitation interventions, as outlined in this Section IV.D., should
emphasize a progressive increase in range-of-motion without exacerbation of the AC joint
injury. With increasing motion and pain control, a strengthening program should be
instituted and return to modified/limited duty would be considered at this time. By 8-11
weeks, with restoration of full motion, return to full duty should be anticipated.
4) Biceps tendon injections may be therapeutic if the patient responds positively to an injection of
an anesthetic. Injection of the corticosteroids directly into the tendon should be avoided
due to possible tendon breakdown and degeneration, limited to 3 injections per year at
the same site, and avoided in patients under 30 years of age.
f. Operative Procedures (Bicipital Tendon Disorders)
1) Bicipital Tendinitis: Conservative care prior to potential surgery must address flexibility and
strength imbalances. Surgical remedies would be considered after 12 weeks of
appropriate conservative care has failed. Since impingement of the biceps tendon could
cause continued irritation, an acromioplasty may be necessary, especially when the
presence of an obstructing osteophyte is demonstrated on plain x-rays.
2) Subluxing Bicipital Tendon: The decision to surgically stabilize the bicipital tendon is not
commonly indicated. In the vast majority of cases, optimal outcome is achieved through
successful rehabilitation procedures and appropriate conservative measures should be
maximized prior to surgical intervention.
3) Acute Disruption of the Bicipital Tendon: Surgical treatment shows variable responses.
Conservative care should be the mainstay of treatment with particular attention given to
the patient's age, work description and motivation.
g. Post-Operative Procedures (Bicipital Tendon Disorders) would include an individualized rehabilitation
program based upon communication between the surgeon and the therapist. Rehabilitation,
lasting 6-12 weeks, is necessary to facilitate maximum medical improvement (MMI).
Rehabilitation procedures discussed in this Section IV.D. should be referenced and used.
4. Brachioplexus Injuries:
Injuries to the nerves and shoulder girdle region resulting in loss of motor and sensory function, pain and
instability of the shoulder. Signs and symptoms vary with the degree of mechanism of injury. The two
modes of injury are: 1) acute direct trauma, and 2) repetitive motion or overuse. Transient compression,
stretch or traction (neuropraxia) causes sensory and motor signs lasting days to weeks. Damage to the
axon (axonomesis) without disruption of the nerve framework may cause similar symptoms. The recovery
time is delayed and depends upon axon regrowth distally from the site of injury. Laceration or disruption of
the entire nerve with complete loss of framework (neuromesis) is the most severe form of nerve injury.
Return of function is dependent upon regrowth of the nerve distal to the injury site.
Electromyography (EMG) is the most commonly used diagnostic modality to analyze nerve injuries.
Electrophysiologic studies, such as electromyography and nerve conduction studies, are generally
accepted, well-estab-lished and widely used for localizing the source of neurological symptoms. These
studies should be utilized as an extension of the history and clinical examination.
Slowing of motor nerve conduction velocities due to demyelinization localizes regions of entrapment and
injury. Denervation demonstrated on the electromyographic portion is indicative of motor axonal or
anterior horn cell loss. Studies should be performed 3-4 weeks following injury or description of
symptoms. If the symptoms have been present for longer than 3-4 weeks, studies may be performed
immediately after the initial evaluation. Serial studies may be indicated if initial studies are negative and
may also be useful for gauging prognosis. Limb temperature should be controlled at 30-40°; centigrade.
There are six relatively common nerve injuries to the shoulder girdle; each type will be addressed
separately.
a. Brachial Plexus is formed by the nerve roots of C5-C8 and T1; these nerve roots exit the cervical
spine and pass through the scalene musculature; after leaving the scalene musculature, at the
level of the clavicle, they form trunks, division and chords which ultimately form the peripheral
nerves of the arm.
1) History and Initial Diagnostic Procedures (Brachial Plexus)
a) Occupational Relationship – direct injury to brachial plexus results in widespread
sensory and motor loss. Direct trauma, subluxation to shoulder, clavicular
fractures, shoulder depression, head deviation away to the arm may result in
variable brachial plexus lesions. It is important to differentiate injuries to the
brachial plexus from the acquired (nonwork-related) syndrome of brachial plexus
neuritis, Parsonage-Turner Syndrome and/or neuralgia demyotrophy.
2) Physical Findings (Brachial Plexus) may include
a) Inspection for evidence of trauma or deformity;
b) Identification of sensory loss and demonstration of weakness which relates to the
severity and anatomy of the injury to the brachial plexus; and/or
c) Pain with recreation of the motions during the mechanism of injury.
3) Laboratory Tests (Brachial Plexus) are not indicated unless a systemic illness or disease is
suspected.
4) Testing Procedures (Brachial Plexus) would include EMG and Nerve Conduction Studies. If
they do not localize and give sufficient information, then additional information may be
obtained from MRI and/or myelography. These studies are employed to differentiate root
avulsion from severe brachial plexus injuries.
5) Nonoperative Treatment Procedures (Brachial Plexus)
a) In closed injuries, observation is favored; repeat electrophysiologic studies may be
helpful to follow recovery.
b) Rehabilitation can be utilized using procedures set forth in this Section IV.D. However,
utilization of ultrasound, cold and heat should be discussed with the Primary
Care Physician since these modalities can aggravate nerve injury.
c) Medications, such as analgesics, nonsteroidal anti-inflammatories and
anticonvulsants, are indicated; steroids may be prescribed to help diminish the
inflammatory response, and narcotics may be indicated acutely; all medications
should be prescribed as seen in this Section IV.C.
6) Operative Procedures (Brachial Plexus) in open injuries, exploration may be worthwhile if
there is poor progression of recovery from a conservative approach; in closed injuries, if
progressive weakness and loss of function is documented after 4-6 months of
conservative care, then exploration is also warranted.
7) Post-Operative Procedures (Brachial Plexus) would include an individualized rehabilitation
program based upon communication between the surgeon and the therapist. This
program would begin with 4-6 weeks of rest followed by progressive increase in motion
and strength.
b. Axillary Nerve is derived from the 5th and 6th cervical roots; it passes around the shoulder and
supplies motor branches to the teres minor and the three heads of the deltoid; it gives sensation
to the top of the shoulder at the level of the deltoid.
1) History and Initial Diagnostic Procedures (Axillary Nerve)
a) Occupational Relationship – direct injury and penetrating wounds to the shoulder and
upward pressure on the axilla can cause injury to the axillary nerve;
abnormalities of the nerve can also be seen with fractures of the surgical neck of
the humerus and dislocation of the shoulder; finally, axillary nerve injury can be
seen with shoulder surgery in and of itself.
2) Physical Findings (Axillary Nerve) may include
a) Weakness and atrophy of the deltoid muscle;
b) Strength is lost in abduction, flexion and extension of the shoulder; and/or
c) Sensory loss can be seen over the upper arm.
3) Laboratory Tests (Axillary Nerve) are not indicated unless a systemic illness or disease is
suspected.
4) Testing Procedures (Axillary Nerve) would include EMG and Nerve Conduction Studies.
5) Nonoperative Treatment Procedures (Axillary Nerve)
a) Rehabilitation can be utilized using procedures set forth in this Section IV.D. Utilization
of ultrasound, cold and heat should be discussed with the Primary Care
Physician since these modalities can aggravate the nerve injury.
b) Medications such as analgesics, nonsteroidal anti-inflammatories and anticonvulsants
are indicated and narcotics may be indicated acutely; all medications should be
prescribed as seen in this Section IV.C.
6) Operative Procedures (Axillary Nerve) are usually not necessary, since most injuries to the
axillary nerve are due to stretch and/or traction. One may consider surgery after 4-6
months with EMG/NCV documentation of ongoing denervation and loss of function.
7) Post-Operative Procedures (Axillary Nerve) would include an individualized rehabilitation
program based upon communication between the surgeon and the therapist. This
program would begin with 4-6 weeks of rest followed by progressive increase in motion
and strength.
c. Long Thoracic Nerve is formed by the cervical fifth, sixth, and seventh roots; it crosses the border of
the first rib and descends along the posterior surface of the thoracic wall to the serratus anterior.
1) History and Initial Diagnostic Procedures (Long Thoracic Nerve)
a) Occupational Relationship – injury can occur by direct trauma to the posterior triangle
of the neck or trauma may be the result of chronically repeated or forceful
shoulder depression. Repeated forward motion of the arms as well as stretch or
compression of the nerve with the arms abducted can lead to long thoracic nerve
dysfunction.
2) Physical Findings (Long Thoracic Nerve) may include
a) Dull ache in the region of the shoulder without sensory loss;
b) Scapular deformity and/or winging may be described by patient or family; and/or
c) Serratus Anterior (scapular winging) may be demonstrated by asking the patient to
extend and lean on his arms, such as against a wall and/or the examiner
resisting protraction.
3) Laboratory Tests (Long Thoracic Nerve) are not indicated unless a systemic illness or disease
is suspected.
4) Testing Procedures (Long Thoracic Nerve) EMG and Nerve Conduction Studies are used to
define the anatomy and severity of the injury; side-to-side comparisons of the nerve can
be helpful to confirm the diagnosis; studies may also exclude more widespread brachial
plexus involvement.
5) Nonoperative Treatment (Long Thoracic Nerve)
a) Rehabilitation can be utilized using procedures set forth in this Section IV.D. Utilization
of ultrasound, cold, and heat should be discussed with the Primary Care
Physician since these modalities can aggravate nerve injury.
b) Medications, such as analgesics, nonsteroidal anti-inflammatories and
anticonvulsants, are indicated and narcotics may be indicated acutely; all
medications should be prescribed as seen in this Section IV.C.
6) Operative Procedures (Long Thoracic Nerve), such as scapular fixation, may be
recommended but only in the most severe cases where there is documented significant
loss of function.
7) Post-Operative Procedures (Long Thoracic Nerve) should include an individualized
rehabilitation program based upon communication between the surgeon and the
therapist. This program would begin with 8-10 weeks of rest followed by progressive
increase in motion and strength.
d. Musculocutaneous Nerve is derived from the fifth and sixth cervical roots; it innervates the
coracobrachialis, biceps and brachioradialis muscles and also provides sensation to the lateral
aspect of the forearm; trauma (including surgery) or penetrating wound to the brachial plexus,
coracobrachialis, and shoulder often can cause nerve injury.
1) History and Initial Diagnostic Procedures (Musculocutaneous Nerve)
a) Occupational Relationship – most commonly a stretch/traction injury due to forceful
extension of the elbow induces nerve dysfunction; trauma can be seen to the
sensory component (lateral antebrachial cutaneous nerve) which delineates loss
of sensation to the forearm.
2) Physical Findings (Musculocutaneous Nerve) may include
a) Pain in the arm;
b) Weakness and atrophy in the biceps and brachialis; and/or
c) Sensory loss over the lateral aspect of the forearm; however, is not always seen.
3) Laboratory Tests (Musculocutaneous Nerve) are not indicated unless a systemic illness or
disease is suspected.
4) Testing Procedures (Musculocutaneous Nerve) include EMG and nerve conduction studies;
side-to-side comparisons of the motor and sensory components of the nerve may be
useful since standard norms are not always reliable.
5) Nonoperative Treatment Procedures (Musculocutaneous Nerve)
a) Rehabilitation can be utilized using procedures set forth in this Section IV.D. Utilization
of ultrasound, cold, and heat should be discussed with the Primary Care
Physician, since these modalities can aggravate nerve injury.
b) Medications, such as analgesics, nonsteroidal anti-inflammatories and
anticonvulsants, are indicated and narcotics may be indicated; all medications
should be prescribed as seen in this Section IV.C.
6) Operative Procedures (Musculocutaneous Nerve) are usually not necessary unless there has
been increasing loss of function over 4-6 months and/or a laceration to the nerve has
been identified.
7) Post-Operative Procedures (Musculocutaneous Nerve) would include an individualized
rehabilitation program based upon communication between the surgeon and the
therapist. This program would begin with 8-10 weeks of rest followed by progressive
increase in motion and strength.
e. Spinal Accessory Nerve is the eleventh cranial nerve; the nerve innervates the ipsilateral
sternocleidomastoid and trapezius muscles which are extremely important for scapular control
and ultimately shoulder function.
1) History and Initial Diagnostic Procedures (Spinal Accessory Nerve)
a) Occupational Relationship – direct trauma to the posterior neck, forceful compression
of the shoulder downward and/or deviation of the head away from the
traumatized shoulder can lead to injury to this nerve; surgical resection of the
posterior neck can disrupt the nerve.
2) Physical Findings (Spinal Accessory Nerve) may include
a) Pain in the shoulder;
b) Weakness or paralysis of the trapezius which is seen as winging with the arms out to
the side (abduction); and/or
c) Drooping of the shoulder.
3) Laboratory Tests (Spinal Accessory Nerve) are not indicated unless a systemic illness or
disease is suspected.
4) Testing Procedures (Spinal Accessory Nerve) include EMG and Nerve Conduction Studies are
used to define the anatomy and severity of the injury; side-to-side comparisons of the
nerve can be helpful to confirm the diagnosis; radiographic procedures may be necessary
to exclude lesion at the base of the brain or upper cervical spine.
5) Nonoperative Treatment Procedures (Spinal Accessory Nerve)
a) Rehabilitation can be utilized using procedures set forth in this Section IV.D. Utilization
of ultrasound, cold, and heat should be discussed with the Primary Care
Physician, since these modalities can aggravate nerve injury.
b) Medications, such as analgesics, nonsteroidal anti-inflammatories and
anticonvulsants, are indicated and narcotics may be indicated acutely; all
medications should be prescribed as seen in this Section IV.C.
6) Operative Procedures (Spinal Accessory Nerve) are usually not necessary unless increased
loss of function over 4-6 months has been documented and/or a laceration to the nerve
has been identified.
7) Post-Operative Procedures (Spinal Accessory Nerve) would include an individualized
rehabilitation program based upon communications between the surgeon and the
therapist. This program would begin with 8-10 weeks of rest followed by progressive
increase in motion and strength.
f. Suprascapular Nerve is derived from the fifth and sixth cervical root, superior trunk of the
brachialplexus, and it innervates the supraspinatus and infraspinatus muscles of the rotator cuff.
1) History and Initial Diagnostic Procedures (Suprascapular Nerve)
a) Occupational Relationship – supraclavicular trauma, stretch, and friction through the
suprascapular notch or against the transverse ligament at the notch can cause
injury to the nerve; repetitive use of the arm has been shown on occasion to
cause traction to the nerve.
2) Physical Findings (Suprascapular Nerve) may include
a) Pain at the shoulder;
b) Wasting at the supraspinatus and/or infraspinatus muscles with weakness; and/or
c) Tinel's can help to elicit a provocative pain response.
3) Laboratory Tests (Suprascapular Nerve) are not indicated unless a systemic illness or disease
is suspected.
4) Testing Procedures (Suprascapular Nerve) include EMG and nerve conduction studies; sideto-side comparisons may be useful since standard norms are not always reliable. If one
suspects a mass lesion at the suprascapular notch, then an MRI may be indicated.
5) Nonoperative Treatment Procedures (Suprascapular Nerve)
a) Rehabilitation can be utilized using procedures set forth in this Section IV.D. Utilization
of ultrasound, cold, and heat should be discussed with the Primary Care
Physician, since these modalities can aggravate nerve injury.
b) Medications, such as analgesics, nonsteroidal anti-inflammatories and anticonvulsants, are indicated and narcotics may be indicated acutely; all
medications should be prescribed as seen in this Section IV.C.
6) Operative Treatment Procedures (Suprascapular Nerve) involving surgical release at the
suprascapular notch or spinoglenoid region is warranted depending upon the results of
the electrophysiologic studies and/or absence of improvement with conservative
management.
7) Post-Operative Procedures (Suprascapular Nerve) would include an individualized
rehabilitation program based upon communication between the surgeon and the
therapist. This program would begin with 8-10 weeks of rest followed by progressive
increase in motion and strength.
5. Bursitis of the Shoulder:
Acute or chronic inflammation of the bursa (a potential fluid filled sac) that may be caused by trauma,
chronic overuse, inflammatory arthritis, and acute or chronic infection which generally presents with
localized pain and tenderness of the shoulder.
a. History and Initial Diagnostic Procedures (Bursitis of the Shoulder)
1) Occupational Relationship – onset of symptoms, date, mechanism of onset, and occupational
history and current requirements should be correlated with the intensity, character,
duration and frequency of associated pain and discomfort.
2) History may include nocturnal pain, pain with over-the-shoulder activities, feeling of shoulder
weakness, prior treatment for presenting complaint(s), specific limitations of movement
and pertinent familial history.
b. Physical Findings (Bursitis of the Shoulder) may include
1) Palpation elicits localized tenderness over the particular bursa or inflamed tendon; loss of
motion during activity;
2) Painful arc may be seen between 40-120°;; and/or
3) Bursitis may be associated with other shoulder injury diagnoses such as impingement, rotator
cuff instability, tendinitis, etc.; refer to applicable diagnosis subsections for additional
guidelines.
c. Laboratory Tests (Bursitis of the Shoulder) may be used to rule out systemic illness or disease when
proper clinical presentation indicates the necessity for such testing. Testing could include
sedimentation rate, rheumatoid profile, CBC with differential, serum uric acid level, routine
screening of other medical disorders may be necessary, as well as bursal aspiration with fluid
analysis.
d. Testing Procedures (Bursitis of the Shoulder)
1) Plain x-rays include
a) AP view visualizes elevation of the humeral head, indicative of absence of the rotator
cuff due to a tear;
b) Lateral view in the plane of the scapula or an axillary view determines if there is
anterior or posterior dislocation or the presence of a defect in the humeral head
(a Hill-Sachs lesion);
c) 30°; caudally angulated AP view determines if there is a spur on the anterior/interior
surface of the acromion and/or the far end of the clavicle; and
d) Outlet view determines if there is a downwardly tipped acromion.
e. Nonoperative Treatment Procedures (Bursitis of the Shoulder)
1) Benefits may be achieved through procedures outlined in this Section IV.D., such as
immobilization, therapeutic exercise, alteration of occupation and work station, thermal
therapy, TENS unit, and ultrasound.
2) May return to work without overhead activities and lifting with involved arm until cleared by
physician for those and heavier activities.
3) Additional modalities/treatment procedures may include biofeedback; physical medicine and
rehabilitation including instruction in therapeutic exercise, proper work technique and
manual therapy; psychosocial intervention; vocational rehabilitation, vocational
assessment and interdisciplinary team approach.
4) Medications, such as nonsteroidal anti-inflam-matories and analgesics. Subacromial space
injection may be therapeutic if the patient responded positively to a diagnostic injection of
an anesthetic. Injection of the corticosteroids directly into the tendons should be
a) Avoided due to possible tendon breakdown and degeneration,
b) Limited to 3 injections per year at the same site, and
c) Avoided in patients under 30 years of age.
f. Operative Procedures (Bursitis of the Shoulder) are not commonly indicated for pure bursitis; refer to
other appropriate diagnoses in this Section IV.B.
6. Impingement Syndrome:
A collection of symptoms, not a pathologic diagnosis. The symptoms result from the encroachment of the
acromion, coracoacromial ligament, coracoid process, and/or the AC Joint of the rotator cuff mechanism
that passes beneath them as the shoulder is moved. The cuff mechanism is intimately related to the
coracoacromial arch. Separated only by the thin lubricating surfaces of the bursa, compression and
friction can be minimized by several factors, such as
– Shape of the coracoacromial arch that allows passage of the subjacent rotator cuff;
– Normal undersurface of the AC Joint;
– Normal bursa;
– Normal capsular laxity; and
– Coordinated scapulothoracic function.
The impingement syndrome may be associated with AC joint arthritis and both partial- and full-thickness
rotator cuff tears, as well as adhesive capsulitis/frozen shoulder. Normal function of the rotator cuff
mechanism and biceps tendon assist to diminish impingement syndrome.
a. History and Initial Diagnostic Procedures (Impingement Syndrome)
1) Occupational Relationship – established repetitive overuse of the upper extremity; many times
this is seen with constant overhead motion.
2) History may include:
a) Delayed presentation; since the syndrome is usually not an acute problem; patients
will access care if their symptoms have not resolved with rest, time and “trying to
work it out”;
b) Complaints of functional losses due to pain, stiffness, weakness and catching when
the arm is flexed and internally rotated; and
c) Poor sleep is common and pain is often felt down the lateral aspect of the upper arm
near the deltoid insertion or over the anterior proximal humerus.
b. Physical Findings (Impingement Syndrome) may include
1) Inspection of the shoulder may reveal deltoid and rotator cuff atrophy;
2) Range-of-motion is limited particularly in internal rotation and in cross-body adduction;
3) Passive motion through the 60-90°; arc of flexion may be accompanied by pain and crepitus;
this is accentuated as the shoulder is moved in-and-out of internal rotation;
4) Active elevation of the shoulder is usually more uncomfortable than passive elevation;
5) Pain on maximum active forward flexion is frequently seen with impingement syndrome, but is
not specific for diagnosis;
6) Strength testing may reveal weakness of flexion and external rotation in the scapular plain;
this weakness may be the result of disuse, tendon damage, or poor scapulothoracic
mechanics;
7) Pain on resisted abduction or external rotation may also indicate that the integrity of the rotator
cuff tendons may be compromised; and/or
8) Weakness of the posterior scapular stabilizers can also be seen as a contributing factor to
impingement syndrome by altering the mechanics of the glenohumeral joint.
c. Laboratory Tests (Impingement Syndrome) are not indicated unless a systemic illness or disease is
suspected.
d. Testing Procedures (Impingement Syndrome)
1) Plain x-rays include:
a) AP view visualizes elevation of the humeral head, indicative of rotator cuff fiber failure
with diminished space at the subacromial area;
b) Lateral view in the plane of the scapula or an axillary view can help to determine
aspects of instability which can give symptoms similar to impingement syndrome;
c) 30°; caudally angulated AP view can assess for a spur on the anterior/inferior surface
of the acromion and/or the distal end of the clavicle which can lead to
encroachment on the rotator cuff mechanism with motion; and
d) Outlet view determines if there is a downwardly tipped acromion.
2) Adjunctive testing, such as standard radiographic techniques (sonography, arthrography or
MRI), should be considered when shoulder pain is refractory to 4-6 weeks of
nonoperative conservative treatment and the diagnosis is not readily identified by a good
history and clinical examination.
e. Nonoperative Treatment Procedures (Impingement Syndrome) may include
1) Medications, such as nonsteroidal anti-inflammatories and analgesics, should be prescribed
as seen in this Section IV.C. Subacromial space injection may be therapeutic if the
patient responded positively to a diagnostic injection of an anesthetic. Injections of
corticosteroids into the subacromial space should be
a) Limited to 3 injections per year at the same site, and
b) Avoided in patients less than 30 years.
2) In order to have the most favorable outcome from a conservative approach, an aggressive
attempt should be made to define the contributing factors which are driving the
syndrome, such as shoulder stiffness, humeral head depressor weakness (rotator cuff
fiber failure), and subacromial crowding AC Joint arthritis.
3) Procedures outlined in this Section IV.D. should considered, such as relative rest,
immobilization, thermal treatment, ultrasound, therapeutic exercise and physical medicine
and rehabilitation.
f. Operative Procedures (Impingement Syndrome) should restore functional anatomy by reducing the
potential for repeated impingement; procedures might include distal clavicular resection,
coracoacromial ligament release, and/or acromioplasty.
g. Post-Operative Procedures (Impingement Syndrome) would include an individualized rehabilitation
program based upon communication between the surgeon and the therapist.
1) Individualized rehabilitation program based upon communication between the surgeon and the
therapist might include:
a) Sling or abduction splint;
b) Gentle pendulum exercise, passive glenohumeral range-of-motion and aggressive
posterior scapular stabilizing training can be instituted;
c) At 4 weeks post-operative, begin isometrics and ADL involvement; and/or
d) Depending upon the patient's functional response, at 6 weeks post-operative consider
beginning light resistive exercise; concomitantly, return to a light/modified duty
may be plausible given the ability to accommodate “no repetitive overhead
activities.”
2) Progressive resistive exercise from 2 months with gradual returning to full activity at 5-7
months; all active nonoperative procedures listed in this Section IV.D. should be
considered.
3) Work restrictions should be evaluated every 4-6 weeks during post-operative recovery and
rehabilitation with appropriate written communications to both the patient and the
employer. Should progress plateau, the provider should reevaluate the patient's condition
and make appropriate adjustments to the treatment plan.
7. Rotator Cuff Tear:
Partial- or full-thickness tears of the rotator cuff tendons, most often the supraspinatus can be caused by
vascular, traumatic or degenerative factors or a combination. Further tear classification includes: a small
tear is less than 1cm; medium tear is 1-3cm; large tear is 3-5cm; and massive tear is greater than 5cm,
usually with retraction.
a. History and Initial Diagnostic Procedures (Rotator Cuff Tear)
1) Occupational Relationship – established with sudden trauma to the shoulder or chronic
overuse with repetitive overhead motion with internal or external rotation.
2) History may include:
a) Partial-thickness cuff tears usually occur in age groups older than 30. Fullthickness
tears can occur in younger age groups.
b) Complaints of pain along anterior, lateral or posterior glenohumeral joint.
b. Physical Findings (Rotator Cuff Tear) may include
1) Partial-Thickness Tear
a) There will be pain at the end of range-of-motion with full passive range-of-motion for
abduction, elevation, external rotation; internal rotation is attainable;
b) Active range-of-motion will be limited and painful for abduction and external rotation,
as well as internal rotation and forward flexion;
c) A painful arc may be present with active elevation;
d) Pain will be positive for resisted tests (abduction, flexion, external rotation, internal
rotation, abduction/internal rotation at 90°;, and abduction/external rotation at
45°;; and/or
e) If there are positive impingement signs, see this Section IV.B., Impingement
Syndrome.
2) Full-Thickness Tears
a) Passive and resisted findings are similar to those for partial-thickness tears; and/or
b) Active elevation will be severely limited with substitution of scapular rotation being
evident.
c. Laboratory Tests (Rotator Cuff Tear) are not indicated unless a systemic illness or disease is
suspected.
d. Testing Procedures (Rotator Cuff Tear)
1) Plain x-rays include
a) AP view visualizes elevation of the humeral head, indicative of absence of the rotator
cuff due to a tear;
b) Lateral view in the plane of the scapula or an axillary view determines if there is
anterior or posterior dislocation or the presence of a defect in the humeral head
(a Hill-Sachs lesion);
c) 30°; caudally angulated AP view determines if there is a spur on the anterior/interior
surface of the acromion and/or the far end of the clavicle; and
d) Outlet view determines if there is a downwardly tipped acromion.
2) Adjunctive testing should be considered when shoulder pain is refractory to 4-6 weeks of
nonoperative conservative treatment and the diagnosis is not readily identified by
standard radiographic techniques, then sonography, arthrography or MRI may be
indicated.
e. Nonoperative Treatment Procedures (Rotator Cuff Tear)
1) Medications, such as nonsteroidal anti-inflammatories and analgesics, would be indicated;
acute rotator cuff tear could indicate the need for limited narcotics use.
2) Relative rest and procedures outlined in this Section IV.D., such as immobilization, therapeutic
exercise, alteration of occupation/work station, thermal treatment, TENS unit, therapeutic
ultrasound, return-to-work, biofeedback and physical medicine and rehabilitation. If no
increase in function for a partial- or full-thickness tear is observed after 6-12 weeks, a
surgical consultation is indicated. Early surgical intervention produces better surgical
outcome due to healthier tissues and often less limitation of movement prior to and after
surgery.
f. Operative Procedures (Rotator Cuff Tear) options would include arthroscopic repair or an open
debridement and repair. Goals of surgical intervention are to restore functional anatomy by
reestablishing continuity of the rotator cuff, and to reduce the potential for repeated impingement
by the performance of procedures such as distal clavicular resection, coracoacromial ligament
release, and/or anterior acromioplasty.
g. Post-Operative Procedures (Rotator Cuff Tear) would include an individualized rehabilitation program
based upon communication between the surgeon and the therapist.
1) Individualized rehabilitation program based on communication between the surgeon and the
therapist might include:
a) Sling or abduction splint;
b) Gentle pendulum exercise, passive glenohumeral range-of-motion in flexion and
external rotation to prevent adhesions and maintain mobilization;
c) At 6 weeks post-operative begin isometrics and ADL involvement;
d) Active assisted range-of-motion in supine with progression to sitting;
e) At 6-8 weeks, depending on quality of tissue, begin light resistive exercise;
f) Pool exercise, manual resistive exercise to 90°;, scapula mobilization exercise with
glenohumeral stabilization; and
g) Scapula plane exercise.
2) Progressive resistive exercise from 3-6 months with gradual returning to full activity at 6-9
months. All active nonoperative procedures listed in this Section IV.D. should be
considered.
3) Work restrictions should be evaluated every 4-6 weeks during post-operative recovery and
rehabilitation with appropriate written communications to both the patient and employer.
Should progress plateau, the provider should reevaluate the patient's condition and make
appropriate adjustments to the treatment plan.
8. Rotator Cuff Tendinitis:
Inflammation of one or more of the four musculotendincus structures which arise from the scapula and
insert on the lesser or greater tuberosity of the humerus. These structures include one internal rotator
(subscapularis), and two external rotators (infraspinatus and teres minor), and the supraspinatus which
assists in abduction.
a. History and Initial Diagnostic Procedures (Rotator Cuff Tendinitis)
1) Occupational Relationship – may include symptoms of pain and/or achiness that occur after
repetitive use of the shoulder and/or blunt trauma to the shoulder.
b. Physical Findings (Rotator Cuff Tendinitis) may include
1) Pain with palpation to the shoulder with active or passive abduction and external rotation of
the shoulder (painful arc);
2) Pain with impingement signs; and/or
3) Pain with specific activation of the involved muscles.
c. Laboratory Tests (Rotator Cuff Tendinitis) are not indicated unless a systemic illness or disease is
suspected.
d. Testing Procedures (Rotator Cuff Tendinitis) may include
1) Plain x-ray films including AP lateral, axial, 30°; caudally angulated AP, Outlet view.
2) If shoulder pain is refractory to 4-6 weeks of nonoperative care and the diagnosis is not readily
identified by standard radiographic techniques, then adjunctive testing, such as MRI,
sonography or arthrography, may be indicated.
3) Subacromial space injection can be used as a diagnostic procedure by injecting an
anesthesia, such as sensorcaine or xylocaine solutions, into the space. If the pain is
alleviated with the injection the diagnosis is confirmed.
e. Nonoperative Treatment Procedures (Rotator Cuff Tendinitis) may include
1) Medications, such as nonsteroidal anti-inflammatories and analgesics. Subacromial space
injection may be therapeutic if the patient responded positively to a diagnostic injection of
an anesthetic. Injection of the corticosteroids directly into the tendons should be:
a) Avoided due to possible tendon breakdown and degeneration,
b) Limited to 3 injections per year at the same site, and
c) Avoided in patients under 30 years of age.
2) Procedures outlined in this Section IV.D. – such as relative rest, immobilization, thermal
treatment, ultrasound, therapeutic exercise, physical medicine and rehabilitation.
f. Operative Procedures (Rotator Cuff Tendinitis) are not indicated for this diagnosis.
9. Shoulder Fractures:
There are five common types of shoulder fractures; each type will be addressed separately and in the
order of most frequent occurrence.
a. Clavicular Fracture
1) History and Initial Diagnostic Procedures (Clavicular Fracture)
a) Occupational Relationship – can result from direct blows or axial loads applied to the
upper limb; commonly associated injuries include rib fractures, long-bone
fractures of the ipsilateral limb and scapulothoracic dislocations.
2) Physical Findings (Clavicular Fracture) may include
a) Pain in the clavicle;
b) Abrasions on the chest wall, clavicle and shoulder can be seen;
c) Deformities can be seen in the above regions; and/or
d) Pain with palpation and motion at the shoulder joint area.
3) Laboratory Tests (Clavicular Fracture) are not indicated unless a systemic illness or disease is
suspected.
4) Testing Procedures (Clavicular Fracture) would usually include routine chest x-rays. If they do
not reveal sufficient information, then a 20°; caudalcranial AP view centered over both
clavicles can be done.
5) Nonoperative Treatment Procedures (Clavicular Fracture)
a) Most are adequately managed by closed techniques and do not require surgery. After
reduction, the arm is immobilized in a sling or figure-8 bandage. Shoulder
rehabilitation is begun with pendulum exercises 10-14 days after injury.
Subsequently, with pain control, the therapy program can be progressed with
therapeutic approaches as seen in this Section IV.D.
b) Medication, such as analgesics and nonsteroidal anti-inflammatories, would be
indicated; narcotics may be indicated acutely for fracture and should be
prescribed as indicated use is indicated in this Section IV.C.
6) Operative Procedures (Clavicular Fracture) would be indicated for open fractures, vascular or
neural injuries requiring repair, bilateral fractures, ipsilateral scapular or glenoid neck
fractures, scapulothoracic dislocations, flail chest and nonunion displaced-closed
fractures that show no evidence of union after 4-6 months. Also a Type II
fracture/dislocation at the AC joint where the distal clavicular fragment remains with the
acromion and the coracoid, and the large proximal fragment is displaced upwards.
7) Post-Operative Procedures (Clavicular Fracture) would include an individualized rehabilitation
program based upon communication between the surgeon and the therapist. This
program would begin with 2-3 weeks of rest with a shoulder immobilizer while
encouraging isometric deltoid strengthening; pendulum exercises with progression to
assisted forward flexion and external rotation would follow; strengthening exercises
should be started at 10-12 weeks as seen in this Section IV.D.
b. Proximal Humeral Fractures
1) History and Initial Diagnostic Procedures (Proximal Humeral Fractures)
a) Occupational Relationship – may be caused by a fall onto an abducted arm; may also
be caused by high-energy (velocity or crush) trauma with an abducted or
nonabducted arm; associated injuries are common, such as glenohumeral
dislocation, stretch injuries to the axillary, musculocutaneous, and radial nerves;
axillary artery injuries with high energy accident.
2) Physical Findings (Proximal Humeral Fractures) may include
a) Pain in the upper arm;
b) Swelling and bruising in the upper arm, shoulder and chest wall;
c) Abrasions about the shoulder; and/or
d) Pain with any attempted passive or active shoulder motion.
3) Laboratory Tests (Proximal Humeral Fractures) are not indicated unless a systemic illness or
disease is suspected.
4) Testing Procedures (Proximal Humeral Fracture)
a) X-ray trauma series (3 views) are needed; AP view, axillary view and a lateral view in
the plane of the scapula. The latter two views are needed to determine if there is
a glenohumeral dislocation.
b) Vascular studies are obtained emergently if the radial and brachial pulses are absent.
c) Classification is by the Neer Method; there can be four fragments – the humeral shaft,
humeral head, greater tuberosity, and the lesser tuberosity. The fragments are
not truly considered fragments unless they are separated by 1cm or are
angulated 45°; or more.
5) Nonoperative Treatment Procedures (Proximal Humeral Fractures)
a) Impacted fractures of the humeral neck or greater tuberosity are managed
nonoperatively.
b) Isolated and minimally displaced (less than 1cm) fractures are treated nonoperatively.
c) Anterior or posterior dislocation associated with minimally displaced fractures can
usually be reduced by closed means, but a general anesthetic is needed.
d) Immobilization is provided with a sling, to support the elbow, or with an abduction
immobilizer if a nonimpacted greater tubercsity fragment is present.
e) Immobilization is continued for 4-6 weeks
f) Shoulder rehabilitation is begun with pendulum exercises 10-14 days after injury.
Subsequently, with pain control, the therapy program can be progressed with
therapeutic approaches as seen in this Section IV.D.
6) Operative Procedures (Proximal Humeral Fractures)
a) Indications for operative treatment would include
(1) Unstable surgical neck fractures (no contact between the fracture fragments).
(2) Partially unstable fractures (only partial contact) with associated same upper
extremity injuries.
(3) Displaced 3- and 4-part fractures may be managed by a prosthetic
hemiarthroplasty and reattachment of the tuberosities.
7) Post-Operative Procedures (Proximal Humeral Fractures) would include an individualized
rehabilitation program based upon communication between the surgeon and the
therapist.
a) See this Subsection IV.B.9., Shoulder Fracture, Nonoperative Treatment Procedures.
b) Schanz pins are removed from the greater tuberosity fragment at 2-3 weeks.
c) Schanz pins across the humeral neck are removed at 4-6 weeks.
c. Humeral Shaft Fractures
1) History and Initial Diagnostic Procedures (Humeral Shaft Fractures)
a) Occupational Relationship – a direct blow can fracture the humeral shaft at the
junction of its middle and distal thirds; twisting injuries to the arm will cause a
spiral humeral shaft fracture; high energy (velocity or crush) will cause a
comminuted humeral shaft fracture.
2) Physical Findings (Humeral Shaft Fractures) may include
a) Deformity of the arm;
b) Bruising and swelling; and/or
c) Possible sensory and/or motor dysfunction of the radial nerve.
3) Laboratory Tests (Humeral Shaft Fractures) are not indicated unless a systemic illness or
disease is suspected.
4) Testing Procedures (Humeral Shaft Fractures)
a) Plain x-rays including AP view and lateral of the entire humeral shaft.
b) Vascular studies if the radial pulse is absent.
c) Compartment pressure measurements if the surrounding muscles are swollen, tense
and painful and particularly if the fracture resulted from a crush injury.
5) Nonoperative Treatment Procedures (Humeral Shaft Fractures)
a) Most isolated humeral shaft fractures can be managed nonoperatively.
b) A coaptation splint may be applied. The splint is started in the axilla, extended around
the elbow and brought up to the level of the acromion. It is held in place with
large elastic bandages.
c) At 2-3 weeks after injury, a humeral fracture orthosis may be used to allow for full
elbow motion.
6) Operative Treatment (Humeral Shaft Fractures)
a) Indications for operative care would include
(1) Open fracture;
(2) Associated forearm or elbow fracture (i.e., the floating elbow injury);
(3) Burned upper extremity;
(4) Associated paraplegia;
(5) Multiple injuries (polytrauma);
(6) A radial nerve palsy which came on after closed reduction; and/or
(7) Pathologic fracture related to an occupational injury.
b) Accepted methods of internal fixation include:
(1) A broad plate and screws; and/or
(2) Intramedullary rodding with or without cross-locking screws.
7) Post-Operative Procedures (Humeral Shaft Fractures would include an individualized
rehabilitation program based upon communication between the surgeon and the
therapist. Following rigid internal fixation, therapy may be started to obtain passive and
later active shoulder motion using appropriate therapeutic approaches as seen in this
Section IV.D. Active elbow and wrist motion may be started immediately.
d. Scapula Fractures
1) History and Initial Diagnostic Procedures (Scapular Fractures)
a) Occupational Relationship – these are the least common of the fractures about the
shoulder and include acromial, glenoid, glenoid neck and scapular body
fractures. With the exception of anterior glenoid lip fractures caused by an
anterior shoulder dislocation, all other scapular fractures are due to a high energy
injury.
2) Physical Findings (Scapular Fractures) may include
a) Pain about the shoulder and thorax;
b) Bruising and abrasions;
c) Possibility of associated humeral or rib fractures; and/or
d) Assess vascular status (pulse evaluation and Doppler examination).
3) Laboratory Tests (Scapular Fractures), because of the association of high energy trauma, may
include a complete blood count, urinalysis and chest x-ray are warranted.
4) Testing Procedures (Scapular Fractures)
a) Trauma x-ray series – AP view axillary view, and a lateral view in the plane of the
scapula.
b) Arteriography if a vascular injury is suspected.
c) Electromyographic exam if nerve injuries are noted.
5) Nonoperative Treatment Procedures (Scapular Fractures)
a) Nondisplaced Acromial, coracoid, glenoid, glenoid neck and scapular body fractures
may all be treated with the use of a shoulder immobilizer.
b) Pendulum exercises may be started within the first week.
c) Progress to assisted range-of-motion exercises at 3-4 weeks using appropriate
therapeutic procedures as seen in this Section IV.D.
6) Operative Treatment (Scapular Fractures)
a) Acromial fractures which are displaced should be internally fixed to prevent a
nonunion. These fractures may be fixed with lagged screws and a superiorly
placed plate to neutralize the muscular forces.
b) Glenoid fractures which are displaced greater than 2-3 mm should be fixed internally.
The approach is determined by studying the results of a CT scan.
c) Scapular body fractures require internal fixation if the lateral or medial borders are
displaced to such a degree as to interfere with scapulothoracic motion.
d) Displaced fractures of the scapular neck and the ipsilateral clavicle require internal
fixation of the clavicle to reduce the scapular neck fracture.
7) Post-Operative Treatment (Scapular Fractures) would include an individualized rehabilitation
program based upon communication between the surgeon and the therapist using the
appropriate therapeutic procedures seen in this Section IV.D., a shoulder immobilizer is
utilized, pendulum exercises at one week, deltoid isometric exercises are started early,
and, at 4-6 weeks, active range-of-motion is commenced.
e. Sternoclavicular Dislocation/Fracture
1) History and Initial Diagnostic Procedures (Sternoclavicular Dislocation/Fracture)
a) Occupational Relationship – established with sudden trauma to the shoulder/anterior
chest wall; anterior dislocations of the sternoclavicular joint usually do not require
active treatment; however, symptomatic posterior dislocations will require
reduction.
2) Physical Findings (Sternoclavicular Dislocation/Fracture) may include
a) Pain at the sternoclavicular area;
b) Abrasions on the chest wall, clavicle and shoulder can be seen;
c) Deformities can be seen in the above regions; and/or
d) Pain with palpation and motion at the sternoclavicular joint area.
3) Laboratory Tests (Sternoclavicular Dislocation/Fracture) are not indicated unless a systemic
illness or disease is suspected.
4) Testing Procedures (Sternoclavicular Dislocation/Fracture)
a) Plain x-rays of the sternoclavicular joint are routinely done. When indicated,
comparative views of the contralateral limb may be necessary.
b) X-rays of other shoulder areas and chest wall may be done if clinically indicated.
c) Vascular studies should be considered if the history and clinical examination indicate
extensive injury.
5) Nonoperative Treatment Procedures (Sternoclavicular Dislocation/Fracture)
a) Symptomatic posterior dislocations should be reduced in the operating room under
general anesthesia.
b) Immobilize with a sling for 3-4 weeks. Subsequently, further rehabilitation may be
utilized using procedures set forth in this Section IV.D.
c) Medications, such as analgesics and nonsteroidal anti-inflammatories, would be
indicated; narcotics may be indicated acutely for fracture and should be
prescribed as indicated use is indicated in this Section IV.C.
6) Operative Procedures (Sternoclavicular Dislocation/Fracture) would be warranted following
failure of reduction by manipulation with pointed reduction forceps. Caution should be
utilized when pins or screws are used for stabilization secondary to migration.
7) Post-Operative Procedures (Sternoclavicular Dislocation/Fracture) would include an
individualized rehabilitation program based upon communication between the surgeon
and the therapist. This program would begin with 4-6 weeks of rest with a shoulder
immobilizer and be followed by pendulum exercises with progression to assisted forward
flexion and external rotation. Strengthening exercises should be started at 8-10 weeks.
10. Shoulder Instability:
Subluxation (partial dislocation) or dislocation of the glenohumeral joint in either an anterior, interior,
posterior or multidirectional position.
a. History and Initial Diagnostic Procedures (Shoulder Instability)
1) Occupational Relationship – instability should be apparent following a direct traumatic blow to
the shoulder, or indirectly by falling on an outstretched arm, or while applying significate
traction to the arm, or may also develop with a cumulative trauma to the shoulder.
Symptoms should be exacerbated or provoked by work and initially alleviated with a
period of rest. Symptoms may be exacerbated by other activities that are not necessarily
work related (e.g., driving a car).
2) History may include:
a) A slipping sensation in the arm;
b) Severe pain with inability to move the arm;
c) Abduction and external rotation produce a feeling that the shoulder might “come out”;
or
d) Feeling of shoulder weakness.
3) In subacute and/or chronic instabilities, age of onset of instability is important in the history.
Older age group (over age 30) has a propensity not to redislocate. Younger age groups
need a more aggressive treatment plan.
4) Avoid any aggressive treatment in patients with history of voluntary subluxation or dislocation.
These patients may need a psychiatric evaluation.
b. Physical Findings (Shoulder Instability) may include
1) Anterior dislocations would likely include loss of normal shoulder contour; a fullness in the
axilla; pain over the shoulder with any motion and often the patient holding the extremity
in a very still position;
2) Posterior dislocations usually occur with a direct fall on the shoulder or outstretched arm
resulting in posteriorly directed forces to the humeral head. These patients present with
inability to externally rotate the shoulder;
3) Neurologic examination could reveal most commonly axillary nerve injuries, but occasionally
musculocutaneous nerve injuries are seen; and/or
4) Abduction and external rotation positioning will produce pain in those who have anterior
instability. Direct posterior stress in a supine position will produce pain in those with
posterior instability. Longitudinal traction will produce a “sulcus sign” (a large dimple on
the lateral side of the shoulder) when there is inferior instability.
c. Laboratory Tests (Shoulder Instability) are not indicated unless a systemic illness or disease is
suspected.
d. Testing Procedures (Shoulder Instability)
1) Plain x-rays to rule out bony deficit on the glenoid, including AP, axillary view, lateral in the
plane of the scapula and possibly the West Point view. Axillary view to identify larger HillSachs lesion of humeral head.
2) On more difficult diagnostic cases with subtle history and physical findings suggesting
instability, MRI, or a CT assisted arthrogram or MRI assisted arthrogram may be ordered
for lateral detachment after 4-8 weeks of therapy. (This is done only after other
conservative therapies have failed.)
e. Nonoperative Treatment Procedures (Shoulder Instability)
1) First-Time Acute Severe Bony Involvement:
a) Therapeutic Procedures
(1) Immobilization
(2) Therapeutic Exercise
(3) Alteration of Occupation & Work Station
(4) Thermal Treatment
(5) TENS Unit
(6) Ultrasound
b) May not return to work with overhead activity or lifting with involved arm until cleared
by physician for heavier activities.
c) Additional modalities may include
(1) Biofeedback
(2) Physical Medicine and Rehabilitation
(a) Instruction in Therapeutic Exercise and Proper Work Techniques
(b) Manual Therapy Techniques
(3) Psychosocial Intervention
(4) Work Conditioning
(a) Vocational Rehabilitation
(b) Vocational Assessment
(c) Interdisciplinary Team Approach
1] Work Hardening
2] Functional Restoration Programs
3] Pain Clinics
d) Medications – medication discussions are in this Section IV.C.
(1) Analgesics
(2) Anti-inflammatories
2) Acute or chronic dislocations with large fracture fragments contributing to instability;
a) Attempt to treat with immobilization if in acceptable position, otherwise repair
surgically
b) Return-to-work may be directly related to time it takes for the fracture to heal
3) Subacute and/or chronic instability:
a) Provocative dislocation should first be treated similarly to acute dislocation.
b) If acute treatment is unsuccessful, and still having findings of instability, would
consider operative repair.
f. Operative Procedures (Shoulder Instability)
1) Identify causative agent for the instability (i.e., labral detachment, bony lesion, or
multidirectional instability), then proceed with
a) Bony block transfer;
b) Capsular tightening; or
c) Bankart lesion repair.
g. Post-Operative Procedures (Shoulder Instability) would include an individualized rehabilitation program
based upon communication between the surgeon and the therapist. Depending upon the type of
surgery, the patient will be immobilized for 3-6 weeks. As soon as it is safe to proceed without
damaging the repair, progressive therapy with consultation involving an occupational and/or
physical therapist should begin with therapeutic exercise, physical medicine and rehabilitation
(refer to this Section IV.D.). During this period of time, the patient could resume working when
1) A job assessment results in the treating physician's identification of needed modifications and
restrictions;
2) The patient has attained a general level of comfort;
3) Medications which would predispose to injury are no longer being prescribed or used; and
4) The treating physician has cleared the patient for the specific vocational activities.
MMI can be expected 3 months after non operative medications and 3-6 months after operative
medications. Further job assessment and adjusted work restrictions may be needed prior to the patients
return to full duty.
C. MEDICATIONS:
For 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.
1. Nonsteroidal 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.
a.
b.
c.
d.
Time to produce
effect:
Frequency:
Optimum duration:
Maximum continuous
duration:
Acute Pain
/ Chronic Pain
3-7 days
1-4 times/day
2 weeks
/ 3-7 days
/ 1-4 times/day
/ Up to 1 year
6 weeks
/ 1 year
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.
2. Analgesics
(acetaminophen and acetylsalicylic acid) are the common choice for non-narcotic analgesia.
a. Time to produce effect: immediate, usually ineffective in severe attacks
b. Frequency: 3-5 times/day
c. Optimum duration: 3-4 days
d. Maximum continuous duration: 6 weeks
3. Psychotropic 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, should be considered for psychological and/or psychiatric consultation. In particular,
benzodiazepams are almost always contraindicated in patients with shoulder injury unless a severe
anxiety state exists 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.
a. Time to produce effect: 2-3 weeks
b. Frequency: for tricyclics, prefer single dose at night
c. Optimum duration: 1-6 months
d. Maximum duration: 6-12 months, with monitoring
4. Hypnotics
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 anti-depressants as an alternative when necessary.
Physical methods of restoring a normal sleep pattern can usually be employed as an alternative to
medication.
a. Time to produce effect: 1-3 days
b. Frequency: at night
c. Optimum duration: 1 week
d. Maximum duration: 2-3 weeks
5. Narcotics
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.
a. Time to produce effect: immediate
b. Frequency: every 3-4 hours
c. Optimum duration: 3 days
d. Maximum duration: 2 weeks
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. Minor 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.
a. Time to produce effect: 1 day
b. Frequency: 1-4 times/day; preferably just at night
c. Optimum duration: 1 week
d. Maximum duration: 4 weeks
D. NONOPERATIVE TREATMENT PROCEDURES:
1. Immobilization
time is dependent upon type of injury, then progress with muscle girdle strengthening
a. Time to produce effect: 1 day
b. Frequency: once
c. Optimum duration: 1 week
d. Maximum duration: 12 weeks
The arm is immobilized in a sling for 1-12 weeks postinjury, depending upon the age of the patient. The
patient is instructed in Isometric exercises while in the sling for the internal and external rotators and the
deltoid.
2. Relative Rest
may last 3-5 weeks and require job modification/modified duty so as not to exacerbate the acute inflamed
shoulder.
3. Therapeutic Exercise
where the therapist instructs the patient in a supervised clinic and home program to increase strength of
the supporting shoulder musculature. Motions and muscles to be strengthened include shoulder internal
and external rotators, abductors and scapula stabilizers. Isometrics are performed initially, progressing to
Isotonic exercises as tolerated.
a. Frequency of visits: 2-3 times/week for 8-12 wks Weeks 1-3: Isometrics in sling Weeks 3-8:
Progressive Isotonic exercises Weeks 8-12: Begin overhead activities when the rotator cuff
strength is normalized and full active elevation has been achieved.
4. Alteration of Occupation and Work Station
early evaluation and training of body mechanics and joint protection and other ergonomic factors is
essential and should be done by a qualified individual. Ergonomic risk factors to be addressed include
repetitive overhead work, lifting and/or tool use.
5. Thermal Treatment
includes applications of heat and cold (superficial and deep); therapeutic modalities in this group are
generally accepted, established and widely used procedures.
a. Time to produce effect: 2-4 treatments
b. Frequency: 2-3 times/week up to 3 weeks, decreasing to 1-2 times/week after 1 month. Ongoing
thermal treatment may be self-administered by the unsupervised patient
c. Optimum duration: 2-3 months in conjunction with other therapies
6. Transcutaneous Electrical Nerve Stimulation (TENS)
is generally accepted, established and widely used but the mode of action is poorly understood.
a. Time to produce effect: 1 or 2 sessions per trial, up to 3 trials
b. Frequency: 2-3 times/week (supervised) for 3 weeks; during this supervised period, the patient may
utilize the TENS unit daily on a self-monitored basis after receiving instructions
c. Optimum duration: 1-3 months
Initially, TENS should be prescribed within a supervised setting in order to assure proper electrode
placement and patient education. TENS can be used for short-term pain control. If the response to three
treatments is beneficial, it may be continued for 1-3 months and for intermittent unsupervised use
thereafter if it facilitates objective functional gains. The Division would not recommend purchase of a
TENS unit until efficacy has been substantiated after a 90-day trial period. It may be occasionally useful in
specific myofascial pain cases within the above time frames.
7. Therapeutic Ultrasound With or Without Electric Stimulation
using sonic generators to deliver acoustic energy for therapeutic thermal and/or nonthermal soft tissue
treatment. There may be a concurrent delivery of electrical energy and/or medication (iontophoresis).
Indications include scar tissue, adhesions, collagen fiber and muscle spasm, and the need to extend
muscle tissue or accelerate the soft tissue healing.
a. Time to produce effect: 6-15 treatments
b. Frequency: 3 times/week
c. Optimum duration: 4 weeks
8. Electrical Therapeutic Modality
can be utilized as an adjunct for recovery. In order to justify its use, one must provide documentation
regarding functional gains.
a. Time to produce effect: 8-12 sessions
b. Frequency: 3 times/week
c. Optimum duration: 4 weeks
9. Return-to-Work
May return to work with no overhead activity, lifting, or repetitive motion with the involved arm until cleared
by the primary treating physician for heavier activities. Each case regarding task tolerance should be
individualized based on the diagnosis and job demands.
10. Biofeedback
is the use of physiological monitoring equipment to:
a. Improve the patient's awareness and control of muscle activity;
b. Reinforce the release of muscle tension that is being obtained from stretches and exercises;
c. Decrease sympathetic arousal that is associated with stress;
d. Improve the patient's ability to feel like they can affect their physical responses and symptoms;
e. Assist in avoiding reinjury through the individual returning to repetitive movement and bracing patterns;
or
f. Prepare for surgery.
Treatment time may or may not overlap return-to-work or MMI.
1) Time to produce effect: 3-4 sessions
2) Frequency: 1-2 times/week
3) Optimum duration: 5-6 sessions
4) Maximum duration: 10-12 sessions
11. Physical Medicine and Rehabilitation
a. Instruction in Therapeutic Exercise and Proper Work Techniques: an active therapeutic exercise
program may be beneficial and should contain elements of improving patient flexibility, mobility,
posture/body mechanics, activities-of-daily-living, splinting, bracing, sensory reeducation,
endurance, strength and education.
1) Time to produce effect: 2 weeks
2) Frequency: 2-3 times/week
3) Optimum duration: 4-6 weeks
4) Maximum duration: 12 weeks
b. Manual Therapy Techniques: soft tissue mobilization/manipulation techniques may be used as an
adjunctive treatment modality.
c. Post-Operative Treatment may include scar/adhesion reduction techniques.
12. Work Simulation
modalities are generally accepted, wellestablished and widely used. They are simulated activities of daily
living including those generally performed by disabled workers in the work place. If placement at modified
duty at the work place is unavailable, work simulation should run concurrently or sequentially based upon
analysis of physical capacity and job analysis:
a. Time to produce effect: 1-3 weeks
b. Frequency: 2-5 times/week
c. Optimum duration: 2-3 weeks
d. Maximum duration: 3-6 weeks
Work simulation is generally followed either by work hardening, return to work, or a combination thereof
(see for Work Hardening additional discussion).
13. Personality/Psychological/Psychosocial Evaluations
are generally accepted and well-established diagnostic procedures with selected use in the shoulder
population, but have more widespread use in the subacute and chronic shoulder population. These
procedures may be useful for patients with delayed recovery, chronic pain, recurrent painful conditions,
suspected concomitant closed head injury, disability problems and pre-operative evaluation, as well as a
possible predictive value for post-operative response. Results may provide clinicians with a better
understanding of the patient, thus allowing for more effective rehabilitation. Formal psychological or
psychosocial screening should be performed on patients not making expected progress within 6-12
weeks following injury and whose subjective symptoms do not correlate with objective signs and tests.
This testing will determine the need for further psychosocial interventions. Evaluations should be
performed by an individual with PH.D., PSY.D., L.S.W. or Psychiatric M.D./D.O. credentials. Initial
psychological screening is generally completed within one hour. If psychometric testing is indicated as a
portion of the initial screening process, the time for such testing should not exceed an additional two
hours of professional time.
14. Vocational Rehabilitation
is a generally accepted intervention, but Colorado limits its use as a result of Senate Bill 87-79. Initiation
of vocational rehabilitation requires adequate evaluation of patients for quantification of highest functional
level, motivation and achievement of MMI. Vocational rehabilitation may be as simple as returning to the
original job or as complicated as being retrained for a new occupation.
15. 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 and
date of MMI, then implementation of a timely vocational assessment can provide valuable guidance in the
determination of future rehabilitation program design. Clarification of rehabilitation goals optimize both
patient motivation and utilization of rehabilitation resources. Except in the most extenuating
circumstances, this process should be implemented within 3-12 months post-injury at the latest, if
prognosis for return to former occupation is determined to be guarded to poor. Declaration of MMI should
not be delayed solely due to lack of attainment of a vocational assessment.
16. Interdisciplinary Team Approach
interventions are generally accepted, well-established and widely used. This approach includes work
hardening programs, functional restoration programs and pain clinics. In general, these programs are
more comprehensive, time consuming and costly and are, therefore, appropriate for patients with greater
levels of (perceived) disability, dysfunction, deconditioning and psychological involvement. For shoulder
injury cases, all interdisciplinary teams should include a physical therapist and/or occupational therapist
who specializes in the upper extremity.
a. Functional Restoration Programs are intended for patients with both physical deconditioning and/or
significant psychological and socioeconomic involvement. It encompasses work hardening,
quantification of function, disability management, adjustment counseling and outcome review.
The interdisciplinary team must consist of physicians and therapists working in a structured
environment. The Division recommends an interdisciplinary team include physical therapy,
occupational therapy and psychology or at least related supervised personnel addressing the
physiologic, psychologic and ergonomic factors impacting a patient's shoulder injury presentation.
Regular, documented interdisciplinary team meetings to discuss patient progress and upgrade
rehabilitation goals must be a part of any credible interdisciplinary approach. The Division
recommends programs which meet criteria consistent with those for work hardening established
by CARF. In nonsurgical shoulder injury patients with evidence of delayed recovery, the Division
strongly recommends referral to an interdisciplinary/functional restoration program within three
months post-injury.
1) Time to produce effect: 4-6 weeks
2) Frequency: 2-6 times/week
3) Optimum duration: 6-12 weeks
4) Maximum duration: 4 months
b. Work Hardening Programs are generally more comprehensive than work simulation programs and
include education, reconditioning and specific work simulation with respect to task quality,
quantity and intensity (for further discussion, refer to Work Simulation). The Division recommends
the Commission for the Accreditation of Rehabilitation Facilities (CARF) eligibility and/or
accreditation of work hardening programs for all facilities treating injured workers to assure that
such programs meet certain standards involving program design and efficacy. Work hardening is
generally initiated after reconditioning or functional restoration has been completed if 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. As discussed in Vocational
Assessment, identification of realistic vocational goals is essential for the successful completion
of a work hardening program. Generally, work hardening programs entail a progressive increase
in the number of hours per day that a patient completes work simulation tasks until the patient
can tolerate a full work day:
1) Time to produce effect: 2-4 weeks
2) Frequency: 2-5 times/week
3) Optimum duration: 4-6 weeks
4) Maximum duration: 2-3 months
c. Pain Clinics have been the traditional rehabilitation program for chronically disabled shoulder patients
who have not responded to functional restoration interventions. In general, pain clinics deal with
irreversible, painful neurological disorders and psychological issues, including drug dependence,
high levels of stress and anxiety, failed surgery and preexisting or latent psychopathology. The
Division recommends CARF eligibility and/or accreditation of pain clinics treating injured workers
to assure that such programs meet certain standards involving program design and efficacy. The
Division also recommends consideration of referral to a pain clinic within 6 months post-injury in
those patients with delayed recovery unless surgical interventions or other medical complications
intervene. It may be useful in determining the appropriateness of referral to a pain clinic to
consider the Colorado Foundation for Medical Care's “Criteria for Outpatient (or Inpatient)
Management of Chronic Pain.”
1) Time to produce effect: 3-8 weeks
2) Frequency: 2-7 times/week for first month decreasing to 2-3 times/week thereafter
3) Optimum duration: 6-12 weeks, including follow-up for outpatient pain clinics; 3-4 weeks for
inpatient pain clinics
4) Maximum duration: 4 months, including follow-up
Periodic review and monitoring on an as-needed basis is thereafter founded upon the documented
maintenance of functional gains.
RULE XVII, EXHIBIT B-V Cumulative Trauma Disorder (CTD) Medical Treatment Guidelines July 30,
2003 (Previously Adopted March 2, 1995 and Revised December 30, 1996, and March 15,
1998)
Presented By:
State of Colorado Department of Labor and Employment DIVISION OF WORKERS'
COMPENSATION
TABLE OF CONTENTS
A. INTRODUCTION
B. GENERAL GUIDELINE PRINCIPLES
1. APPLICATION OF GUIDELINES
2. EDUCATION
3. TREATMENT PARAMATER DURATION
4. ACTIVE INTERVENTIONS
5. ACTIVE THERAPEUTIC EXERCISE PROGRAM
6. POSITIVE PATIENT RESPONSE
7. RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS
8. SURGICAL INTERVENTIONS
9. SIX-MONTH TIME FRAME
10. RETURN-TO-WORK
11. DELAYED RECOVERY
12. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE
13. CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI)
C. DEFINITION AND MECHANISMS OF INJURY:
D. INTTIAL DIAGNOSTIC PROCEDURES
1. HISTORY:
a. Description of Symptoms:
b. Identification of Occupational Risk Factors:
c. Demographics: age, hand dominance, gender, etc.
d. Past Medical History and Review of Systems:
e. Activities of Daily Living (ADLs):
f. Avocational Activities:
g. Social History:
2. PHYSICAL EXAMINATION
3. PAIN BEHAVIOR EVALUATION
4. RISK FACTORS
5. MEDICAL CAUSALITY ASSESSMENT FOR CUMULATIVE TRAUMA DISORDERS
6. STAGING
STAGE 1
STAGE 2
STAGE 3
STAGE 4
E. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES
1. ELECTRODIAGNOSTIC (EDX) STUDIES
2. IMAGING STUDIES
a. Radiographic Imaging
b. MRI
3. ADJUNCTIVE TESTING
a. Personality/Psychological/Psychosocial Evaluations
b. Laboratory Tests
c. Pinch And Grip Strength Measurements
d. Quantitative Sensory Testing (QST)
4. SPECIAL TESTS
a. Computer-Enhanced Evaluations
b. Functional Capacity Evaluation (FCE)
c. Job Site Evaluation
d. Vocational Assessment
e. Work Tolerance Screening
F. THERAPEUTIC PROCEDURES – NON-OPERATIVE
1. ACUPUNCTURE
a. Acupuncture - Definition
b. Acupuncture with Electrical Stimulation
c. Other Acupuncture Modalities
2. BIOFEEDBACK
3. INJECTIONS – THERAPEUTIC
a. Steroid Injections
b. Trigger Point Injections
4. JOB SITE ALTERATION
a. Ergonomic changes
b. Interventions
c. Seating Description
d. Job Hazard Checklist
5. MEDICATIONS
a. Acetaminophen
b. Minor Tranquilizer/Muscle Relaxants
c. Narcotics
d. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
e. Psychotropic/Anti-anxiety/Hypnotic Agents
f. Tramadol
g. Topical Drug Delivery
6. OCCUPATIONAL REHABILITATION PROGRAMS
a. Non-Interdisciplinary
b. Interdisciplinary
7. PATIENT EDUCATION
8. PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION
9. RETURN TO WORK
a. Establishment of Return-To-Work
b. Establishment of Activity Level Restrictions
c. Compliance with Activity Level Restrictions
10. SLEEP DISTURBANCES
11. THERAPY-ACTIVE
a. Activities of Daily Living
b. Functional Activities
c. Nerve Gliding
d. Neuromuscular Re-education
e. Proper Work Techniques
f. Therapeutic Exercise
12. THERAPY - PASSIVE
a. Electrical Stimulation (Unattended)
b. Extracorporeal shock wave treatment
c. Iontophoresis
d. Laser irradiation
e. Manual Therapy Techniques
f. Massage
g. Orthotics/Immobilization with Splinting
h. Superficial Heat and Cold Therapy
i. Ultrasound
13. RESTRICTION OF ACTIVITIES
14. VOCATIONAL REHABILITATION
G. OPERATIVE TREATMENT:
1. PERIPHERAL NERVE DECOMPRESSION:
a. Median Nerve Decompression at the Wrist (carpal tunnel release)
b. Median Nerve Decompression in the Forearm (pronator teres or flexor digitorum
superficialis release)
c. Ulnar Nerve Decompression at the Wrist (ulnar tunnel release or Guyon's canal
release)
d. Ulnar Nerve Decompression/Transposition at the Elbow
e. Radial Sensory Nerve Decompression at the Wrist
f. Radial Nerve Decompression at the Elbow
g. Thoracic Outlet Syndrome
2. TENDON DECOMPRESSION OR DEBRIDEMENT
a. Subacromial Decompression
b. Medial or Lateral Epicondyle Release/Debridement
c. First Extensor Compartment Release (de Quervain's Tenosynovitis)
d. Trigger Finger/Thumb Release
3. CONSIDERATIONS FOR POST-OPERATIVE THERAPY ARE:
a. Immobilization
b. Home Program
c. Supervised Therapy Program
A. INTRODUCTION
This document has been prepared by the Colorado Department of Labor and Employment, Division of
Workers' Compensation (Division) and should be interpreted within the context of guidelines for
physicians/providers treating individuals qualifying under Colorado's Workers' Compensation Act as
injured workers with CTD.
Although the primary purpose of this document is advisory and educational, these guidelines are
enforceable under the Workers' Compensation rules of Procedure, 7 CCR 1101-3. The Division
recognizes that acceptable medical practice may include deviations from these guidelines, as individual
cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of
professional care.
To properly utilize this document, the reader should not skip nor overlook any sections.
B. GENERAL GUIDELINE PRINCIPLES
The principles summarized in this section are key to the intended implementation of all Division of
Workers' Compensation guidelines and critical to the reader's application of the guidelines in this
document.
1. Application of Guidelines
The Division provides procedures to implement medical treatment guidelines and to foster communication
to resolve disputes among the provider, payer and patient through the Worker's Compensation Rules of
Procedure, Rule XVII and Rule VIII. In lieu of more costly litigation, parties may wish to seek
administrative dispute resolution services through the Division.
2. Education
Education of the patient and family, as well as the employer, insurer, policy makers and the community
should be the primary emphasis in the treatment of CTD and disability. Currently, practitioners often think
of education last, after medications, manual therapy and surgery. Practitioners must develop and
implement an effective strategy and skills to educate patients, employers, insurance systems, policy
makers and the community as a whole. An education-based paradigm should always start with
inexpensive communication providing reassuring information to the patient. More in-depth education
currently exists within a treatment regime employing functional restorative and innovative programs of
prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or
group patient education as a means of facilitating self-management of symptoms and prevention.
3. Treatment Paramater Duration
Time frames for specific interventions commence once treatments have been initiated, not on the date of
injury. Obviously, duration will be impacted by patient compliance, as well as availability of services.
Clinical judgment may substantiate the need to accelerate or decelerate the time frames discussed in this
document.
4. Active Interventions
Interventions emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment,
are generally emphasized over passive modalities, especially as treatment progresses. Generally,
passive interventions are viewed as a means to facilitate progress in an active rehabilitation program with
concomitant attainment of objective functional gains.
5. Active Therapeutic Exercise Program
Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and
education. This includes functional application in vocational or community settings.
6. Positive Patient Response
Positive results are defined primarily as functional gains that can be objectively measured. Objective
functional gains include, but are not limited to, positional tolerances, range-of-motion, strength,
endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures
that can be quantified. Subjective reports of pain and function should be considered and given relative
weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on
objective findings.
7. Re-Evaluate Treatment Every 3 to 4 Weeks
If a given treatment or modality is not producing positive results within 3 to 4 weeks, the treatment should
be either modified or discontinued. Reconsideration of diagnosis should also occur in the event of poor
response to a seemingly rational intervention.
8. Surgical Interventions
Surgery should be contemplated within the context of expected functional outcome and not purely for the
purpose of pain relief. The concept of “cure” with respect to surgical treatment by itself is generally a
misnomer. All operative interventions must be based upon positive correlation of clinical findings, clinical
course and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific
diagnosis with positive identification of pathologic conditions.
9. Six-Month Time Frame
The prognosis drops precipitously for returning an injured worker to work once he/she has been
temporarily totally disabled for more than six months. The emphasis within these guidelines is to move
patients along a continuum of care and return-to-work within a six-month time frame, whenever possible.
It is important to note that time frames may not be pertinent to injuries that do not involve work-time loss
or are not occupationally related.
10. Return-to-Work
Return-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 and the patient should never be
released to “sedentary” or “light duty.” The following physical limitations should be considered and
modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, bending at the waist,
awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data
entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors. Even if there is
residual chronic pain, return-to-work is not necessarily contraindicated.
The practitioner should understand all of the physical demands of the patient's job position before
returning the patient to full duty and should request clarification of the patient's job duties. Clarification
should be obtained from the employer or, if necessary, including, but not limited to, an occupational health
nurse, occupational therapist, vocational rehabilitation specialist, or an industrial hygienist.
11. Delayed Recovery
Strongly consider a psychological evaluation, if not previously provided, as well as initiating
interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to
make expected progress 6 to 12 weeks after an injury. The Division recognizes that 3 to 10% of all
industrially injured patients will not recover within the timelines outlined in this document despite optimal
care. Such individuals may require treatments beyond the limits discussed within this document, but such
treatment will require clear documentation by the authorized treating practitioner focusing on objective
functional gains afforded by further treatment and impact upon prognosis.
12. Guideline Recommendations and Inclusion of Medical Evidence
Guidelines are recommendations based on available evidence and/or consensus recommendations.
When possible, guideline recommendations will note the level of evidence supporting the treatment
recommendation. When interpreting medical evidence statements in the guideline, the following apply:
Consensus means the opinion of experienced professionals based on general medical principles.
Consensus recommendations are designated in the guideline as “generally well accepted,”
“generally accepted,” “acceptable,” or “well established.”
“Some” means the recommendation considered at least one adequate scientific study, which
reported that a treatment was effective.
“Good” means the recommendation considered the availability of multiple adequate scientific
studies or at least one relevant high-quality scientific study, which reported that a treatment was
effective.
“Strong” means the recommendation considered the availability of multiple relevant and high
quality scientific studies, which arrived at similar conclusions about the effectiveness of a
treatment.
All recommendations in the guideline are considered to represent reasonable care in appropriately
selected cases, regardless of the level of evidence or consensus statement attached to it. Those
procedures considered inappropriate, unreasonable, or unnecessary are designated in the guideline as
being “not recommended.”
13. Care Beyond Maximum Medical Improvement (MMI)
MMI should be declared when a patient's condition has plateaued to the point where the authorized
treating physician no longer believes further medical intervention is likely to result in improved function.
However, some patients may require treatment after MMI has been declared in order to maintain their
functional state. The recommendations in this guideline are for pre-MMI care and are not intended to limit
post-MMI treatment.
The remainder of this document should be interpreted within the parameters of these guideline principles
that may lead to more optimal medical and functional outcomes for injured workers.
C. DEFINITION AND MECHANISMS OF INJURY:
Cumulative Trauma Disorders (CTDs) of the upper extremity comprise a heterogeneous group of
diagnoses which include numerous specific clinical entities, including disorders of the muscles, tendons
and tendon sheaths, nerve entrapment syndromes, joint disorders, and neurovascular disorders.
The terms “cumulative trauma disorder”, “repetitive motion syndrome”, “repetitive strain injury” and other
similar nomenclatures are umbrella terms that are not acceptable diagnoses. The health care provider
must provide specific diagnoses in order to appropriately educate, evaluate, and treat the patient.
Examples include DeQuervain's tendonitis, cubital tunnel syndrome, lateral/medial epicondylitis,
olecranon bursitis, and hand-arm vibration syndrome. Many patients present with more than one
diagnosis, which requires thorough upper extremity and cervical evaluation by the health care provider.
Furthermore, there must be a causal relationship between work activities and the diagnosis (see Initial
Diagnostic Procedures). The mere presence of a diagnosis that may be associated with cumulative
trauma does not presume work-relatedness unless the appropriate work exposure is present.
Mechanisms of injury for the development of CTDs remain controversial. Posture, repetition, force,
vibration, cold exposure, and combinations thereof are postulated and generally accepted as risk factors
for the development of CTDs. Evaluation of a CTD requires an integrated approach that incorporates
ergonomics, clinical assessment, and psychosocial evaluation on a case-by-case basis.
D. INITIAL DIAGNOSTIC PROCEDURES
History and physical examination (Hx & PE) are generally accepted, well established and widely used
procedures which establish the foundation/basis for and dictate all other diagnostic and therapeutic
procedures. When findings of clinical evaluations and those of other diagnostic procedures do not
complement each other, the objective clinical findings should have preference.
1. History:
Should inquire about the following issues, where relevant, and document pertinent positives and
negatives where appropriate. In evaluating potential Cumulative Trauma Disorders (CTDs), the following
actions should be taken:
a. Description of Symptoms:
1) Onset: date of onset, sudden vs. gradual;
2) Nature of Symptoms: pain, numbness, weakness, swelling, stiffness, temperature change, color
change;
3) Intensity: pain scale (0 = no pain, and 10 = worst imaginable pain) may be used.
4) Location and Radiation: use of a pain diagram is encouraged for characterizing sensory symptoms;
use comprehensive diagrams and do not use limited diagrams depicting only the hand or arm, as
it is important to solicit the reporting of more proximal symptoms;
5) Provocative and Alleviating Factors (occupational and non-occupational): Attempt to identify the
specific physical factors that are aggravating or alleviating the problem;
6) Sleep disturbances;
7) Other associated signs and symptoms noted by the injured worker;
b. Identification of Occupational Risk Factors:
Job title alone is not sufficient information. The clinician is responsible for documenting specific
information regarding repetition, force and other risk factors, as listed in the Risk Factors Associated with
Cumulative Trauma Table. A job site evaluation may be required.
c. Demographics: age, hand dominance, gender, etc.
d. Past Medical History and Review of Systems:
1) Past injury/symptoms involving the upper extremities, trunk and cervical spine;
2) Past work-related injury or occupational disease;
3) Past personal injury or disease that resulted in temporary or permanent job limitation;
4) Medical conditions associated with CTD - A study of work-related upper extremity disorder patients
showed a 30% prevalence of co-existing disease. Medical conditions commonly occurring with
CTD include:
a) Pregnancy,
b) Arthropathies including connective tissue disorders, rheumatoid arthritis, systemic lupus
erythematosus, gout, osteoarthritis and spondyloarthropathy,
c) Amyloidosis,
d) Hypothyroidism, especially in older females,
e) Diabetes mellitus, including family history or gestational diabetes,
f) Acromegaly,
g) Use of corticosteroids.
e. Activities of Daily Living (ADLs):
ADLs include such activities as self care and personal hygiene, communication, ambulation, attaining all
normal living postures, travel, non-specialized hand activities, sexual function, sleep, and social and
recreational activities. Specific movements in this category include pinching or grasping keys/pens/other
small objects, grasping telephone receivers or cups or other similar-sized objects, and opening jars. The
quality of these activities is judged by their independence, appropriateness, and effectiveness. Assess not
simply the number of restricted activities but the overall degree of restriction or combination of restrictions.
f. Avocational Activities:
Information must be obtained regarding sports, recreational, and other avocational activities that might
contribute to or be impacted by CTD development. Activities such as hand-operated video games,
crocheting/needlepoint, home computer operation, golf, tennis, and gardening are included in this
category.
g. Social History:
Exercise habits, alcohol consumption, and psychosocial factors.
2. Physical Examination
The evaluation of any upper extremity complaint should begin at the neck and upper back and then
proceed down to the fingers and include the contralateral region. It should include evaluation of vascular
and neurologic status, and describe any dystrophic changes or variation in skin color or turgor. A
description of the patient's body habitus (e.g., neck rotation, shoulder depression, spine kyphosis), and
anthropometric measurements, e.g. BMI (body mass index), should be documented. Refer to the Physical
Examination and Findings Reference Table.
Table 2: Physical Examination Findings Reference Table (continues on next page)
DIAGNOSIS
DeQuervain's
Tenosynovitis
Extensor Tendinous
Disorders
Flexor Tendinous
SYMPTOMS
Pain and swelling in the
anatomical snuffbox; pain
radiating into the hand
and forearm; pain
worsened by thumb
abduction and/or
extension.
Pain localized to the
affected tendon(s); pain
worsened by active
and/or resisted wrist or
finger extension.
Pain localized to the
SIGNS
Pain worsened by active
thumb abduction and/or
extension; crepitus along
the radial forearm;
positive Finkelstein's.
Swelling along the dorsal
aspects of the hand/wrist/
forearm, and pain with
active and/or resisted
wrist/digit extension, or
creaking/crepitus with
wrist extension.
Pain with wrist/digit
Disorders
Lateral Epicondylitis
Medial Epicondylitis
Cubital tunnel syndrome
Hand-Arm Vibration
Syndrome
affected tendons; pain in
the affected tendons
associated with wrist
flexion and ulnar
deviation, especially
against resistance.
Lateral elbow pain
exacerbated by repetitive
wrist motions; pain
emanating from the
lateral aspect of the
elbow.
Pain emanating from the
medial elbow; mild grip
weakness; medial elbow
pain exacerbated by
repetitive wrist motions.
Activity-related
pain/paresthesias
involving the 4th and 5th
fingers coupled with pain
in the medial aspect of
the elbow;
pain/paresthesias worse at
night; decreased sensation
of the 5th finger and ulnar
half of the ring finger
(including dorsum 5th
finger); progressive
inability to separate
fingers; loss of power
grip and dexterity;
atrophy/weakness of the
ulnar intrinsic hand
muscles (late sign).
Pain/paresthesias in the
digits; blanching of the
digits; cold intolerance;
tenderness/swelling of the
digits/hand/forearm;
muscle weakness of the
hand; joint pains in
hand/wrist/elbow/neck/
shoulders; trophic skin
changes and cyanotic
flexion and ulnar
deviation, or crepitus with
active motion of the
flexor tendons.
Pain localized to lateral
epicondyle with resisted
wrist extension and/or
resisted supination.
Pain localized to the
medial epicondyle with
resisted wrist flexion and
resisted pronation.
Diminished sensation of
the fifth and ulnar half of
the ring fingers; elbow
flexion/ulnar compression
test; Tinels' sign between
olecranon process and
medial epicondyle; Later
stages manifested by
intrinsic atrophy and ulnar
innervated intrinsic
weakness. Specific
physical signs include
clawing of the ulnar 2
digits (Benediction
posture), ulnar drift of the
5th finger (Wartenberg's
sign), or flexion at the
thumb IP joint during
pinch (Froment's sign).
Sensory deficits in the
digits/hand; blanching of
digits; swelling of the
digits/hand/forearm;
muscle weakness of the
hand; arthropathy at the
hand/wrist/elbow; trophic
skin changes and cyanotic
color in hand/digits.
Guyon Canal (Tunnel)
Syndrome
color in hand/digits.
Numbness/tingling in
ulnar nerve distribution
distal to wrist.
Pronator Syndrome
Pain/numbness/tingling in
median nerve distribution
distal to elbow.
Radial Tunnel Syndrome
Numbness/tingling or
pain in the lateral
posterior forearm.
Positive Tinel's at hook of
hamate. Numbness or
paresthesias of the palmar
surface of the ring and
small fingers. Later stages
may affect ulnar
innervated intrinsic
muscle strength.
Tingling in median nerve
distribution on resisted
pronation with elbow
flexed at 90°; Tenderness
or Tinel's at the proximal
edge of the pronator teres
muscle over the median
nerve.
Tenderness over the radial
nerve near the proximal
edge of the supinator
muscle. Rarely,
paresthesias in the radial
nerve distribution or
weakness of thumb or
finger extension.
3. Pain Behavior Evaluation
a. Evaluate the patient's overall pain behavior. The behavior should be consistent with the current pain
levels reported by the patient.
b. Use a measurement tool to quantify and/or qualify pain. Reference the pain scale (0-10) with the worst
pain imaginable being the top end of the scale (10) and/or other pain scales such as the Visual
Analog Scale, Pain Drawing, or McGill Pain Questionnaire.
4. Risk Factors
A critical review of epidemiologic literature identifies a number of physical exposures associated with
CTDs. Physical exposures considered risk factors include: repetition, force, vibration, pinching and
gripping, and cold environment. When workers are exposed to several risk factors simultaneously, there is
an increased likelihood of a CTD. Not all risk factors have been extensively studied. Exposure to cold
environment, for example, was not examined independently; however, there is good evidence that,
combined with other risk factors, cold environment increases the likelihood of a CTD. The table at the end
of this section entitled, “Risk Factors Associated CTDs,” summarizes the results of currently available
literature.
No single epidemiologic study will fulfill all criteria for causality. The clinician must recognize that currently
available epidemiologic data is based on population results, and that individual variability lies outside the
scope of these studies. Many published studies are limited in design and methodology, and, thus,
preclude conclusive results. Most studies' limitations tend to attenuate, rather than inflate, associations
between workplace exposures and CTDs.
Many specific disorders, such as ulnar neuropathy (at the elbow and wrist) and pronator teres syndrome,
have not been studied sufficiently to formulate evidence statements regarding causality. Based on the
present understanding of mechanism of injury and utilizing the rationale of analogy, it is generally
accepted that these disorders are similar to other CTDs at the elbow and wrist and are susceptible to the
same risk factors. No studies examined the relationship between the development of ganglion cysts and
work activities; however, work activities may aggravate existing ganglion cysts. It is generally accepted
that keyboarding less than four hours per day is unlikely to be associated with a CTD when no other risk
factors are present. It remains unclear how computer mouse use affects CTDs. The posture involved in
mouse use should always be evaluated when assessing risk factors.
Studies measured posture, repetition and force in variable manners. In general, jobs that require less than
50% of maximum voluntary contractile strength for the individual are not considered “high force.”
Likewise, jobs with wrist postures less than or equal to 25°; flexion or extension, or ulnar deviation less
than or equal to 10°; are not likely to cause posture problems.
These guidelines are based on current epidemiologic knowledge. As with any scientific work, the
guidelines are expected to change with advancing knowledge. The clinician should remain flexible and
consider new information revealed in future studies.
Table 3: Risk Factors Associated with Cumulative Trauma
Diagnosis
Strong evidence
Good evidence
Elbow Musculoskeletal
Disorders (Epicondylitis)
Combination high force
and high repetition
(Exposures were based on
EMG data, observation or
video analysis of job
tasks, or categorization by
job title. Observed
movements include
repeated extension,
flexion, pronation and
supination. Repetition
work cycles<30 sec or
>50% of cycle time
performing same task,
and number of items
assembled in one hour).
Combination of risk
factors: High repetition,
forceful hand/wrist
exertions, extreme wrist
postures (Assessed by
direct observation, EMG,
and video analysis. One
study measured time
spent in deviated wrist
High force alone.
Wrist Tendonitis,
including DeQuervain's
Tenosynovitis
Repetition, (as previously
defined), not including
keyboarding or force
independently.
Some evidence
Posture
posture).
Trigger Finger
Forceful grip (Holdin
tools, knives. Assesse
direct observation an
video analysis).
5. Medical Causality Assessment for Cumulative Trauma Disorders
The clinician must determine if it is medically probable (greater than 50% likely) that the need for
treatment in a case is due to a work-related exposure or injury. Treatment for a work-related condition is
covered when: 1) the work exposure causes a new condition, or 2) the work exposure causes the
activation of a previously asymptomatic or latent medical condition, or 3) the work exposure worsens a
pre-existing symptomatic condition. In legal terms, the question that should be answered is: “Is it
medically probable that the patient would need the treatment that the clinician is recommending if the
work exposure had not taken place?” If the answer is “yes,” then the condition is not work-related. If the
answer is “no,” then the condition is work-related. In some cases, the clinician may need to assess
diagnostic testing or work site evaluations to make a judgment on medical probability. The following steps
should be used to evaluate causality in CTD cases:
Step 1: Make a specific and supportable diagnosis. Remember that cumulative trauma and
repetitive motion are not diagnoses. Examples of appropriate diagnoses include
tendonitis, strains, sprains, and mono-neuropathies.
Step 2: Determine whether the disorder is known to be or is plausibly associated with work. The
identification of work-related risk factors are largely based on comparison of risk factors
(as described in Section 3, “Risk Factors”) with the patient's work tasks.
Step 3: Interview the patient to find out whether risk factors are present in sufficient degree and
duration to cause or aggravate the condition. Consider any recent change in the
frequency or intensity of job tasks. In some cases, work site evaluations may be
necessary to quantify the actual ergonomic risks. Refer to the Work Site Evaluation and
Risk Factors sections.
Step 4: Determine whether a temporal association exists between the workplace risk factors and
the onset or aggravation of symptoms.
Step 5: Identify non-occupational diagnoses, such as rheumatoid arthritis, as well as avocational
activities, such as golf and tennis.
6. Staging
Staging Cumulative Trauma Disorder may be helpful to track the progress of cases and to rate permanent
impairment of specific disorders when no other rating is available in the AMA Guides. CTD can be staged
only after taking a thorough history and performing an appropriate physical examination (see History and
Physical Examination). The CTD Staging Matrix may be used to help determine the need for further
diagnostic tests and/or more extensive treatment. The factors included in the CTD Staging Matrix are:
A = History and Physical Examination
B = Response to Modification of Specific Aggravating Factors
C = Activities of Daily Living
It is expected that objective signs on physical examination will correlate with subjective symptoms. The
signs and symptoms are staged in the Cumulative Trauma Staging Matrix as:
Stage 1 = Minimal
Stage 2 = Mild
Stage 3 = Moderate
Stage 4 = Severe
At initial evaluation, some patients in Stages 1 or 2 for History and Physical Examination may qualify for
higher stages in Response to Modification of Specific Aggravating Factors or ADLs. With treatment,
patients should show progress to a stage of lower severity. In the event of failure to progress or
inconsistencies in staging, the provider should consider further diagnostic testing, a psychosocial
evaluation, and/or a change in treatment plan.
Stages 3 and 4 frequently may be associated with other secondary symptoms of chronic pain such as
sleep alteration, chronic generalized weakness, fatigue, or depression.
Table 1: Cumulative Trauma Staging Matrix
History and Physical
Examination
Response to Modification
of Specific Aggravating
Factors
Activities of Daily Living
(ADLs)
Impairment Grades at
MMI (See Note to obtain
Multiplier below)
Stage 1 (Minimal)
1-2 symptoms with signs
identified on history and
supported by physical
examination with
consistency of subjective
and objective findings
AND
Symptoms and/or signs
improve or resolve with
modification of specific
aggravating activity
Stage 2 (Mild)
2 or more symptoms with
signs identified and
supported by physical
examination with
consistency of subjective
and objective findings
AND
Symptoms and/or signs
may improve but will not
resolve completely with
modification of specific
aggravating activity
OR
Minimal problems with
ADLs
0-9%
OR
Noticeable aggravation
by more difficult ADLs
10-19%
Stage 3 (Moderate)
3 or more symptoms
signs identified and
supported by the phy
examination with
consistency of subjec
and objective finding
AND
Symptoms and/or sig
do not improve with
modification of the
specific aggravating
activity, but may imp
with elimination of th
specific aggravating
activity
OR
Significant interferen
with most ADLs
20-29%
NOTE: When the Staging Matrix is used for impairment rating at Maximum Medical Improvement (MMI),
assignment of the patient to a Stage should be based primarily on limitations in ADLs and history and
physical examination findings. The response to modification of specific aggravating activities may be used
to aid the rater in choosing a number within the available rating range. The staging number chosen from
the Impairment Grades at MMI row is to be used as a multiplier in conjunction with the AMA Guides to the
Evaluation of Permanent Impairment, Third Edition, Revised, Chapter 3, Table 17, to determine the
impairment rating for each specific diagnosis. All of the joints that correspond with the established
diagnoses should be rated.
E. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES
1. Electrodiagnostic (EDX) Studies
a. Electrodiagnostic (EDX) studies are well established and widely accepted for evaluation of patients
suspected of having peripheral nerve pathology. Studies may confirm the diagnosis or direct the
examiner to alternative disorders. Studies may require clinical correlation due to the occurrence
of false positive and false negative results. Symptoms of peripheral nerve pathology may occur
with normal EDX studies, especially early in the clinical course. Findings include fibrillations,
fasciculations, neurogenic recruitment and polyphasic units (reinnervation).
b. To assure accurate testing, temperature should be maintained at 30-34C preferably recorded from the
hand/digits. For temperature below 30C the hand should be warmed.
c. All studies must include normative values for their laboratories.
2. Imaging Studies
a. Radiographic Imaging
Not generally required for most CTD diagnoses. However, it may be necessary to rule out other pathology
in the cervical spine, shoulder, elbow, wrist or hand. Wrist and elbow radiographs would detect
degenerative joint disease, particularly scapholunate dissociation and thumb carpometacarpal
abnormalities which occasionally occur with CTD.
b. MRI
May show increased T2-weighted signal intensity of the common extensor tendon in lateral epicondylitis,
but this finding has commonly been found in the asymptomatic contralateral elbow and may not be
sufficiently specific to warrant the use of MRI as a diagnostic test for epicondylitis. Its routine use for CTD
is not recommended.
3. Adjunctive Testing
a. Personality/Psychological/Psychosocial Evaluations
Personality/ psychological/ psychosocial evaluations are generally accepted and well-established
diagnostic procedures with selective use in the CTD population, but have more widespread use in subacute and chronic pain populations.
Diagnostic testing procedures may be useful for patients with symptoms of depression, delayed recovery,
chronic pain, recurrent painful conditions, disability problems, and for pre-operative evaluation as well as
a possible predictive value for post-operative response. Psychological testing should provide
differentiation between pre-existing depression versus injury-caused depression, as well as posttraumatic stress disorder.
Formal psychological or psychosocial evaluation should be performed on patients not making expected
progress within 6-12 weeks following injury and whose subjective symptoms do not correlate with
objective signs and tests. In addition to the customary initial exam, the evaluation of the injured worker
should specifically address the following areas:
1) Employment history;
2) Interpersonal relationships — both social and work;
3) Leisure activities;
4) Current perception of the medical system;
5) Results of current treatment;
6) Perceived locus of control; and
7) Childhood history, including abuse and family history of disability.
Results should provide clinicians with a better understanding of the patient, thus allowing for more
effective rehabilitation. The evaluation will determine the need for further psychosocial interventions, and
in those cases, a DSM IV diagnosis should be determined and documented. An individual with a PhD,
PsyD, or Psychiatric MD/DO credentials may perform initial evaluations, which are generally completed
within one to two hours. When issues of chronic pain are identified, the evaluation should be more
extensive and follow testing procedures as outlined in Division Rule XVII, Exhibit F, Chronic Pain Disorder
Medical Treatment Guideline.
Frequency: One time visit for evaluation. If psychometric testing is indicated as a portion of the initial
evaluation, time for such testing should not exceed an additional two hours of professional time.
b. Laboratory Tests
Generally accepted, well established and widely used procedures. Patients should be carefully screened
at the initial exam for signs or symptoms of diabetes, hypothyroidism, arthritis, and related inflammatory
diseases. The presence of concurrent disease does not negate work-relatedness of any specific case. In
one study of patients with cumulative trauma disorder, other than CTD, seen by specialists, 3% of patients
were diagnosed with diabetes, 6% with hypothyroidism, and 9% with chronic inflammatory disease
including spondyloarthropathy, arthritis, and systemic lupus erythematosis. Up to two thirds of the patients
were not aware of their concurrent disease. 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 nonsteroidal anti-inflammatory medications), then laboratory tests, including, but not
limited to, the following can provide useful diagnostic information:
1) Serum rheumatoid factor, ANA, HLA-B27 titre for rheumatoid work-up;
2) TSH for hypothyroidism.
3) Fasting glucose - recommended for obese men and women over 40 years of age, patients with a
history of family diabetes, those from high risk ethnic groups, and with a previous history of
impaired glucose tolerance. A fasting blood glucose >125mg/dl is diagnostic for diabetes. Urine
dipstick positive for glucose is a specific but not sensitive screening test. Quantitative urine
glucose is sensitive and specific in high risk populations.
4) Serum protein electrophoresis;
5) Sedimentation rate and C-Reactive Protein are nonspecific, but elevated in infection, neoplastic
conditions and rheumatoid arthritis;
6) Serum calcium, phosphorus, uric acid, alkaline and acid phosphatase for metabolic, endocrine and
neo-plastic conditions;
7) CBC, liver and kidney function profiles for metabolic or endocrine disorders or for adverse effects of
various medications;
8) Bacteriological (microorganism) work-up for wound, blood and tissue.
The Division recommends the above 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. Laboratory testing may be required periodically to monitor patients on chronic
medications.
c. Pinch And Grip Strength Measurements
Not generally accepted as a diagnostic tool for CTS. Strength is defined as the muscle force exerted by a
muscle or group of muscles to overcome a resistance under a specific set of circumstances. Pain, the
perception of pain secondary to abnormal sensory feedback, and/or the presence of abnormal sensory
feedback affecting the sensation of the power used in grip/pinch may cause a decrease in the force
exerted and thereby not be a true indicator of strength. When a bell-shaped curve is present, these
measures provide a method for quantifying strength that can be used to follow a patient's progress and to
assess response to therapy. In the absence of a bell-shaped curve, clinical reassessment is indicated.
d. Quantitative Sensory Testing (QST)
May be used as a screening tool in clinical settings pre-and post-operatively. Results of tests and
measurements of sensory integrity are integrated with the history and review of systems findings and the
results of other tests and measures. QST tests the entire sensory pathway, limiting its ability to localize a
deficit precisely. It depends on the patient's report of perception and may not be objective. Cutaneous
conditions may alter sensory thresholds.
1) Threshold tests measure topognosis, the ability to exactly localize a cutaneous sensation, and
pallesthesia, the ability to detect mechanical sensation using vibration discrimination testing
(quickly adapting fibers); and/or Semmes-Wienstein monofilament testing (slowly adapting fibers);
2) Density Tests also measure topognosis and pallesthesia using static two-point discrimination (slowly
adapting fibers); and/or moving two-point discrimination (quickly adapting fibers).
4. Special Tests
a. Computer-Enhanced Evaluations
Computer-enhanced evaluations may include isotonic, isometric, isokinetic and/or isoinertial
measurement of movement, range of motion, 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.
Frequency: One time for evaluation. Can monitor improvements in strength every 3 to 4 weeks up to a
total of 6 evaluations.
b. Functional Capacity Evaluation (FCE)
Functional capacity evaluation is a comprehensive or modified evaluation of the various aspects of
function as they relate to the worker's ability to return to work. Areas such as endurance, lifting (dynamic
and static), postural tolerance, specific range of motion, coordination and strength, worker habits,
employability and financial status, as well as psychosocial aspects of competitive employment may be
evaluated. Components of this evaluation may include: (a) musculoskeletal screen; (b) cardiovascular
profile/aerobic capacity; (c) coordination; (d) lifting/carrying analysis; (e) job-specific activity tolerance; (f)
maximum voluntary effort; (g) pain assessment/psychological screening; and (h) non-material and
material handling activities.
Frequency: Can be used initially to determine baseline status. Additional evaluations can be performed to
monitor and assess progress and aid in determining the endpoint for treatment.
c. Job Site Evaluation
Job site evaluation is a comprehensive analysis of the physical, mental and sensory components of a
specific job. These components may include, but are not limited to: (a) postural tolerance (static and
dynamic); (b) aerobic requirements; (c) range of motion; (d) torque/force; (e) lifting/carrying; (f) cognitive
demands; (g) social interactions; (h) visual perceptual; (i) environmental requirements of a job; (j)
repetitiveness; and (k) essential functions of a job. Job descriptions provided by the employer are helpful
but should not be used as a substitute for direct observation.
Frequency: One time with additional visits as needed for follow-up per job site.
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 should not be delayed solely due to lack of attainment of a
vocational assessment.
Frequency: One time with additional visits as needed for follow-up.
e. Work Tolerance Screening
Work tolerance screening is a determination of an individual's tolerance for performing a specific job as
based on a job activity or task. It may include a test or procedure to specifically identify and quantify workrelevant cardiovascular demands, physical fitness, and postural tolerance. It may also address ergonomic
issues affecting the patient's return-to-work potential. May be used when a full Functional Capacity
Evaluation is not indicated.
Frequency: One time for evaluation. May monitor improvements in strength every 3 to 4 weeks up to a
total of 6 evaluations.
F. THERAPEUTIC PROCEDURES – NON-OPERATIVE
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 selfmanagement of symptoms.
Last, formal psychological or psychosocial screening should be performed on patients not making
expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate
with objective signs and tests.
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.
1. Acupuncture
Acupuncture 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
licensed practitioners.
a. Acupuncture - Definition
Acupuncture 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.
1) Time to produce effect: 3 to 6 treatments
2) Frequency: 1 to 3 times per week
3) Optimum duration: 1 to 2 months
4) Maximum duration: 14 treatments
b. Acupuncture with Electrical Stimulation
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.
1) Time to produce effect: 3 to 6 treatments
2) Frequency: 1 to 3 times per week
3) Optimum duration: 1 to 2 months
4) Maximum duration: 14 treatments
c. Other 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.
1) Time to produce effect: 3 to 6 treatments
2) Frequency: 1 to 3 times per week
3) Optimum duration: 1 to 2 months
4) Maximum 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 must be documented with respect to need and ability to facilitate positive
symptomatic or functional gains.
2. Biofeedback
Biofeedback 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.
Parameters:
1) Time to produce effect: 3 to 4 sessions
2) Frequency: 1 to 2 times per week
3) Optimum duration: 5 to 6 sessions
4) 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.
3. Injections – Therapeutic
Therapeutic injections 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.
a. Steroid Injections
Steroid injections may provide both diagnostic and therapeutic value in treating a variety of upper
extremity cumulative trauma disorders. These include tendonitis or bursitis about the elbow, wrist or hand.
In contrast, there is no evidence to support their therapeutic use in other upper extremity compressive
neuropathies; however, it is a widely accepted procedure.
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.
For epicondylitis, there is good evidence that although steroid injections with physical therapy may
provide short-term symptomatic relief, there is no benefit over placebo injections at 6 months. A program
of physical rehabilitation in combination with judicious use of anti-inflammatory medications should be the
core treatment for epicondylitis.
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:
1) Time to produce effect: 3 days
2) Frequency: monthly
3) Optimum duration: 2 injections
4) Maximum duration: 3 injections
b. Trigger Point Injections
Trigger 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.
1) Time to produce effect: Local anesthetic 30 minutes; 24 to 48 hours for no anesthesia.
2) Frequency: Weekly. Suggest no more than 4 injection sites per session per week
3) Optimum duration: 4 Weeks
4) Maximum duration: 8 weeks. Occasional patients may require 2 to 4 repetitions of trigger point
injection series over a 1 to 2 year period.
4. Job 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 work site
evaluation. Some evidence supports alteration of the work site in the early treatment of Cumulative
Trauma Disorder. There is no single factor or combination of factors that is proven to prevent or
ameliorate CTD, but a combination of ergonomic and psychosocial factors 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. Psychosocial factors to
be considered include pacing, degree of control over job duties, perception of job stress, and supervisory
support.
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.
a. Ergonomic changes
Ergonomic changes should be made to modify the hazards identified. In addition, workers should be
counseled to vary tasks throughout the day whenever possible. OSHA suggests that workers who perform
repetitive tasks, including keyboarding, take 15-30 second breaks every 10 to 20 minutes, or 5-minute
breaks every hour. Mini breaks should include stretching exercises.
b. Interventions
Interventions should consider engineering controls, e.g., mechanizing the task, changing the tool used, or
adjusting the work site; or administrative controls, e.g., adjusting the time an individual performs the task.
c. Seating Description
The following description may aid in evaluating seated work positions: The head should incline only
slightly forward, and if a monitor is used, there should be 18-24 inches of viewing distance with no glare.
Arms should rest naturally, with forearms parallel to the floor, elbows at the sides, and wrists straight or
minimally extended. The back must be properly supported by a chair, which allows change in position and
backrest adjustment. There must be good knee and legroom, with the feet resting comfortably on the floor
or footrest. Tools should be within easy reach, and twisting or bending should be avoided.
d. Job Hazard Checklist
The following Table 4 is adopted from Washington State's job hazard checklist, and may be used as a
generally accepted guide for identifying job duties which may pose ergonomic hazards. The fact that an
ergonomic hazard exists at a specific job, or is suggested in the table, does not establish a causal
relationship between the job and the individual with a musculoskeletal injury. However, when an individual
has a work-related injury and ergonomic hazards exist that affect the injury, appropriate job modifications
should be made. Proper correction of hazards may prevent future injuries to others, as well as aid in the
recovery of the injured worker.
Table 4 : Identifying Job Duties Which May Pose Ergonomic Hazards
Type of Job Duty
Pinching an unsupported object(s) weighing 2 lbs or
more per hand, or pinching with a force of 4 lbs or
more per hand (comparable to pinching a half a ream of
paper):
1. Highly repetitive
motion
2. Palmar flexion >30
degrees, dorsiflexion >45
degrees, or radial
deviation >30 degrees
____________________
____________________
__________
3. No other risk factors
Gripping an unsupported object(s) weighing 10 lbs or
more/hand, or gripping with a force of 10 lbs or
more/hand (comparable to clamping light duty
automotive jumper cables onto a battery):
*Handles should be rounded and soft, with at least 12.5” in diameter grips at least 5” long.
14. Highly repetitive
motion
15. Palmar flexion >30
degrees, dorsiflexion >45
degrees, or radial
deviation > 30 degrees
____________________
____________________
__________
16. No other risk factors
Repetitive Motion (using the same motion with little or
no variation every few seconds) excluding keying
activities:
1. High, forceful
exertions with the hands,
with palmar flexion >30
Hours per Day
More than 3 hours
total/day
_____________________
_____________________
________
More than 4 hours
total/day
More than 3 hours
total/day
_____________________
_____________________
________
More than 4 hours
total/day
More than 2 hours
total/day
degrees, dorsiflexion >45
degrees, or radial
deviation > 30 degrees
____________________
____________________
__________
2. No other risk factors
_____________________
_____________________
________
More than 6 hours
total/day
Intensive Keying:
1. Palmar flexion >30
degrees, dorsiflexion >45
degrees, or radial
deviation > 30 degrees
____________________
____________________
__________
2. No other risk factors
More than 4 hours
total/day
_____________________
_____________________
________
More than 7 hours
total/day
Repeated Impact:
More than 2 hours
total/day
1. Using the hand
(heel/base of palm) as a
hammer more than
once/minute
Vibration:
Two determinants of the tolerability of segmental
vibration of the hand are the frequency and the
acceleration of the motion of the vibrating tool, with
lower frequencies being more poorly tolerated at a
given level of imposed acceleration, expressed below in
multiples of the acceleration due to gravity
(10m/sec/sec).
1. Frequency range 8-15
Hz and acceleration 6 g
2. Frequency range 80 Hz
and acceleration 40 g
3. Frequency range 250
Hz and acceleration 250 g
____________________
____________________
__________
4. Frequency range 8-15
Hz and acceleration 1.5 g
More than 30 minutes at a
time
_____________________
_____________________
________
More than 4 hours at a
time
5. Frequency range 80 Hz
and acceleration 6 g
6. Frequency range 250
Hz and acceleration 20 g
5. Medications
Medication use in the treatment of CTD is appropriate for controlling acute and chronic pain and
inflammation. Use of medications will vary widely due to the spectrum of injuries from simple strains to
post-surgical analgesia. A thorough medication history, including use of alternative and over the counter
medications, should be performed at the time of the initial visit and updated periodically.
Acetaminophen is an effective and safe initial analgesic. Non-steroidal anti-inflammatory drugs (NSAIDs)
are useful in the treatment of inflammation, and for pain control. Pain is subjective in nature and should be
evaluated using a scale to rate effectiveness of the analgesic in terms of functional gain. Other
medications, including antidepressants, may be useful in selected patients with chronic pain (Refer to
Chronic Pain Guideline). Narcotics are rarely indicated for treatment of upper extremity CTDs, and they
should be primarily reserved for the treatment of acute severe pain for a limited time on a case-by-case
basis. Topical agents may be beneficial in the management of localized upper extremity pain.
The following are listed in alphabetical order:
a. Acetaminophen
Acetaminophen is an effective analgesic with antipyretic but not anti-inflammatory activity. Acetaminophen
is generally well tolerated, causes little or no gastrointestinal irritation and is not associated with ulcer
formation. Acetaminophen has been associated with liver toxicity in doses over 10 gm/day or in chronic
alcohol use.
1) Optimum duration: 7 to 10 days
2) Maximum duration: Chronic use as indicated on a case-by-case basis.
b. Minor Tranquilizer/Muscle Relaxants
Minor tranquilizer/muscle relaxants are appropriate for muscle spasm, mild pain and sleep disorders.
1) Optimum duration: 1 week
2) Maximum duration: 4 weeks
c. Narcotics
Narcotic medications should be prescribed with strict time, quantity and duration guidelines, and with
definitive cessation parameters. Adverse effects include respiratory depression, impaired alertness, and
the development of physical and psychological dependence.
1) Optimum duration: 3 to 7 days
2) Maximum duration: 2 weeks. Use beyond two weeks is acceptable in appropriate cases, such as
patients requiring complex surgical treatment.
d. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs are useful for pain and inflammation. In mild cases, they may be the only drugs required for
analgesia. There are several classes of NSAIDs, and the response of the individual injured worker to a
specific medication is unpredictable. For this reason, a variety of NSAIDs may be tried in each case with
the most effective preparation being continued. Patients should be educated in and monitored for adverse
reactions, including GI toxicity, liver and renal dysfunction, and thrombotic events in the case of COX-2
inhibitors. Intervals for screening are dependent on the patient's age, health status, concomitant
medications usage, and specific NSAID prescribed. Intervals for metabolic screening are dependent upon
the patient's age, general health status and should be within parameters listed for each specific
medication.
Selective Nonsteroidal Anti-Inflammatory Drugs - Include Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
and acetylsalicylic acid (aspirin).
1) Optimal duration: 1 week
2) Maximum duration: 1 year
Selective Cyclo-oxygenase-2 (COX-2) Inhibitors - Selective cyclo-oxygenase-2 (COX-2) inhibitors are
more recent NSAIDs and differ in adverse side effect profiles from the traditional NSAIDs. The major
advantages of selective COX-2 inhibitors over traditional NSAIDs are that they have less gastrointestinal,
hepatic and renal toxicity, but may have thrombotic effects. COX-2 inhibitors should not be first-line for
low risk patients who will be using an NSAID short term but are indicated in select patients whom
traditional NSAIDs are not tolerated or in certain high-risk patients.
1) Optimal duration: 7 to 10 days
2) Maximum duration: Chronic use is appropriate in individual cases.
e. Psychotropic/Anti-anxiety/Hypnotic Agents
Psychotropic/anti-anxiety/hypnotic agents may be useful for treatment of mild and chronic pain,
dysesthesias, sleep disorders, and depression. Antidepressant medications, such as tricyclics and
Selective Serotonin Reuptake Inhibitors (SSRIs), are useful for affective disorders and chronic pain
management. Tricyclic antidepressant agents, in low dose, are useful for chronic pain but have more
frequent side effects.
Anti-anxiety medications are best used for short-term treatment (i.e., less than 6 months). Accompanying
sleep disorders are best treated with sedating antidepressants prior to bedtime. Frequently, combinations
of the above agents are useful. As a general rule, physicians should assess the patient for a prior history
of substance abuse or depression prior to prescribing any of these agents.
1) Optimum duration: 1 to 6 months
2) Maximum duration: 6 to 12 months, with monitoring.
f. Tramadol
Tramadol is useful in relief of upper extremity pain and has been shown to provide pain relief equivalent
to that of commonly prescribed narcotics. Although Tramadol may cause impaired alertness, it is generally
well tolerated, does not cause gastrointestinal ulceration, or exacerbate hypertension or congestive heart
failure. Tramadol should be used cautiously in patients who have a history of seizures or who are taking
medication that may lower the seizure threshold, such as MAO inhibiters, SSRIs, and tricyclic
antidepressants. This medication has physically addictive properties and withdrawal may follow abrupt
discontinuation. It is not recommended for those with prior opioid addiction.
1) Optimum duration: 3 to 7 days
2) Maximum duration: 2 weeks. Use beyond 2 weeks is acceptable in appropriate cases.
g. Topical Drug Delivery
Topical drug delivery may be an alternative treatment for localized musculoskeletal disorders and is an
acceptable form of treatment in selected patients although there is no scientific evidence to support its
use. It is necessary that all topical agents be used with strict instructions for application as well as
maximum number of applications per day to obtain the desired benefit and avoid potential toxicity. As with
all medications, patient selection must be rigorous to choose those patients with the highest probability of
compliance. Refer to “Iontophoresis” in the Passive Therapy section for information regarding topical
iontophoretic agents.
6. Occupational Rehabilitation Programs
a. 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.
1) Work Conditioning
Work Conditioning is usually initiated once reconditioning has been completed but may be offered at any
time throughout the recovery phase. It 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.
(a) Length of visit: 1 to 2 hours per day
(b) Frequency: 2 to 5 visits per week
(c) Optimum duration: 2 to 4 weeks
(d) Maximum duration: 6 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.
2) Work Simulation
Work simulation is a program where an individual completes specific work-related tasks for a particular
job and return to work. Use of this program is appropriate when modified duty can only be partially
accommodated in the work place, when modified duty in the work place is unavailable, or when the
patient requires more structured supervision. The need for work place simulation should be based upon
the results of a Functional Capacity Evaluation and or Job site Analysis.
(a) Length of visit: 2 to 6 hours per day
(b) Frequency: 2 to 5 visits per week
(c) Optimum duration: 2 to 4 weeks
(d) Maximum duration: 6 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.
b. Interdisciplinary
Interdisciplinary programs are characterized by a variety of disciplines that participate in the assessment,
planning, and/or implementation of an injured worker's program with the goal of the patient gaining full or
optimal function and returning to work. There should be close interaction and integration among the
disciplines to ensure that all members of the team interact to achieve team goals. These programs are for
patients with greater levels of perceived disability, dysfunction, deconditioning and psychological
involvement. For patients with chronic pain, refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder
Medical Treatment Guideline.
1) Work Hardening
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,
psychological, behavioral, physical, functional, and vocational components of employability and return-towork.
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, physicians having
experience in occupational rehabilitation, occupational therapist, physical therapist, case manager, and
psychologist. As appropriate, the team may also include: chiropractor, RN, or vocational specialist.
(a) Length of visit: Up to 8 hours/day
(b) Frequency: 2 to 5 visits per week
(c) Optimum duration: 2 to 4 weeks
(d) Maximum duration: 6 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.
7. Patient 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 function
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.
(a) Time to produce effect: Varies with individual patient.
(b) Frequency: Should occur at every visit.
8. Personality/Psychological/Psychosocial Intervention
Personality/Psychological/Psychosocial Intervention is generally accepted, widely used and well
established. This group of therapeutic and diagnostic modalities includes, but is not limited to, individual
counseling, group therapy, stress management, psychosocial crises intervention, hypnosis and
meditation. Any screening or diagnostic workup should clarify and distinguish between preexisting versus
aggravated versus purely causative psychological conditions. Psychosocial intervention is recommended
as an important component in the total management program that should be implemented as soon as the
problem is identified. This can be used alone or in conjunction with other treatment modalities. Providers
treating patients with chronic pain should refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder
Medical Treatment Guideline.
(a) Time to produce effect: 2 to 4 weeks
(b) Frequency: 1 to 3 times weekly for the first 4 weeks (excluding hospitalization, if required), decreasing
to 1 to 2 times per week for the second month. Thereafter, 2 to 4 times monthly.
(c) Optimum duration: 6 weeks to 3 months
(d) Maximum duration: 3 to 12 months. Counseling is not intended to delay but to enhance functional
recovery. For select patients, longer supervised treatment may required, and if further counseling
beyond 3 months is indicated, documentation addressing which pertinent issues are preexisting
versus aggravated versus causative, as well as projecting a realistic functional prognosis, should
be provided by the authorized treating provider every 4 to 6 weeks during treatment.
9. Return to Work
Early return-to-work should be a prime goal in treating Cumulative Trauma Disorder (CTD) given the poor
prognosis for the injured employee who is out of work for more than six months. The employee and
employer should be educated in the benefits of early return-to-work. When attempting to return an
employee with CTD to the workplace, clear, objective physical restrictions that apply to both work and
non-work related activities should be specified by the provider. Good communication between the
provider, employee, and employer is essential.
Return-to-work is any work or duty that the employee can safely perform, which may not be the worker's
regular job activities. Due to the large variety of jobs and the spectrum of severity of CTD, it is not
possible for the Division to make specific return-to-work guidelines, but the following general approach is
recommended:
a. Establishment of Return-To-Work
Ascertainment of return-to-work status is part of the medical treatment and rehabilitation plan, and should
be addressed at every visit. Limitations in activities of daily living (ADLs) should also be reviewed at every
encounter, and help to provide the basis for work restrictions provided they are consistent with objective
findings. In some severe CTD cases, cessation of most ADLs may be required for a short period of time.
The Division recognizes that employers vary in their ability to accommodate restricted duty, but
encourages employers to be active participants and advocates for early return-to-work. In most cases, the
patient can be returned to work in some capacity, either at a modified job or alternate position,
immediately unless there are extenuating circumstances, which should be thoroughly documented and
communicated to the employer. Return-to-work status should be periodically reevaluated, at intervals
generally not to exceed three weeks, and should show steady progression towards full activities and full
duty.
b. Establishment of Activity Level Restrictions
It is the responsibility of the physician/provider to provide both the employee and employer clear, concise,
and specific restrictions that apply to both work and non-work related activities. The employer is
responsible to determine whether modified duty can be provided within the medically determined
restrictions. The Division's WC M164 form can be used as a guide to document and communicate the
activity level restrictions. Refer to the “Job Site Alteration” section for specific activity and ergonomic
factors to be considered when establishing work restrictions for an employee with CTD.
c. Compliance with Activity Level Restrictions
The employee's compliance with the activity level restrictions is an important part of the treatment plan
and should be reviewed at each visit. In some cases, a job site analysis, a functional capacity evaluation,
or other special testing may be required to facilitate return-to-work and document compliance. Refer to
the “Job Site Alteration” and “Work Tolerance Screening” sections.
10. Sleep Disturbances
Disturbances of sleep 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 nonrestorative 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:
a. Maintaining a regular sleep schedule, retiring and rising at approximately the same time on weekdays
and weekends.
b. Avoiding daytime napping.
c. Avoiding caffeinated beverages after lunchtime
d. Making the bedroom quiet and comfortable, eliminating disruptive lights, sounds, television sets, and
keeping a bedroom temperature of about 65°;F.
e. Avoiding alcohol or nicotine within two hours of bedtime.
f. Avoiding large meals within two hours of bedtime.
g. Exercising vigorously during the day, but not within two hours of bedtime, since this may raise core
temperature and activate the nervous system.
h. Associating the bed with sleep and sexual activity only, using other parts of the home for television,
reading and talking on the telephone.
i. Leaving the bedroom when unable to sleep for more than 20 minutes, retuning to the bedroom when
ready to sleep again.
These modifications should be undertaken before sleeping medication is prescribed for long term use.
11. Therapy-Active
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.
a. Activities 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.
1) Time to produce effect: 4 to 5 treatments
2) Frequency: 3 to 5 times per week
3) Optimum Duration: 4 to 6 weeks
4) Maximum Duration: 6 weeks
b. Functional Activities
Functional activities are the use of therapeutic activity to enhance mobility, body mechanics,
employability, coordination, and sensory motor integration.
1) Time to produce effect: 4 to 5 treatments
2) Frequency: 3 to 5 times per week
3) Optimum duration: 4 to 6 weeks
4) Maximum duration: 6 weeks
c. Nerve Gliding
Nerve gliding exercises consist of a series of flexion and extension movements of the hand, wrist, elbow,
shoulder and neck that produce tension and longitudinal movement along the length of the median and
other nerves of the upper extremity. These exercises are based on the principle that the tissues of the
peripheral nervous system are designed for movement, and that tension and glide (excursion) of nerves
may have an effect on neurophysiology through alterations in vascular and axoplasmic flow.
Biomechanical principles have been more thoroughly studied than clinical outcomes.
1) Time to Produce Effect: 2-4 weeks
2) Frequency: Up to 5 times per day by patient (patient-initiated)
3) Optimum Duration: 2 sessions
4) Maximum Duration: 3 sessions
d. Neuromuscular Re-education
Neuromuscular 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.
1) Time to produce effect: 2 to 6 treatments
2) Frequency: 3 times per week
3) Optimum duration: 4 to 8 weeks
4) Maximum duration: 8 weeks
e. Proper Work Techniques
Please refer to the “Job Site Evaluation” and “Job Site Alteration” sections of this guideline.
f. Therapeutic Exercise
Therapeutic exercise, with or without mechanical assistance or resistance, may include isoinertial,
isotonic, isometric and isokinetic types of exercises. Indications include the need for cardiovascular
fitness, reduced edema, improved muscle strength, improved connective tissue strength and integrity,
increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle
recruitment, increased range-of-motion, and are used to promote normal movement patterns. Can also
include complementary/alternative exercise movement therapy.
1) Time to produce effect: 2 to 6 treatments
2) Frequency: 3 to 5 times per week
3) Optimum duration: 4 to 8 weeks
4) Maximum duration: 8 weeks
12. Therapy - Passive
Passive therapy includes those treatment modalities that do not require energy expenditure on the part of
the patient. They are principally effective during the early phases of treatment and are directed at
controlling symptoms such as pain, inflammation and swelling and to improve the rate of healing soft
tissue injuries. They should be used 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.
a. Electrical Stimulation (Unattended)
Electrical stimulation, once applied, requires minimal on-site supervision by the physician or nonphysician provider. Indications include pain, inflammation, muscle spasm, atrophy, and decreased
circulation.
1) Time to produce effect: 2 to 4 treatments
2) Frequency: Varies, depending upon indication, between 2 to 3 times/day to 1 time/week. Provide
home unit if frequent use.
3) Optimum duration: 1 to 3 months
4) Maximum duration: Home unit as needed.
b. Extracorporeal 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 lateral epicondylitis. It has not been shown to
have an advantage over other conservative treatments and remains investigational. It is not
recommended.
c. Iontophoresis
Iontophoresis 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).
1) Time to produce effect: 1 to 4 treatments
2) Frequency: 2-3 times per week with at least 48 hours between treatments.
3) Optimum duration: 6 to 9 treatments
4) Maximum duration: 9 treatments
d. Laser irradiation
Consists of the external application of an array of visible and infrared wavelengths to soft tissues. There is
no evidence to support its effectiveness in epicondylitis and its use in upper extremity cumulative trauma
disorders is still experimental. It is not recommended.
e. Manual Therapy Techniques
Manual Therapy Techniques are passive interventions in which the providers uses his/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 noncontractile 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.
1) Mobilization (Joint)/Manipulation
Mobilization 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. Contraindications
include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory
arthridities, and signs of progressive neurologic deficits.
(a) Time to produce effect: 4 to 6 treatments
(b) Frequency: 2 to 3 times per week
(c) Optimum duration: 4 to 6 weeks
(d) Maximum duration: 6 weeks
2) Mobilization (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.
(a) Time to produce effect: 4 to 6 treatments
(b) Frequency: 2 to 3 times per week
(c) Optimum duration: 4 to 6 weeks
(d) Maximum duration: 6 weeks
f. Massage
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 practitioners 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.
1) Time to produce effect: Immediate.
2) Frequency: 1 to 2 times per week
3) Optimum duration: 6 weeks
4) Maximum duration: 2 months
g. Orthotics/Immobilization with Splinting
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.
1) Time to produce effect: 1-4 weeks
2) Frequency: Daytime intermittent, or night use, depending on symptoms and activities.
3) Optimum duration: 4 to 8 weeks
4) Maximum duration: 2 to 4 months. If symptoms persist, consideration should be given to further
diagnostic studies or to other treatment options.
h. Superficial Heat and Cold Therapy
Superficial heat and cold 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.
1) Time to produce effect: Immediate
2) Frequency: 2 to 5 times per week (clinic). Home treatment as needed.
3) Optimum duration: 3 weeks as primary or intermittently as an adjunct to other therapeutic procedures
up to 2 months
4) Maximum duration: 2 months If symptoms persist, consideration should be given to further diagnostic
studies or other treatment options.
i. Ultrasound
Ultrasound 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.
1) Time to produce effect: 4 to 8 treatments
2) Frequency: 2-3 times per week
3) Optimum duration: 4 to 6 weeks
4) Maximum duration: 2 months
13. Restriction of Activities
Continuation of normal daily activities is the recommendation for Cumulative Trauma 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 CTD.
14. Vocational Rehabilitation
Vocational rehabilitation is a generally accepted intervention, but Colorado limits its use as a result of
Senate Bill 87-79. 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.
G. OPERATIVE TREATMENT:
THE FOLLOWING SURGICAL GUIDELINES ARE NOT INTENDED TO REPLACE THE SURGEON'S
JUDGMENT.
Over a decade's experience has demonstrated that operative treatment of most CTD conditions is not
usually necessary. Operative treatment may be indicated when the individual component diagnoses that
make up CTD prove unresponsive to the full complement of non-operative options, including work site
analysis and modification over four to six months. Physical exam findings should be well localized and
consistent with the diagnosis. Severe neurologic findings are an exception to these indications, and may
suggest earlier surgical intervention. Surgical results must anticipate objective functional gains and
improved activities of daily living.
Surgery in CTD usually falls into two broad categories: peripheral nerve decompression and muscle or
tendon sheath release or debridement. The treating surgeon must determine the appropriate procedure
and timing for the individual case. The most common surgical procedures that are performed in CTD
patients are listed below; other procedures may be indicated in certain cases.
Since CTD often involves several areas in an upper extremity, surgical treatment of one problem should
be performed in conjunction with conservative treatment of other problems in the upper extremity.
1. Peripheral Nerve Decompression:
Surgery may be considered when findings on history and physical exam correlate specifically with the
diagnosis being considered. Subjective complaints should be localized and appropriate to the diagnosis,
neurologic complaints should be consistent with the nerve distribution in question, and physical exam
findings should correlate with the history. Surgery may be considered as an initial therapy in situations
where there is clinical and electrodiagnostic evidence of severe or progressive neuropathy. Objective
evidence should be present in all cases in which surgery is contemplated. Objective evidence may
include: electrodiagnostic (EDX) studies, diagnostic peripheral nerve block which eradicates the majority
of the patient's symptoms, or a motor deficit commensurate with the suspected neurologic lesion. Refer to
Physical Examination Findings Reference Table in the Physical Examination section of this guideline for
objective diagnostic findings. Job modification should be considered prior to surgery. Refer to the “Job
Site Alteration” section for additional information on job modification.
When no objective evidence is present and the patient continues to have signs and symptoms consistent
with the diagnosis after six months of conservative treatment including a psychological evaluation, a
second opinion should be obtained before operative treatment is considered.
Specific procedures and their indications are outlined below:
a. Median Nerve Decompression at the Wrist (carpal tunnel release)
Please refer to Rule XVII, Exhibit B., Upper Extremity Medical Treatment Guidelines, Section II.
Occupational Carpal Tunnel Syndrome.
b. Median Nerve Decompression in the Forearm (pronator teres or flexor digitorum superficialis
release)
Please refer to Physical Examination Findings Table in Physical Examination section of this guideline.
Electrodiagnostic (EDX) studies may show delayed median nerve conduction in the forearm. If nerve
conduction velocity is normal with suggestive clinical findings, the study may be repeated after a 3-6
month period of continued conservative treatment. If the study is still normal, the decision on treatment is
made on the consistency of clinical findings and the factors noted above.
c. Ulnar Nerve Decompression at the Wrist (ulnar tunnel release or Guyon's canal release)
Please refer to Physical Examination Findings Reference Table in the Physical Examination section of this
guideline. Electrodiagnostic testing may confirm the diagnosis and differentiate from ulnar entrapment
neuropathy at the elbow.
d. Ulnar Nerve Decompression/Transposition at the Elbow
Please refer to Physical Examination Findings Reference Table in the Physical Examination section of this
guideline. Electrodiagnostic studies (EDX) may indicate an ulnar neuropathy at the elbow. In general,
patients with minimal symptoms or without objective findings of weakness tend to respond better to
conservative treatment than patients with measurable pinch or grip strength weakness. If objective
findings persist despite conservative treatment, surgical options include: simple decompression, medial
epicondylectomy with decompression, anterior subcutaneous transfer, and submuscular or intramuscular
transfer.
e. Radial Sensory Nerve Decompression at the Wrist
Please refer to Physical Examination Findings Reference Table in the Physical Examination section of this
guideline. Electrodiagnostic (EDX) studies can be useful in establishing a diagnosis.
f. Radial Nerve Decompression at the Elbow
Please refer to Physical Examination Findings Reference Table in the Physical Examination section of this
guideline. Electrodiagnostic (EDX) studies are helpful when positive, but negative studies do not exclude
the diagnosis.
g. Thoracic Outlet Syndrome
Please refer to Rule XVII, Exhibit B., Upper Extremity Medical Treatment Guidelines, Section III, Thoracic
Outlet Syndrome.
2. Tendon Decompression or Debridement
Surgery may be considered when several months of appropriate treatment have failed, and findings on
history and physical exam correlate specifically with the diagnosis being considered. Subjective
complaints should be localized and appropriate to the diagnosis, and physical exam findings should
correlate with the history. Refer to the Physical Examination Findings Table in the Physical Examination
section of this guideline. Job modification should be considered prior to surgery. Refer to the “Job Site
Alteration” section for additional information on job modification.
Specific procedures and their indications are outlined below:
a. Subacromial Decompression
Please refer to Rule XVII, Exhibit B., Upper Extremity Medical Treatment Guidelines, Section IV, Shoulder
Injury.
b. Medial or Lateral Epicondyle Release/Debridement
Please refer to Physical Examination Findings Reference Table in the Physical Examination section of this
guideline. It is generally accepted that 80% of cases improve with conservative therapy. Intermittent
discomfort may recur over six months to one year after initial conservative treatment. Surgery should only
be performed to achieve functional gains on those with significant ongoing impaired activities of daily
living. X-rays may be normal or demonstrate spur formation over the involved epicondyle.
c. First Extensor Compartment Release (de Quervain's Tenosynovitis)
Please refer to Physical Examination Findings Reference Table in the Physical Examination section of this
guideline. Surgery should be performed to achieve functional gains on those with significant ongoing
impaired activities of daily living.
d. Trigger Finger/Thumb Release
Please refer to Physical Examination Findings Reference Table in the Physical Examination section of this
guideline. Surgery should be performed to achieve functional gains on those with significant ongoing
impaired activities of daily living.
3. Considerations for post-operative therapy are:
a. Immobilization
Controlled mobilization, and/or formal physical/occupational therapy should begin as soon as possible
following surgery at the discretion of the treating surgeon. Final decisions regarding the need for splinting
post-operatively should be left to the discretion of the treating physician based upon his/her
understanding of the surgical technique used and the specific conditions of the patient.
b. Home Program
It is generally accepted that all patients should receive a home therapy protocol involving stretching,
ROM, scar care, and resistive exercises. Once they have been cleared for increased activity by the
surgeon, patients should be encouraged to use the hand as much as possible for daily activities, allowing
pain to guide their level of activity.
c. Supervised Therapy Program
May be helpful in patients who do not show functional improvements post-operatively or in patients with
heavy or repetitive job activities. The therapy program may include some of the generally accepted
elements of soft tissue healing and return to function:
1) Soft tissue healing/remodeling:
May be used after the incision has healed. It may include any of the following: evaluation,
whirlpool, electrical stimulation, soft tissue mobilization, scar compression pad, heat/cold
application, splinting or edema control may be used as indicated. Following wound healing,
ultrasound and iontophoresis with sodium chloride (NaCl) may be considered for soft tissue
remodeling. Diathermy is not an acceptable adjunct.
2) Return to function:
Range-of-motion and stretching exercises, strengthening, activity of daily living adaptations, joint
protection instruction, posture/body mechanics education. Worksite modifications may be
indicated.
(a) Time to produce effect: 2-4 weeks
(b) Frequency: 2-3 times/week
(c) Optimum duration: 4-6 weeks
(d) Maximum duration: 8 weeks
RULE XVII, EXHIBIT C Lower Extremity Injury Medical Treatment Guidelines December 1, 2001
(Previously Adopted March 2, 1995, Revised March 15, 1998)
Presented By:
State of Colorado
Department of Labor and Employment
DIVISION OF WORKERS' COMPENSATION
TABLE OF CONTENTS
Lower Extremity Injury
Medical Treatment Guideline
SECTION
DESCRIPTION
A.
B.
INTRODUCTION
GENERAL GUIDELINE PRINCIPLES
1.
Application of Guidelines
2.
Education
3.
Treatment Parameter Duration
4.
Active Interventions
5.
Active Therapeutic Exercise Program
6.
Positive Patient Response
7.
Re-Evaluate Treatment Every 3 to 4 Weeks
8.
Surgical Interventions
9.
Six-Month Time Frame
10.
Return-to-Work
11.
Delayed Recovery
12.
Guideline Recommendations and Inclusion of Med
Evidence
13.
Care Beyond Maximum Medical Improvement (M
INITIAL DIAGNOSTIC PROCEDURES
1.
History-taking and Physical Examination (Hx & PE
a.
History of Present In
b.
Past History:
c.
Physical Examinatio
2.
Radiographic Imaging
3.
Laboratory Tests
C.
4.
D.
Other Procedures
a.
Joint Aspiration
SPECIFIC LOWER EXTREMITY INJURY DIAGNOSIS, TESTING, AND
TREATMENT
1.
Foot and Ankle
a.
Ankle Sprain/Fractur
b.
Talar Fracture
c.
Calcaneal Fractures
d.
Midfoot (Lisfranc's)
Fracture Dislocation
e.
Metatarsal-Phalangea
Tarsal-Metatarsal, an
Interphalangeal Joint
Arthropathy
f.
Pilon Fracture
g.
Puncture Wounds of
Foot
h.
Achilles Tendon
Injury/Rupture
i.
Ankle Osteoarthropa
j.
Ankle or Subtalar Jo
Dislocation
k.
Heel Spur
Syndrome/Plantar
Fasciitis
l.
Tarsal Tunnel Syndro
m.
Neuroma
2.
Knee
a.
Chondral Defects
b.
Aggravated Osteoart
c.
Anterior Cruciate
Ligament Injury
d.
Posterior Cruciate
Injuries
e.
Meniscus Injury
f.
Patellar Subluxation
g.
Retropatellar Pain
Syndrome
h.
Tendonitis/Tenosyno
i.
Bursitis of the Lower
Extremity
3.
Hip and Leg
a.
Hip Fracture
b.
Pelvic Fracture
c.
Acetabulum Fracture
d.
Hamstring Tendon
E.
F.
Rupture
e.
Hip Dislocation
f.
Trochanteric Fracture
g.
Femur Fracture
h.
Tibia Fracture
FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES
1.
Imaging Studies
a.
Magnetic Resonance
Imaging (MRI)
b.
Computerized Axial
Tomography (CT)
c.
Lineal Tomography
d.
Bone Scan (Radioiso
Bone Scanning)
e.
Other Radionuclide
Scanning
f.
Arthrograms
g.
Diagnostic Arthrosco
Examination
2.
Other Tests
a.
Personality/Psycholo
/Psychosocial Evalua
b.
Electrodiagnostic Tes
c.
Doppler
Ultrasonography/Ple
mography
d.
Venogram/Arteriogra
e.
Compartment Pressu
Testing and Measure
Devices
3.
Special Tests
a.
Computer Enhanced
Evaluations
b.
Functional Capacity
Evaluation (FCE)
c.
Jobsite Evaluation
d.
Vocational Assessme
e.
Work Tolerance
Screening
THERAPEUTIC PROCEDURES — NON-OPERATIVE
1.
Acupuncture
a.
Acupuncture
b.
Acupuncture with
Electrical Stimulation
c.
Other Acupuncture
Modalities
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Biofeedback
Injections — Therapeutic
a.
b.
c.
d.
e.
Medications
a.
b.
Joint Injections
Soft Tissue Injection
Trigger Point Injectio
Prolotherapy
Intra-Capsular Acid S
Acetaminophen
Minor
Tranquilizer/Muscle
Relaxants
c.
Narcotics
d.
Nonsteroidal AntiInflammatory Drugs
(NSAIDs)
e.
Oral Steroids
f.
Psychotropic/Antianxiety/Hypnotic Ag
g.
Tramadol
h.
Topical Drug Deliver
Occupational Rehabilitation Programs
a.
Non-Interdisciplinary
b.
Interdisciplinary
Orthotics and Prosthetics
a.
Fabrication/Modifica
of Orthotics
b.
Orthotic/Prosthetic
Training
c.
Splints or Adaptive
Equipment
Patient Education
Personality/Psychological/Psychosocial Interventio
Restriction of Activity
Return-To-Work
a.
Establishment of A
Return-To-Work Stat
b.
Establishment of Act
Level Restrictions
c.
Compliance with Act
Restrictions
Therapy — Active
a.
Activities of Daily L
(ADL)
b.
Functional Activities
c.
Functional Electrical
d.
e.
f.
g.
12.
Therapy — Passive
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
G.
q.
r.
s.
13.
Vocational Rehabilitation
THERAPEUTIC PROCEDURES — OPERATIVE
a.
b.
c.
d.
e.
f.
g.
Stimulation
Gait Training
Neuromuscular ReEducation
Therapeutic Exercise
Wheelchair Managem
and Propulsion
Continuous Passive
Movement (CPM)
Contrast Baths
Electrical Stimulation
(Unattended)
Fluidotherapy
Infrared Therapy
Iontophoresis
Manipulation
Manual Electrical
Stimulation
Massage — Manual
Mechanical
Mobilization (Joint)
Mobilization (Soft
Tissue)
Paraffin Bath
Superficial Heat And
Cold Therapy
Short-wave Diatherm
Traction
Transcutaneous Elec
Nerve Stimulation
(TENS)
Ultrasound
Vasopneumatic Devi
Whirlpool/Hubbard T
Ankle and Subtalar
Fusion
Knee Fusion
Total Knee Replacem
Total Hip Replaceme
Amputation
Manipulation Under
Anesthesia
Bursectomy
h.
i.
j.
Osteotomy
Hardware Removal
Release of Contractu
A. INTRODUCTION
This document has been prepared by the Colorado Department of Labor and Employment, Division of
Workers' Compensation (Division) and should be interpreted within the context of guidelines for
physicians/providers treating individuals qualifying under Colorado Workers' Compensation Act as injured
workers with lower extremity injuries.
Although the primary purpose of this document is advisory and educational, these guidelines are
enforceable under the Workers' Compensation rules of Procedure, 7 CCR 1101-3. The Division
recognizes that acceptable medical practice may include deviations from these guidelines, as individual
cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of
professional care.
To properly utilize this document, the reader should not skip nor overlook any sections.
B. GENERAL GUIDELINE PRINCIPLES
The principles summarized in this section are key to the intended implementation of all Division of
Workers' Compensation guidelines and critical to the reader's application of the guidelines in this
document.
1. Application of Guidelines
The Division provides procedures to implement medical treatment guidelines and to foster communication
to resolve disputes among the provider, payer and patient through the Workers' Compensation Rules of
Procedure, Rule XVII and Rule VIII. In lieu of more costly litigation, parties may wish to seek
administrative dispute resolution services through the Division.
2. Education
Education of the patient and family, as well as the employer, insurer, policy makers and the community
should be the primary emphasis in the treatment of lower extremity pain and disability. Currently,
practitioners often think of education last, after medications, manual therapy and surgery. Practitioners
must develop and implement an effective strategy and skills to educate patients, employers' insurance
systems, policy makers and the community as a whole. An education-based paradigm should always start
with inexpensive communication providing reassuring information to the patient. More in-depth education
currently exists within a treatment regime employing functional restorative and innovative programs of
prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or
group patient education as a means of facilitating self-management of symptoms and prevention.
3. Treatment Parameter Duration
Time frames for specific interventions commence once treatments have been initiated, not on the date of
injury. Obviously, duration will be impacted by patient compliance, as well as availability of services.
Clinical judgment may substantiate the need to accelerate or decelerate the time frames discussed in this
document.
4. Active Interventions
Interventions emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment,
are generally emphasized over passive modalities, especially as treatment progresses. Generally,
passive interventions are viewed as a means to facilitate progress in an active rehabilitation program with
concomitant attainment of objective functional gains.
5. Active Therapeutic Exercise Program
Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and
education. This includes functional application in vocational or community settings.
6. Positive Patient Response
Positive results are defined primarily as functional gains that can be objectively measured. Objective
functional gains include, but are not limited to, positional tolerances, range-of-motion, strength,
endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures
that can be quantified. Subjective reports of pain and function should be considered and given relative
weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on
objective findings.
7. Re-Evaluate Treatment Every 3 to 4 Weeks
If a given treatment or modality is not producing positive results within 3 to 4 weeks, the treatment should
be either modified or discontinued. Reconsideration of diagnosis should also occur in the event of poor
response to a seemingly rational intervention.
8. Surgical Interventions
Surgery should be contemplated within the context of expected functional outcome and not purely for the
purpose of pain relief. The concept of “cure” with respect to surgical treatment by itself is generally a
misnomer. All operative interventions must be based upon positive correlation of clinical findings, clinical
course and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific
diagnosis with positive identification of pathologic conditions.
9. Six-Month Time Frame
The prognosis drops precipitously for returning an injured worker to work once he/she has been
temporarily totally disabled for more than six months. The emphasis within these guidelines is to move
patients along a continuum of care and return-to-work within a six-month time frame, whenever possible.
It is important to note that time frames may not be pertinent to injuries that do not involve work-time loss
or are not occupationally related.
10. Retum-to-Work
Retum-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 and the patient should never be
released to “sedentary” or “light duty.” The following functions should be considered and modified as
recommended: lifting, pushing, pulling, crouching, walking, using stairs, bending at the waist, awkward
and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and
other repetitive motion tasks, sustained grip, tool usage and vibration factors. Even if there is residual
chronic pain, return-to-work is not necessarily contraindicated.
The practitioner should understand all of the physical demands of the patient's job position before
returning the patient to full duty and should request clarification of the patient's job duties Clarification
should be obtained from the employer or, if necessary, including, but not limited to, an occupational health
nurse, occupational therapist, vocational rehabilitation specialist, or an industrial hygienist.
11. Delayed Recovery
Strongly consider a psychological evaluation, if not previously provided, as well as initiating
interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to
make expected progress 6 to 12 weeks after an injury.
The Division recognizes that 3 to 10% of all industrially injured patients will not recover within the
timelines outlined in this document despite optimal care. Such individuals may require treatments beyond
the limits discussed within this document, but such treatment will require clear documentation by the
authorized treating practitioner focusing on objective functional gains afforded by further treatment and
impact upon prognosis.
12. Guideline Recommendations and Inclusion of Medical Evidence
Guidelines are recommendations based on available evidence and/or consensus recommendations.
When possible, guideline recommendations will note the level of evidence supporting the treatment
recommendation. When interpreting medical evidence statements in the guideline, the following apply:
Consensus means the opinion of experienced professionals based on general medical principles.
Consensus recommendations are designated in the guideline as “generally well accepted,”
“generally accepted,” “acceptable,” or “well established.”
“Some” means the recommendation considered at least one adequate scientific study, which
reported that a treatment was effective.
“Good” means the recommendation considered the availability of multiple adequate scientific
studies or at least one relevant high-quality scientific study, which reported that a treatment was
effective.
“Strong” means the recommendation considered the availability of multiple relevant and high
quality scientific studies, which arrived at similar conclusions about the effectiveness of a
treatment.
All recommendations in the guideline are considered to represent reasonable care in appropriately
selected cases, regardless of the level of evidence or consensus statement attached to it. Those
procedures considered inappropriate, unreasonable, or unnecessary are designated in the guideline as
“not recommended.”
13. Care Bevond Maximum Medical Improvement (MMI)
MMI should be declared when a patient's condition has plateaued to the point where the authorized
treating physician no longer believes further medical intervention is likely to result in improved function.
However, some patients may require treatment after MMI has been declared in order to maintain their
functional state. The recommendations in this guideline are for pre-MMI care and are not intended to limit
post-MMI treatment.
The remainder of this document should be interpreted within the parameters of these guideline principles
that may lead to more optimal medical and functional outcomes for injured workers.
C. INITLAL DIAGNOSTIC PROCEDURES
The Division 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 workrelated lower extremity complaint, are listed below.
1. History-taking and Physical Examination (Hx & PE)
History taking and physical examinations are generally accepted, well-established and widely used
procedures that establish the foundation/basis for and dictates 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. History of Present Injury:
1) Mechanism of injury. This includes details of symptom onset and progression;
2) Relationship to work. This includes a statement of the probability that the illness or injury is workrelated;
3) Prior occupational and non-occupational injuries to the same area including specific prior treatment
and any prior bracing devices;
4) History of locking, clicking, giving way, acute or chronic swelling, crepitation, pain while ascending or
descending stairs, or popping;
5) Ability to perform job duties and activities of daily living; and
6) Exacerbating and alleviating factors of the injury.
b. Past History:
1) Past medical history includes neoplasm, gout, arthritis, and diabetes;
2) Review of systems includes symptoms of rheumatologic, neurologic, endocrine, neoplastic, and other
systemic diseases;
3) Smoking history; and
4) Vocational and recreational pursuits.
c. Physical Examination
Examination of a joint should include the joint above and below the affected area. Physical examinations
should include accepted tests and exam techniques applicable to the joint or area being examined,
including:
1) Visual inspection;
2) Palpation;
3) Range of motion/quality of motion;
4) Strength;
5) Joint stability;
6) If applicable to injury, integrity of distal circulation, sensory, and motor function; and
7) If applicable, full neurological exam including muscle atrophy and gait abnormality.
2. Radiographic Imaging
Radiographic imaging of the lower extremities is a generally accepted, well-established and widely used
diagnostic procedure when specific indications based on history and/or physical examination are present.
It should not be routinely performed. The mechanism of injury and specific indications for the radiograph
should be listed on the request form to aid the radiologist and x-ray technician. For additional specific
clinical indications, see Section IV, “Specific Diagnosis, Testing and Treatment Procedures.” Indications
include:
1) The inability to transfer weight for four steps at the time of the initial visit, regardless of limping;
2) History of significant trauma, especially blunt trauma or fall from a height;
3) Age over 55 years;
4) Unexplained or persistent lower extremity pain over two weeks. (Occult fractures, especially stress
fractures, may not be visible on initial x-ray. A follow-up radiograph and/or bone scan may be
required to make the diagnosis);
5) History or exam suggestive of intravenous drug abuse or osteomyelitis; and
6) Pain with swelling and/or range of motion (ROM) limitation localizing to an area of prior fracture,
internal fixation, or joint prosthesis.
3. Laboratory Tests
Laboratory tests are generally accepted, well established and widely used procedures. They are,
however, rarely indicated at the time of initial evaluation, unless there is suspicion of systemic illness,
infection, neoplasia, connective tissue disorder, or underlying arthritis or rheumatologic disorder based on
history and/or physical examination. Laboratory tests can provide useful diagnostic information. Tests
include, but are not limited to:
1) CBC with differential can detect infection, blood dyscrasias, and medication side effects;
2) Erythrocyte sedimentation rate, rheumatoid factor, ANA, HLA, and C-reactive protein (CRP) can be
used to detect evidence of a rheumatologic, infection, or connective tissue disorder;
3) Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect
metabolic bone disease;
4) Liver and kidney function may be performed for prolonged anti-inflammatory use or other medications
requiring monitoring; and
5) Analysis of joint aspiration for bacteria, white cell count, red cell count, fat globules, crystalline
birefringence and chemistry to evaluate joint effusion.
4. Other Procedures
a. Joint Aspiration
Joint aspiration is a generally accepted, well-established and widely used procedure when specifically
indicated and performed by individuals properly trained in these techniques. This is true at the initial
evaluation when history and/or physical examination are of concern for a septic joint or bursitis.
Particularly at the knee, aspiration of a large effusion can help to decrease pain and speed functional
recovery. Persistent or unexplained effusions may be examined for evidence of infection, rheumatologic,
or inflammatory processes. The presence of fat globules in the effusion strongly suggests occult fracture.
D. SPECIFIC LOWER EXTREMITY INJURY DIAGNOSIS, TESTING, AND TREATMENT
1. Foot and Ankle
a. Ankle Sprain/Fracture
1) Description/Definition — An injury to the ankle joint due to abnormal motion of the talus that causes a
stress on the malleoli and the ligaments. Instability can result from a fracture of a malleolus
(malleolli), rupture of ligaments, or a combination. Circumstances surrounding the injury are of
importance in consideration of other injuries and locations. Additionally, the position of the foot at
the time of injury is helpful in determining the extent and type of injury. Grading of soft tissue
injuries includes:
(a) Grade 1 injuries are those with microscopic tears of the ligament, minimal swelling, normal
stress testing, and the ability to bear weight.
(b) Grade 2 injuries have partial disruption of the ligament, significant swelling, indeterminate
results on stress testing, and difficulty bearing weight.
(c) Grade 3 injuries have a ruptured ligament, swelling and ecchymosis, abnormal results on
stress testing, and the inability to bear weight.
2) Occupational Relationship — Sudden twisting, direct blunt trauma, and falls.
3) Specific Physical Findings — Varies with individual: normal-appearing ankle or minimal tenderness on
examination, ability/inability to bear weight, pain, swelling, ecchymosis. If the patient is able to
transfer weight from one foot and has normal physical findings, then likelihood of fracture is
reduced.
4) Diagnostic Testing Procedures — Ankle x-rays for bone tenderness, inability to bear weight, or
significant edema/ecchymosis.
5) Non-Operative Treatment — For patients able to bear weight: NSAIDs and RICE (rest, ice,
compression, elevation) in first 24 hours. After the acute phase, isometric and range of motion
exercises are recommended followed by strengthening exercises. Partial weight bearing and
splinting may be used in the initial stage of treatment. Active and/or passive therapy may be
utilized to achieve optimal function.
For patients unable to bear weight: Bracing plus NSAIDs and RICE.
For patients with a clearly unstable joint: immobilization may be necessary for 4 to 6 weeks, with active
and/or passive therapy to achieve optimal function.
6) Surgical Indications — Severe instability, failure of conservative treatment, chronic instability,
displaced fracture.
7) Operative Treatment — Soft tissue: primary repair for acute and severe instability, delayed primary
repair for chronic instability. Osseous: Open reduction internal fixation.
8) Post-Operative Therapy — Casting, bracing, active and/or passive therapy.
b. Talar Fracture
1) Description/Definition — Osseous fragmentation of talus confirmed by radiographic, CT or MRI
evaluation.
2) Occupational Relationship — Usually occurs from a fall or crush injury.
3) Specific Physical Findings — Clinical findings consistent with fracture of talus: pain with range of
motion, palpation, swelling, ecchymosis. Pain with weight-bearing attempt.
4) Diagnostic Testing Procedures — Radiographs, CT scans, MRI. CT scans preferred for spatial
alignment.
5) Non-Operative Treatment — Active and/or passive therapy, casting, nonweight-bearing for 6 to 8
weeks for non-displaced fractures.
6) Surgical Indications — Osseous displacement, joint involvement and instability per physician
discretion.
7) Operative Treatment — Open reduction internal fixation.
8) Post-Operative Therapy — Nonweight-bearing 6 to 8 weeks followed by weight-bearing cast. MRI
follow-up if suspect avascular necrosis. Active and/or passive therapy.
c. Calcaneal Fractures
1) Description/Definition — Osseous fragmentation/separation confirmed by diagnostic studies.
2) Occupational Relationship — Usually occurs by fall or crush injury.
3) Specific Physical Findings — Pain with range of motion and palpation of calcaneus. Inability to weightbear, malpositioning of heel, possible impingement of sural nerve.
4) Diagnostic Testing Procedures—Radiographs/ CT scans.
5) Non-Operative Treatment — Active and/or passive therapy, nonweight-bearing 6 to 8 weeks, followed
by weight-bearing cast at physician's discretion.
6) Surgical Indications — Displacement of fragments, joint depression, intra-articular involvement,
malposition of heel.
7) Operative Treatment — Open reduction internal fixation.
8) Post-Operative Therapy — Nonweight-bearing for 6 to 8 weeks followed by weight-bearing for
approximately 6 to 8 weeks at physician's discretion. Active and/or passive therapy.
d. Midfoot (Lisfranc's) Fracture Dislocation
1) Description/Definition — Fracture/ligamentous disruption of the tarsal-metatarsal joints, i.e.,
metatarsal-cuneiform and metatarsal-cuboid bones.
2) Occupational Relationship—Usually occurs by a fall, crush, or sagittal plane hyperflexion/extension.
3) Specific Physical Findings — Fracture dislocation at Lisfranc's joint. CT scans usually needed to
evaluate. Fracture at base of 2nd metatarsal commonly seen.
4) Diagnostic Testing Procedures — X-rays, CT scans, MRI, mid-foot stress x-rays.
5) Non-Operative Treatment — Active and/or passive therapy. If minimal or no displacement (soft tissue)
then casting, nonweight-bearing 6 to 10 weeks.
6) Surgical Indications — If displacement of fragments or intra-articular. Most Lisfranc's
fracture/dislocations are treated surgically.
7) Operative Treatment — Open reduction internal fixation with removal of hardware approximately 3 to 6
months afterwards, pending healing status.
8) Post-Operative Therapy—Active and/or passive therapy, foot orthoses, nonweight-bearing 6 to 12
weeks.
e. Metatarsal-Phalangeal, Tarsal-Metatarsal, and Interphalangeal Joint Arthropathy
1) Description/Definition — Internal derangement of joint.
2) Occupational Relationship — Jamming, contusion, crush injury, or repetitive motion posttraumatic
arthrosis.
3) Specific Physical Findings — Pain with palpation and ROM of joint, effusion.
4) Diagnostic Testing Procedures — Radiographs, diagnostic joint injection, MRI.
5) Non-Operative Treatment — Active and/or passive therapy, joint splinting, injection therapy.
6) Surgical Indications — Pain, unresponsive to conservative care. Surgery may include athroplasty,
implant, and fusion.
7) Operative Treatment — Fusion, arthroplasty, joint debridement.
8) Post-Operative Therapy — Active and/or passive therapy, early range of motion with arthroplasty,
bracing-protected, weight-bearing with fusion.
f. Pilon Fracture
1) Description/Definition — Crush/comminution fracture of distal metaphyseal tibia that has intra-articular
extensions into the weight-bearing surface of the tibio-talar joint.
2) Occupational Relationship—Usually from a fall.
3) Specific Physical Findings—Multiple fracture fragments at distal tibia with intra-articular extensions into
the weight-bearing surface of the tibio-talar joint.
4) Diagnostic Testing Procedures—Radiographs, CT scans.
5) Non-Operative Treatment — Active and/or passive therapy. Prolonged nonweight-bearing at
physician's discretion.
6) Surgical Indications — Displacement of fracture with viable attempt at joint salvage, severe
comminution necessitating primary fusion.
7) Operative Treatment — Open reduction internal fixation, fusion, external fixation.
8) Post-Operative Therapy—Active and/or passive therapy.
g. Puncture Wounds of the Foot
1) Description/Definition — Penetration of skin by foreign object.
2) Occupational Relationship — Usually by stepping on foreign object, open wound.
3) Specific Physical Findings — Site penetration by foreign object consistent with history. In early onset,
may show classic signs of infection.
4) Diagnostic Testing Procedures — X-ray, MRI, ultrasound.
5) Non-Operative Treatment — Appropriate antibiotic therapy, tetanus toxoid booster, nonweight-bearing
at physician's discretion.
6) Surgical Indications — Cellulitis, retained foreign body suspected, abscess, compartmental syndrome,
and bone involvement.
7) Operative Treatment — Incision and drainage with cultures.
8) Post-Operative Therapy — Nonweight-bearing, antibiotic therapy based upon cultures, follow-up xrays may be needed to evaluate for osseous involvement. Active and/or passive therapy.
h. Achilles Tendon Injury/Rupture
1) Description/Definition — Rupture, tear, or strain of Achilles tendon.
2) Occupational Relationship — Related to a fall, twisting, jumping, or sudden load on ankle with
dorsiflexion.
3) Specific Physical Findings — Swelling and pain at tendon, palpable deficit in tendon.
4) Diagnostic Testing Procedures — MRI, ultrasound.
5) Non-Operative Treatment — Cast, nonweight-bearing, active and/or passive therapy.
6) Surgical Indications — Total rupture.
7) Operative Treatment — Repair of tendon by various methods, therapy.
8) Post-Operative Therapy — Nonweight-bearing cast for 6 to 8 weeks followed by active and/or passive
therapy.
i. Ankle Osteoarthropathy
1) Description/Definition — Internal joint pathology of ankle.
2) Occupational Relationship — Chronic: work activities exacerbating a pathologic condition. Acute:
internal derangement of joint caused by trauma (twisting, fall).
3) Specific Physical Findings — Pain within joint, swelling.
4) Diagnostic Testing Procedures — X-ray, CT, MRI, diagnostic injection.
5) Non-Operative Treatment — Injection therapy, bracing, active and/or passive therapy.
6) Surgical Indications — Pain and loss of joint function. Unresponsive to conservative care.
7) Operative Treatment — Arthroscopy, arthrotomy, fusion.
8) Post-Operative Therapy — Active and/or passive therapy.
j. Ankle or Subtalar Joint Dislocation
1) Description/Definition — Dislocation of ankle or subtalar joint.
2) Occupational Relationship — Usually occurs by fall, twist.
3) Specific Physical Findings — Disruption of articular arrangements of ankle, subtalar joint.
4) Diagnostic Testing Procedures — Radiographs, CT scans.
5) Non-Operative Treatment — Closed reduction under anesthesia with pre and post-reduction
neurovascular assessment.
6) Surgical Indications — Inability to reduce closed fracture, association with unstable fractures.
7) Operative Treatment — Open reduction of dislocation.
8) Post-Operative Therapy — Immobilization, followed by active and/or passive therapy.
k. Heel Spur Syndrome/Plantar Fasciitis
1) Description — Pain along the inferior aspect of the heel at the attachment of the plantar fascia.
2) Occupational Relationship — Condition may be exacerbated by prolonged standing on hard surfaces.
Acute injury may be caused by trauma. This may include jumping from a height or hyperextension
of the forefoot upon the rear foot.
3) Specific Physical Findings — Pain with palpation at the inferior attachment of the plantar fascia to the
os calcis. May be associated with calcaneal spur.
4) Diagnostic Testing — Standard radiographs to rule out fracture, identify spur after conservative
therapy. Bone scans may be utilized to rule out stress fractures in chronic cases.
5) Non-Operative Treatment — This condition usually responds to conservative management consisting
of active and/or passive therapy, taping, injection therapy, non-steroidal anti-inflammatory drugs,
and custom foot orthoses.
6) Surgical Indications — Surgery is usually employed only after failure of conservative management (3
to 6 months).
7) Operative Treatment — Plantar fascial release with or without calcaneal spur removal.
8) Post-Operative Therapy — Nonweight-bearing 7 to 10 days followed by weight-bearing cast or shoe
for four weeks. Active and/or passive therapy.
l. Tarsal Tunnel Syndrome
1) Description — Pain and paresthesias along the medial aspect of the ankle and foot due to nerve
irritation and entrapment of the tibial nerve or its branches.
2) Occupational Relationship — Acute injuries may occur after blunt trauma along the medial aspect of
the foot. Non-traumatic occurrences are determined at physician's discretion after review of
environmental and biomechanical risk factors. Examples may include abnormal foot mechanics
and excessive weight bearing.
3) Specific Physical Findings — Positive Tinel's sign. Pain with percussion of the tibial nerve radiating
distally or proximally. Pain and paresthesias with weight-bearing activities.
4) Diagnostic Testing Procedures — Nerve conduction velocity studies, MRI.
5) Non-Operative Treatment — Active and/or passive therapy, injection therapy, cast immobilization, foot
orthoses, non-steroidal anti-inflammatories.
6) Surgical Indications — Failure of condition to respond to conservative management (3 to 6 months).
7) Operative Treatment — Tarsal tunnel release.
8) Post-Operative Therapy — Active and/or passive therapy.
m. Neuroma
1) Description — This condition is a perineural fibrosis of the intermetatarsal nerve creating pain and/or
paresthesias in the forefoot region. Symptoms appear with weight-bearing activities. Usually
occurs between the third and fourth metatarsals or between the second and third metatarsals.
2) Occupational Relationship — Acute injuries may include excessive loading of the forefoot region
caused from jumping or pushing down on the ball the foot. Non-traumatic occurrences are
determined at physician's discretion after review of environmental and biomechanical risk factors.
Examples may include excessive weight-bearing on hard surfaces in conjunction with abnormal
foot mechanics.
3) Specific Physical Findings — Paresthesias and or pain with palpation of the intermetatarsal nerve
(Mulder's sign) diagnostic testing-radiographs to rule out osseous involvement. Diagnostic and
therapeutic injections. Diagnosis is usually made upon clinical judgment; however MRI and
ultrasound imaging have also been employed in difficult cases.
4) Diagnostic Testing — Radiographs to rule out osseous involvement. Diagnostic and therapeutic
injections. Diagnosis is usually made upon clinical judgment; however MRI and ultrasound
imaging have also been employed in difficult cases.
5) Non-Operative Treatment — Injection therapy, nonsteroidal anti-inflammatories, foot orthoses, active
and/or passive therapy.
6) Surgical Indications — Failure of conservative management (2 to 3 months).
7) Operative Treatment — Excision of the neuroma.
8) Post-Operative Therapy — Active and/or passive therapy. May involve a period of nonweight-bearing
up to two weeks followed by gradual protected weight-bearing 4 to 6 weeks.
2. Knee
a. Chondral Defects
1) Description/Definition — Cartilage or cartilage and bone defect at the articular or meniscal surface of a
joint.
2) Occupational Relationship — Usually caused by a traumatic knee injury.
3) Specific Physical Findings — Knee effusion, pain in joint.
4) Diagnostic Testing Procedures — MRI may show bone bruising, osteochondral lesion, or possibly
articular cartilage injury. Radiographs, contrast radiography, CT may also be used.
5) Non-Operative Treatment — Limited indications. The size and extent of the injury should be
determined first. This form of therapy is reserved for non-displaced, stable lesions. Immobilization
(for acute injury), active and/or passive therapy.
6) Surgical Indications — Symptoms not responsive to conservative therapy. Identification of an
osteochondral lesion by diagnostic testing procedures should be done to determine the size of
the lesion and stability of the joint.
a. Cartilage Grafts and or Transplantations remain controversial and have some scientific
evidence. These procedures are technically difficult and require specific physician
expertise. Cartilage transplantation requires the harvesting and growth of patients'
cartilage cells in a highly specialized lab and may incur extraneous laboratory charges.
Indications – They may be effective in patients less than 40 years of age, with a singular,
traumatically caused grade III or IV femoral condyle deficit, and who plan to maintain an active
lifestyle. The diameter of the deficit should not exceed 20 mm for osteochondral autograft
transplant procedure.
Contraindications – Grafts and transplants are not recommended for individuals with obesity,
inflammatory or osteoarthritis, or other chondral defects, associated ligamentous or meniscus
pathology, or who are greater than 55 years of age. For cartilage grafts or transplants, prior
authorization is required.
b. Cartilage Repair involves the repair and or removal of torn cartilage.
7) Operative Treatment — Arthroscopy with debridement or shaving of cartilage, microfracture,
mosiacplasty, fixation of loose osteochondral fragments and cartilage transplantation.
8) Post-Operative Therapy — May include restricted weight bearing, bracing, active and/or passive
therapy. Continuous passive motion is suggested after microfracture.
b. Aggravated Osteoarthritis
1) Description/Definition — Swelling and/or pain in a joint due to an aggravating activity in a patient with
pre-existing degenerative change in a joint.
2) Occupational Relationship — May be caused by repetitive activity or constant position.
3) Specific Physical Findings — Increased pain and swelling in a joint.
4) Diagnostic Testing Procedures — Radiographs, MRI to rule out degenerative menisci tear.
5) Non-Operative Treatment — NSAIDs, ice, bracing, active and/or passive therapy, therapeutic
injections, restricted activity.
6) Surgical Indications — Symptoms not responsive to conservative therapy.
7) Operative Treatment — Arthroscopic joint lavage, debridement, removal of loose bodies. For
symptoms not responsive to conservative measures, treatment may involve total joint
replacement.
8) Post-Operative Therapy — Active and/or passive therapy.
c. Anterior Cruciate Ligament Injury
1) Description/Definition — Rupture or partial rupture of the anterior cruciate ligament; may be associated
with other internal derangement of the knee.
2) Occupational Relationship — May be caused by virtually any traumatic force to the knee but most
often caused by a twisting or a hyperextension force.
3) Specific Physical Findings — Findings on physical exam include effusion or hemarthrosis, instability,
Lachman's test, pivot shift test, and anterior drawer test.
4) Diagnostic Testing Procedures — MRI. Radiographs may show avulsed portion of tibial spine but this
is a rare finding.
5) Non-Operative Treatment — Active and/or passive therapy, bracing, therapeutic injection.
6) Surgical Indications — Physically active individual less than 50 years old or any individual with
complaints of recurrent instability.
7) Operative Treatment — Diagnostic/surgical arthroscopy followed by ACL reconstruction using
autograft. If meniscus repair is performed, an ACL repair should be performed concurrently.
8) Post-Operative Therapy — Active and/or passive therapy, bracing.
d. Posterior Cruciate Injuries
1) Description/Definition — Rupture of posterior cruciate ligament; may have concurrent ACL rupture.
2) Occupational Relationship — Most often caused by a posterior directed force to flexed knee.
3) Specific Physical Findings — Findings on physical exam include acute effusion, instability, reverse
Lachman's test, reverse pivot shift, posterior drawer test.
4) Diagnostic Testing Procedures — MRI, radiographs may reveal avulsed bone.
5) Non-Operative Treatment — Active and/or passive therapy, bracing, therapeutic injection.
6) Surgical Indications — Complaints of instability. Carefully consider the patients' normal daily activity
level before initiation of surgical intervention. Most commonly done when the PCL rupture is
accompanied by multiligament injury.
7) Operative Treatment — Autograft or allograft reconstruction.
8) Post-Operative Therapy — Active and/or passive therapy, bracing.
e. Meniscus Injury
1) Description/Definition — A tear, disruption, or avulsion of medial or lateral meniscus tissue.
2) Occupational Relationship — Trauma to the menisci from rotational, shearing, torsion, and/or impact
injuries.
3) Specific Physical Findings — Patient describes a popping, tearing, or catching sensation. Findings on
physical exam may include joint line tenderness, locked joint, or occasionally, effusion.
4) Diagnostic Testing Procedures — Radiographs including standing PA, lateral, tunnel, and Skyline
views.
5) Non-Operative Treatment — Active and/or passive therapy, bracing.
6) Surgical Indications — Symptoms not responsive to conservative therapy. Sustained marked reduction
of ROM of joint; acute effusion with positive ligament laxity; recurrent effusions; infection; loose
bodies.
7) Operative Treatment — Debridement of meniscus, repair of meniscus, partial or complete excision of
meniscus. Complete excision of meniscus should only be performed when clearly indicated due
to the long-term risk of arthritis in these patients.
8) Post-Operative Therapy — Active and/or passive therapy, bracing.
f. Patellar Subluxation
1) Description/Definition — An incomplete subluxation or dislocation of the patella. Recurrent episodes
can lead to subluxation syndrome that can cause frank dislocation of the patella.
2) Occupational Relationship — Primarily associated with contusion, lateral force direct contact.
Secondary causes associated with shearing forces on the patella.
3) Specific Physical Findings — Patient may report buckling sensation. Findings on physical exam may
include retinacular weakness, swelling, effusion, marked pain with patellofemoral
tracking/compression and glides. In addition, other findings include atrophy of muscles, positive
patellar apprehension test, patella alta.
4) Diagnostic Testing Procedures — CT or Radiographs including Merchant views, Q-angle versus
congruents.
5) Non-Operative Treatment — Active and/or passive therapy, bracing, therapeutic injection.
6) Surgical Indications — Symptoms not responsive to conservative therapy, fracture, recurrent
subluxation or recurrent effusion.
7) Operative Treatment — Diagnostic arthroscopy with possible arthrotomy; debridement of soft tissue
and articular cartilage disruption; open reduction internal fixation with fracture. Retinacular
release, quadriceps reefing, and patellar tendon transfer should only be considered after 6 to 9
months of conservative therapy.
8) Post-Operative Therapy — Active and/or passive therapy, bracing.
g. Retropatellar Pain Syndrome
1) Description/Definition — A retropatellar pain syndrome lasting over three months. Retropatellar
pathologies are associated with resultant weakening instability, and pain of the patellofemoral
mechanism. Can include malalignment, persistent quadriceps tendonitis, distal patellar tendonitis,
patellofemoral arthrosis, and symptomatic plica syndrome.
2) Occupational Relationship — Usually associated with contusion; repetitive patellar compressive
forces, shearing articular injuries associated with subluxation or dislocation of patella, fractures,
infection, and connective tissue disease.
3) Specific Physical Findings — Patient complains of pain, instability and tenderness that interfere with
daily living and work functions. Findings on physical exam may include retinacular tenderness,
pain with patellar compressive ranging, positive patellar glide test, atrophy of quadriceps muscles,
positive patellar apprehensive test. Associated anatomical findings may include increased Q
angle; rotational lower extremity joints; ligament laxity, and effusion.
4) Diagnostic Testing Procedures — Radiographs including tunnel, Merchant, or Laurin views. MRI rarely
identifies pathology. Occasionally CT or Bone scan.
5) Non-Operative Treatment — Active and/or passive therapy, bracing, orthotics, therapeutic injections.
6) Surgical Indications — Symptoms not responsive to conservative therapy, patellar tendon disruption,
quadriceps tendon rupture/avulsion, fracture.
7) Operative Treatment — Arthroscopic debridement of articular surface, plica, synovial tissue, loose
bodies, arthrotomy, open reduction internal fixation with fracture, patellar button (prosthesis) with
grade III-IV OA, and possible patellectomy. Retinacular release, quadriceps reefing, and tibial
transfer procedures should only be considered after 6 to 9 months of conservative therapy.
8) Post-Operative Therapy — Active and/or passive therapy; bracing.
h. Tendonitis/Tenosynovitis
1) Description/Definition — Inflammation of the lining of the tendon sheath or of the enclosed tendon.
Usually occurs at the point of insertion into bone or a point of muscular origin. Can be associated
with bursitis or calcium deposits or systemic connective diseases.
2) Occupational Relationship — Extreme or repetitive trauma, strain, or excessive unaccustomed
exercise or work.
3) Specific Physical Findings — Involved tendons may be visibly swollen with possible fluid accumulation
and inflammation; popping or crepitus; and decreased ROM.
4) Diagnostic Testing Procedures — Rarely indicated.
5) Non-Operative Treatment — Active and/or passive therapy, including ergonomic changes at work
station(s), NSAIDs, therapeutic injections.
6) Surgical Indications — Suspected avulsion fracture, severe functional impairment unresponsive to
conservative therapy.
7) Operative Treatment — Rarely indicated and only after extensive conservative therapy.
8) Post-Operative Therapy — Active and/or passive therapy.
i. Bursitis of the Lower Extremity
1) Description/Definition — Inflammation of bursa tissue. Can be precipitated by tendonitis, bone spurs,
foreign bodies, gout, arthritis, muscle tears, or infection.
2) Occupational Relationship — Sudden change in work habits, frequent repetitive motions in non-routine
work profile, postural changes, contusion, frequent climbing, soft tissue trauma, fracture,
continuous work on uneven surfaces, sustained compression force.
3) Specific Physical Findings — Palpable, tender and enlarged bursa, decreased ROM, warmth. May
have increased pain with ROM.
4) Diagnostic Testing Procedures — Bursal fluid aspiration with testing for connective tissue, rheumatic
disease, and infection. Radiographs, CT, MRI are rarely indicated.
5) Non-Operative Treatment — Active and/or passive therapy, ice, therapeutic injection, treatment of an
underlying infection, if present.
6) Surgical Indications — Bursa excision after failure of conservative therapy.
7) Operative Treatment — Surgical excision of the bursa.
8) Post-Operative Therapy — Active and/or passive therapy.
3. Hip and Leg
a. Hip Fracture
1) Description/Definition — Fractures of the neck and peritrochanteric regions of the proximal femur.
2) Occupational Relationship — Usually from a traumatic injury such as a fall or crush. Patients with
intracapsular femoral fractures have a risk of developing avascular necrosis of the femoral head
requiring treatment months to years after the initial injury.
3) Specific Physical Findings — Often a short, and externally rotated lower extremity.
4) Diagnostic Testing Procedures — Radiographs. Occasional use of tomography, CT scanning or MRI.
5) Non-Operative Treatment — Rarely indicated. May be considered in a stable, undisplaced fracture.
6) Surgical Indications — Unstable peritrochanteric fractures with potential for displacement; femoral
neck fracture to be considered for pinning or prosthetic replacement based upon pattern and
displacement of fracture. Open fracture.
7) Operative Treatment — Prosthetic replacement for displaced neck fractures. Closed reduction, and
internal fixation for peri-trochanteric fractures and undisplaced or minimally displaced neck
fractures.
8) Post-Operative Therapy — Active and/or passive therapy. Weight-bearing progression based upon
fracture pattern and stability. In all cases, communication between the physician and physical
therapist is important to the timing of weight-bearing and exercise progressions.
b. Pelvic Fracture
1) Description/Definition — Fracture of one or more components of the pelvic ring (sacrum and iliac
wings).
2) Occupational Relationship — Usually from a traumatic injury such as a fall or crush.
3) Specific Physical Findings — Displaced fractures may cause pelvic deformity and shortening or
rotation of the lower extremities.
4) Diagnostic Testing Procedures — Radiographs, CT scanning. Occasionally MRI, angiogram,
urethrogram.
5) Non-Operative Treatment — For stable, undisplaced or minimally displaced fractures. May include
analgesics, a limited period of bed rest, limited weight-bearing and passive therapy.
6) Surgical Indications — Unstable fracture pattern, open fracture.
7) Operative Treatment — External or internal fixation dictated by fracture pattern.
8) Post-Operative Therapy — Graduated weight-bearing according to fracture healing. Active and/or
passive therapy for gait, pelvic stability and strengthening and restoration of joint and extremity
function.
c. Acetabulum Fracture
1) Description/Definition — Subgroup of pelvic fractures with involvement of the hip articulation.
2) Occupational Relationship — Usually from a traumatic injury such as a fall or crush.
3) Specific Physical Findings — Displaced fractures may have short and/or abnormally rotated lower
extremity.
4) Diagnostic Testing Procedures — Radiographs, CT scanning.
5) Non-Operative Treatment — May be considered for undisplaced fractures or minimally displaced
fractures that do not involve the weight-bearing surface of the acetabular dome.
6) Surgical Indications — Displaced or unstable fracture pattern associated femoral head fracture, open
fracture.
7) Operative Treatment — Usually open reduction internal fixation.
8) Post-Operative Therapy — Active and/or passive therapy for early range-of-motion and weight-bearing
progression, strengthening, flexibility, and neuromuscular training. In all cases, communication
between the physician and physical therapist is important to the timing of weight-bearing and
exercise progressions.
d. Hamstring Tendon Rupture
1) Description/Definition — Most commonly, a disruption of the muscular portion of the hamstring. Extent
of the tear is variable. Occasionally a proximal tear or avulsion. Rarely a distal injury.
2) Occupational Relationship — Excessive tension on the hamstring either from an injury or from to a
rapid, forceful contraction of the muscle.
3) Specific Physical Findings — Local tenderness, swelling, ecchymosis.
4) Diagnostic Testing Procedures — Occasionally radiographs or MRI for proximal tears/possible
avulsion.
5) Non-Operative Treatment — Usual treatment is local ice followed by heat in 24 to 48 hours, protected
weight-bearing, active and/or passive therapy, nonsteroidal anti-inflammatory drugs.
6) Surgical Indications — Usually for proximal or distal injuries only if significant functional impairment is
expected without repair, open fracture.
7) Operative Treatment — Occasionally re-attachment of proximal avulsions and repair of distal tendon
disruption.
8) Post-Operative Therapy — Active and/or passive therapy, protected weight-bearing.
e. Hip Dislocation
1) Description/Definition — Disengagement of the femoral head from the acetabulum.
2) Occupational Relationship — Usually from a traumatic injury such as a fall or crush.
3) Specific Physical Findings — Most commonly a short, internally rotated, adducted lower extremity with
a posterior dislocation. A short externally rotated extremity with an anterior dislocation.
4) Diagnostic Testing Procedures — Radiographs, occasionally CT scanning.
5) Non-Operative Treatment — Urgent closed reduction. Sedation or general anesthesia usually
required.
6) Surgical Indications — Failure of closed reduction. Associated fracture of the acetabulum or femoral
head, open fracture.
7) Operative Treatment — Open reduction of the femoral head.
8) Post-Operative Therapy — Active and/or passive therapy for early range of motion, protected weightbearing.
f. Trochanteric Fracture
1) Description/Definition — Fracture of the greater trochanter of the proximal femur.
2) Occupational Relationship — Usually from a traumatic injury such as a fall or crush.
3) Specific Physical Findings — Local tenderness over the greater trochanter. Sometimes associated
swelling, ecchymosis.
4) Diagnostic Testing Procedures — Radiographs. Occasionally tomograms or CT scans.
5) Non-Operative Treatment — Active and/or passive therapy for protected weight-bearing.
6) Surgical Indications — Large, displaced fragment, open fracture.
7) Operative Treatment — Open reduction, internal fixation.
8) Post-Operative Therapy — Active and/or passive therapy for protected weight-bearing. Full weightbearing with radiographic and clinical signs of healing.
g. Femur Fracture
1) Description/Definition — Fracture of the femur distal to the lesser trochanter.
2) Occupational Relationship — Usually from a traumatic injury such as a fall or crush.
3) Specific Physical Findings — May have a short, abnormally rotated extremity. Effusion if the knee joint
involved.
4) Diagnostic Testing Procedures — Radiographs. Occasionally tomography or CT scanning, particularly
if the knee joint is involved.
5) Non-Operative Treatment — Active and/or passive therapy for functional bracing, protected weight
bearing.
6) Surgical Indications — Unstable fracture pattern, displaced fracture, especially if the knee joint is
involved, open fracture.
7) Operative Treatment — Often closed, rodding for shaft fractures. Open reduction and internal fixation
more common for fractures involving the knee joint.
8) Post-Operative Therapy — Active and/or passive therapy for protected weight-bearing, early range of
motion if joint involvement.
h. Tibia Fracture
1) Description/Definition — Fracture of the tibia proximal to the malleoli.
2) Occupational Relationship — Usually from a traumatic injury such as a fall or crush.
3) Specific Physical Findings — May have a short, abnormally rotated extremity. Effusion if the knee joint
involved.
4) Diagnostic Testing Procedures — Radiographs. Occasionally tomography or CT scanning, particularly
if the knee joint is involved.
5) Non-Operative Treatment — Active and/or passive therapy for functional bracing, protected weightbearing.
6) Surgical Indications — Unstable fracture pattern, displaced fracture (especially if the knee joint is
involved), open fracture.
7) Operative Treatment — Often closed rodding for shaft fractures. Open reduction and internal fixation
more common for fractures involving the knee joint.
8) Post-Operative Therapy — Active and/or passive therapy for protected weight-bearing, early range of
motion if joint involvement.
E. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES
One diagnostic imaging procedure may provide the same or distinctive information as obtained by other
procedures. Therefore, prudent choice of procedure(s) for a single diagnostic procedure, a
complementary procedure in combination with other procedures(s), or a proper sequential order in
multiple procedures will ensure maximum diagnostic accuracy; minimize adverse effect to patients and
cost effectiveness by avoiding duplication or redundancy.
All diagnostic imaging procedures have a significant percentage of specificity and sensitivity for various
diagnoses. None is specifically characteristic of a certain diagnosis. Clinical information obtained by
history taking and physical examination should be the basis for selection and interpretation of imaging
procedure results.
When a diagnostic procedure, in conjunction with clinical information, provides sufficient information to
establish an accurate diagnosis, the second diagnostic procedure will become a redundant procedure. At
the same time, a subsequent diagnostic procedure can be a complementary diagnostic procedure if the
first or preceding procedures, in conjunction with clinical information, cannot provide an accurate
diagnosis. Usually, preference of a procedure over others depends upon availability, a patient's tolerance
and/or the treating practitioner's familiarity with the procedure.
1. Imaging Studies
Imaging studies are generally accepted, well established and widely used diagnostic procedures. When
indicated, the following additional imaging studies can be utilized for further evaluation of the lower
extremity, based upon the mechanism of injury, symptoms, and patient history. For specific clinical
indications, see “Specific Diagnosis, Testing and Treatment Procedures.” The studies below are listed in
frequency of use, not importance.
a. Magnetic Resonance Imaging (MRI)
MRI provides a more definitive visualization of soft tissue structures, including ligaments, tendons, joint
capsule, menisci and joint cartilage structures, than x-ray or Computerized Axial Tomography in the
evaluation of traumatic or degenerative injuries. The addition of intravenous or intra-articular contrast can
enhance definition of selected pathologies.
In general, the high field, conventional, MRI provides better resolution. A lower field scan may be
indicated when a patient cannot fit into a high field scanner or is too claustrophobic despite sedation.
Inadequate resolution on the first scan may require a second MRI using a different technique. All
questions in this regard should be discussed with the MRI center and/or radiologist.
b. Computerized Axial Tomography (CT)
CT provides excellent visualization of bone and is used to further evaluate bony masses and suspected
fractures not clearly identified on radiographic window evaluation. Instrument scatter-reduction software
provides better resolution when metallic artifact is of concern.
c. Lineal Tomography
Lineal tomography is infrequently used, yet may be helpful in the evaluation of joint surfaces and bone
healing.
d. Bone Scan (Radioisotope Bone Scanning)
Bone scanning is generally accepted, well established and widely used. Bone scanning is more sensitive
but less specific than MRI. 99MTechnecium diphosphonate uptake reflects osteoblastic activity and may be
useful in metastatic/primary bone tumors, stress fractures, osteomyelitis, and inflammatory lesions, but
cannot distinguish between these entities.
Bone scanning is more sensitive but less specific than MRI. It is useful for the investigation of traurna,
infection, stress fracture, occult fracture, Charcot joint, Complex Regional Pain Syndrome, and suspected
neoplastic conditions of the lower extremity.
e. Other Radionuclide Scanning
Indium and gallium scans are generally accepted, well established, and widely used procedures usually to
help diagnose lesions seen on other diagnostic imaging studies. 67Gallium citrate scans are used to
localize tumor, infection, and abcesses. 111Indium-labeled leukocyte scanning is utilized for localization of
infection or inflammation.
f. Arthrograms
Arthograms may be useful in the evaluation of internal derangement of a joint, including when MRI or
other tests are contraindicated or not available. Potential complications of this more invasive technique
include pain, infection, and allergic reaction. Arthrography gains additional sensitivity when combined with
CT in the evaluation of internal derangement, loose bodies, and articular cartilage surface lesions.
Diagnostic arthroscopy should be considered before arthrogram with strong clinical correlation.
g. Diagnostic Arthroscopic Examination
Diagnostic arthroscopic (DA) examination allows direct visualization of the interior of a joint, enabling the
diagnosis of conditions when other diagnostic tests have failed to reveal an accurate diagnosis. DA may
also be employed in the treatment of joint disorders. In some cases, the mechanism of injury and physical
examination findings will strongly suggest the presence of a surgical lesion. In those cases, it is
appropriate to proceed directly with the interventional arthroscopy.
2. Other Tests
The studies below are listed by frequency of use, not importance.
a. Personality/Psychological/Psychosocial Evaluations
Personality/psychological/psychosocial evaluations are generally accepted and well-established
diagnostic procedures with selective use in the acute lower extremity population, but have more
widespread use in sub-acute and chronic lower extremity populations.
Diagnostic testing procedures may be useful for patients with symptoms of depression, delayed recovery,
chronic pain, recurrent painful conditions, disability problems, and for pre-operative evaluation as well as
a possible predictive value for post-operative response. Psychological testing should provide
differentiation between pre-existing depression versus injury-caused depression, as well as posttraumatic stress disorder.
Formal psychological or psychosocial evaluation should be performed on patients not making expected
progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate with
objective signs and tests. In addition to the customary initial exam, the evaluation of the injured worker
should specifically address the following areas:
1) Employment history;
2) Interpersonal relationships — both social and work;
3) Leisure activities;
4) Current perception of the medical system;
5) Results of current treatment;
6) Perceived locus of control; and
7) Childhood history, including abuse and family history of disability.
Results should provide clinicians with a better understanding of the patient, thus allowing for more
effective rehabilitation.
The evaluation will determine the need for further psychosocial interventions, and in those cases, a DSM
IV diagnosis should be determined and documented. An individual with a PhD, PsyD, or Psychiatric
MD/DO credentials may perform initial evaluations, which are generally completed within one to two
hours. When issues of chronic pain are identified, the evaluation should be more extensive and follow
testing procedures as outlined in “Psychosocial Evaluation,” in Division Rule XVII, Exhibit F, Chronic Pain
Disorder Medical Treatment Guideline.
(1) Frequency: One time visit for evaluation. If psychometric testing is indicated as a portion of the initial
evaluation, time for such testing should not exceed an additional two hours of professional time.
b. Electrodiagnostic Testing
Electrodiagnostic tests include, but are not limited to, Electromyography (EMG), Nerve Conduction
Studies (NCS) and Somatosensory Evoked Potentials (SSEP). These are generally accepted, wellestablished and widely used diagnostic procedures. The SSEP study, although generally accepted, has
limited use. Electrodiagnostic studies may be useful in the evaluation of patients with suspected
involvement of the neuromuscular system, including disorder of the anterior horn cell, radiculopathies,
peripheral nerve entrapments, peripheral neuropathies, neuromuscular junction and primary muscle
disease.
In general, these diagnostic procedures are complementary to imaging procedures such as CT, MRI,
and/or myelography or diagnostic injection procedures. Electrodiagnostic studies may provide useful,
correlative neuropathophysiological information that would be otherwise unobtainable from standard
radiologic studies.
c. Doppler Ultrasonography/Plethysmography
Doppler ultrasonography/plethysmography is useful in establishing the diagnosis of arterial and venous
disease in the lower extremity and should be considered prior to the more invasive venogram or
arteriogram study. Doppler is less sensitive in detecting deep-vein thrombosis in the calf muscle area. If
the test is initially negative, an ultrasound should be repeated 7 days post initial symptoms to rule out
popliteal thrombosis. It is also useful for the diagnosis of popliteal mass when MRI is not available or
contraindicated.
d. Venogram/Arteriogram
Venogram/arteriogram is useful for investigation of vascular injuries or disease, including deep-venous
thrombosis. Potential complication may include pain, allergic reaction, and deep-vein thrombosis.
e. Compartment Pressure Testing and Measurement Devices
Compartment pressure testing and measurement devices, such as pressure manometer, are useful in the
evaluation of patients who present symptoms consistent with a compartment syndrome.
3. Special Tests
Special tests are generally well-accepted tests and are performed as part of a skilled assessment of the
patient's capacity to return to work, his/her strength capacities, and physical work demand classifications
and tolerances.
a. Computer Enhanced Evaluations
Computer-enhanced evaluations may include isotonic, isometric, isokinetic and/or isoinertial
measurement of movement, range of motion, 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.
(1) Frequency: One time for evaluation. Can monitor improvements in strength every 3 to 4 weeks up to
a total of 6 evaluations.
b. Functional Capacity Evaluation (FCE)
Functional capacity evaluation is a comprehensive or modified evaluation of the various aspects of
function as they relate to the worker's ability to return to work. Areas such as endurance, lifting (dynamic
and static), postural tolerance, specific range of motion, coordination and strength, worker habits,
employability and financial status, as well as psychosocial aspects of competitive employment may be
evaluated. Components of this evaluation may include: (a) musculoskeletal screen; (b) cardiovascular
profile/aerobic capacity; (c) coordination; (d) lift/carrying analysis; (e) job-specific activity tolerance; (f)
maximum voluntary effort; (g) pain assessment/psychological screening; and (h) non-material and
material handling activities.
(1) Frequency: Can be used initially to determine baseline status. Additional evaluations can be
performed to monitor and assess progress and aid in determining the endpoint for treatment.
c. Jobsite Evaluation
Jobsite evaluation is a comprehensive analysis of the physical, mental and sensory components of a
specific job. These components may include, but are not limited to: (a) postural tolerance (static and
dynamic); (b) aerobic requirements; (c) range of motion; (d) torque/force; (e) lifting/carrying; (f) cognitive
demands; (g) social interactions; (h) visual perceptual; (i) environmental requirements of a job; (j)
repetitiveness; and (k) essential functions of a job. Job descriptions provided by the employer are helpful
but should not be used as a substitute for direct observation.
(1) Frequency: One time with additional visits as needed for follow-up per job site.
d. Vocational Assessment
Once an authorized practitioner has reasonably determined and objectively documented that a patient will
not be able to return to her/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 should not be delayed solely due to lack of attainment of a
vocational assessment.
(1) Frequency: One time with additional visits as needed for follow-up
e. Work Tolerance Screening
Work tolerance screening 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 workrelevant cardiovascular, physical fitness and postural tolerance. It may also address ergonomic issues
affecting the patient's return-to-work potential. May be used when a full FCE is not indicated.
(1) Frequency: One time for evaluation. May monitor improvements in strength every 3 to 4 weeks up to
a total of 6 evaluations.
F. THERAPEUTIC PROCEDURES — NON-OPERATIVE
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, restricted
or full 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 selfmanagement of symptoms.
Lastly, formal psychological or psychosocial screening should be performed on patients not making
expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate
with objective signs and tests.
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.
1. Acupuncture
Acupuncture is an accepted and widely used procedure for the relief of pain and inflammation and there is
some scientific evidence to support its use. The exact mode of action is only partially understood.
Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the
brain, promotes deep relaxation, and affects the release of neurotransmitters. Acupuncture is commonly
used as an alternative or in addition to traditional Western pharmaceuticals. While it is commonly used
when pain medication is reduced or not tolerated, it may be used as an adjunct to physical rehabilitation
and/or surgical intervention to hasten the return of functional activity. Acupuncture should be performed by
credentialed practitioners.
a. Acupuncture
Acupuncture is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points).
Needles may be inserted, manipulated and retained for a period of time. Acupuncture can be used to
reduce pain, reduce inflammation, increase blood flow, increase range of motion, decrease the side effect
of medication-induced nausea, promote relaxation in an anxious patient, and reduce muscle spasm.
Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthia, post-surgical
pain relief, muscle spasm, and scar tissue pain.
(1) Time to produce effect: 3 to 6 treatments
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 1 to 2 months
(4) Maximum duration: 14 treatments
b. Acupuncture with Electrical Stimulation
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.
(1) Time to produce effect: 3 to 6 treatments
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 1 to 2 months
(4) Maximum duration: 14 treatments
c. Other Acupuncture Modalities
Acupuncture treatment is based on individual patient needs and therefore treatment may include a
combination of procedures to enhance treatment effect. Other procedures may include the use of heat,
soft tissue manipulation/massage, and exercise. Refer to Active Therapy (Therapeutic Exercise) and
Passive Therapy sections (Massage and Superficial Heat and Cold Therapy) for a description of these
adjunctive acupuncture modalities.
(1) Time to produce effect: 3-6 treatments
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 1 to 2 months
(4) Maximum 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 treatments must be documented with respect to need and ability to facilitate
positive symptomatic or functional gains. Such care should be re-evaluated and documented with each
series of treatments.
2. Biofeedback
Biofeedback 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.
(1) Time to produce effect: 3 to 4 sessions
(2) Frequency: 1 to 2 times per week
(3) Optimum duration: 5 to 6 sessions
(4) 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.
3. Injections — Therapeutic
Description — Therapeutic injection procedures are generally accepted, well-established procedures that
may play a significant role in the treatment of patients with lower 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; (c) allow a break from pain;
and (d) 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.
Indications — Diagnostic injections are procedures which may be used to identify pain generators or
pathology. For additional specific clinical indications, see “Specific Diagnosis, Testing and Treatment
Procedures.”
Special Considerations — The use of injections has become progressively sophisticated. Each procedure
considered has an inherent risk, and risk versus benefit should be evaluated when considering injection
therapy. In addition, all injections must include sterile technique.
Contraindications — General contraindications include local or systemic infection, bleeding disorders,
allergy to medications used and patient refusal. Specific contraindications may apply to individual
injections.
a. Joint Injections
Joint injections are generally accepted, well-established procedures that can be performed as analgesic
or anti-inflammatory procedures.
(1) Frequency: Not more than 3 to 4 times annually. Usually 1 or 2 injections adequate.
(2) Time to produce effect: Immediate with local anesthesia, or within 3 days if no anesthesia
(3) Optimum/Maximum duration: Varies
b. Soft Tissue Injections
Soft tissue injections include bursa and tendon insertions. When performing tendon insertion injections,
the risk of tendon rupture should be discussed with the patient and the need for restricted duty
emphasized.
(1) Frequency: Not more than 3 to 4 times annually. Usually 1 or 2 injections adequate.
(2) Time to produce effect: Immediate with local anesthesia, or within 3 days if no anesthesia
(3) Optimum/Maximum duration: Varies
c. Trigger Point Injections
Trigger-point injections, although generally accepted, have only rare indications in the treatment of lower
extremity disorders. Therefore, the Division does not recommend their routine use in the treatment of
lower extremity injuries.
d. Prolotherapy
Prolotherapy (also known as sclerotherapy) consists of intra-articular injections of hypertonic dextrose
with or without phenol with the goal of inducing an inflammatory response that will recruit cytokine growth
factors involved in the proliferation of connective tissue. Advocates of prolotherapy propose that these
injections will alleviate complaints related to joint laxity by promoting the growth of connective tissue and
stabilizing the involved joint.
Laboratory studies may lend some biological plausibility to claims of connective tissue growth, but high
quality published clinical studies are lacking. The dependence of the therapeutic effect on the
inflammatory response is poorly defined, raising concerns about the use of conventional anti-inflammatory
drugs when proliferant injections are given. The evidence in support of prolotherapy is insufficient and
therefore, its use is not recommended in lower extremity injuries.
e. Intra-Capsular Acid Salts
Intra-capsular acid salts, or viscosupplementation, are an accepted form of treatment for osteoarthritis or
degenerative changes in the knee joint. While there is good scientific evidence to support their use,
studies have not included patients with severe (Grade 4) degenerative changes. It is recommended that
these injections can be considered a therapeutic alternative in patients who have failed nonpharmacological and analgesic treatment, and particularly, if non-steroidal anti-inflammatory drug
treatment is contraindicated or surgery is not an option. The utility of viscosupplementation in severe
osteoarthritis and its efficacy beyond 6 months is not well known.
(1) Time to produce effect: After 1 or 2 series of injections
(2) Frequency: 1 series (3 to 5 injections, generally spaced 1 week apart)
(3) Optimum/maximum duration: Varies. Efficacy beyond 6 months is not well known.
4. Medications
Medication use in the treatment of lower extremity injuries is appropriate for controlling acute pain and
inflammation. Use of medications will vary widely due to the spectrum of injuries from simple strains to
complicated fractures. All drugs should be used according to patient needs. A thorough medication
history, including use of alternative and over the counter medications, should be performed at the time of
the initial visit and updated periodically.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are useful in the treatment of injuries
associated with degenerative joint disease and/or inflammation. These same medications can be used for
pain control.
Narcotic medications should be prescribed with strict time, quantity and duration guidelines, and with
definitive cessation parameters. Pain is subjective in nature and should be evaluated using a scale to rate
effectiveness of the narcotic prescribed. Severe pain associated with fractures and other major joint
derangements should be treated with narcotics pending a surgical evaluation. Tramadol, a centrally acting
non-narcotic, can be useful to provide pain relief. Other medications, including antidepressants, may be
useful in selected patients with chronic pain.
Topical agents can be beneficial for pain management in lower extremity injuries. This includes topical
capsaicin, nonsteroidals, as well as topical iontphoretics/phonophoretics, such as steroid creams and
lidocaine.
Glucosamine and chondroitin, dietary supplements, may have potential in the treatment of degenerative
joint conditions of the knee but high quality, long-term studies demonstrating objective improvement or
side effects are lacking at this time. Long-term side effects of these dietary supplements are unknown.
The following are listed in alphabetical order.
a. Acetaminophen
Acetaminophen is an effective analgesic with antipyretic but not antiinflammatory activity. Acetaminophen
is generally well tolerated, causes little or no gastrointestinal irritation and is not associated with ulcer
formation. Acetaminophen has been associated with liver toxicity in overdose situations or in chronic
alcohol use.
(1) Optimal duration: 7 to 10 days
(2) Maximum duration: Chronic use as indicated on a case-by-case basis
b. Minor Tranquilizer/Muscle Relaxants
Minor tranquilizer/muscle relaxants are appropriate for muscle spasm, mild pain and sleep disorders.
(1) Optimal duration: 1 week
(2) Maximum duration: 4 weeks
c. Narcotics
Narcotics should be primarily reserved for the treatment of severe lower extremity pain. There are
circumstances where prolonged use of narcotics is justified based upon specific diagnosis, and in these
cases, it should be documented and justified. In mild to moderate cases of lower extremity pain, narcotic
medication should be used cautiously on a case-by-case basis. Adverse effects include respiratory
depression, the development of physical and psychological dependence, and impaired alertness.
(1) Optimal duration: 3 to 7 days
(2) Maximum duration: 2 weeks. Use beyond two weeks is acceptable in appropriate cases.
d. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs are useful for pain and inflammation. In mild cases, they may be the only drugs required for
analgesia. There are several classes of NSAIDs, and the response of the individual injured worker to a
specific medication is unpredictable. For this reason, a range of NSAIDs may be tried in each case with
the most effective preparation being continued. Patients should be closely monitored for adverse
reactions. Intervals for metabolic screening are dependent upon the patient's age, general health status
and should be within parameters listed for each specific medication. Liver and renal function should be
monitored at least every six months in patients on chronic NSAIDs.
1) Nonselective Nonsteroidal Anti-Inflammatory Drugs
Includes Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and acetylsalicylic acid (aspirin).
Serious GI toxicity, such as bleeding, perforation, and ulceration can occur at any time, with or
without warning symptoms in patients treated with traditional NSAIDs. Physicians should inform
patients about the signs and/or symptoms of serious gastrointestinal toxicity and what steps to
take if they occur. Anaphylactoid reactions may occur in patients taking NSAIDs. NSAIDs may
interfere with platelet function. Fluid retention and edema have been observed in some patients
taking NSAIDs.
Due to the cross-reactivity between aspirin and NSAIDs, NSAIDs should not be used in aspirinsensitive patients, and should be used with caution in all asthma patients. NSAIDs are associated
with abnormal renal function, including renal failure, as well as abnormal liver function. Certain
NSAIDs may have interactions with various other medications. Individuals may have adverse
events not listed above.
(1) Optimal duration: 1 week
(2) Maximum duration: 1 year
1) Selective Cyclo-oxygenase-2 (COX-2) Inhibitors
Selective cyclo-oxygenase-2 (COX-2) inhibitors are more recent NSAIDs and differ in adverse
side effect profiles from the traditional NSAIDs. The major advantages of selective COX-2
inhibitors over traditional NSAIDs are that they have less gastrointestinal toxicity and no platelet
effect. COX-2 inhibitors can worsen renal function in patients with renal insufficiency, thus renal
function may need monitoring.
COX-2 inhibitors should not be first-line for low risk patients who will be using an NSAID short
term but are indicated in select patients whom traditional NSAIDs are not tolerated or in certain
high-risk patients. Patients most at risk of having a complication from traditional NSAIDs include
patients with a prior history of peptic ulcer disease, gastrointestinal bleeding, gastrointestinal
perforation, or hemophilia, as well as patients with thrombocytopenia or systemic anticoagulation.
Celecoxib is FDA approved for osteoarthritis and rheumatoid arthritis. Rofecoxib is FDA approved
for acute pain and osteoarthritis. Celecoxib is contraindicated in sulfonamide allergic patients.
(1) Optimal duration: 7 to 10 days
(2) Maximum duration: Chronic use is appropriate in individual cases.
e. Oral Steroids
Oral steroids have limited use but are accepted in cases requiring potent anti-inflammatory drug effect in
carefully selected patients. A one-week regime of steroids may be considered in the treatment of patients
who have arthritic flare-ups with significant inflammation of the joint. The physician must be fully aware of
potential contraindications for the use of all steroids such as hypertension, diabetes, glaucoma, peptic
ulcer disease, etc., which should be discussed with the patient.
(1) Optimal duration: 3 to 7 days
(2) Maximum duration: 7 days
f. Psychotropic/Anti-anxiety/Hypnotic Agents
Psychotropic/anti-anxiety/hypnotic agents may be useful for treatment of mild and chronic pain,
dysesthesias, sleep disorders, and depression. Antidepressant medications, such as tricyclics and
Selective Serotonin Reuptake Inhibitors (SSRIs), are useful for affective disorder and chronic pain
management. Tricyclic antidepressant agents, in low dose, are useful for chronic pain but have more
frequent side effects.
Anti-anxiety medications are best used for short-term treatment (i.e., less than 6 months). Accompanying
sleep disorders are best treated with sedating antidepressants prior to bedtime. Frequently, combinations
of the above agents are useful. As a general rule, physicians should access the patient's prior history of
substance abuse or depression prior to prescribing any of these agents.
(1) Optimal Duration: 1 to 6 months
(2) Maximum duration: 6 to 12 months, with monitoring
g. Tramadol
Tramadol is useful in relief of lower extremity pain and has been shown to provide pain relief equivalent to
that of commonly prescribed NSAIDs. Although Tramadol may cause impaired alertness, it is generally
well tolerated, does not cause gastrointestinal ulceration, or exacerbate hypertension or congestive heart
failure. Tramadol should be used cautiously in patients who have a history of seizures or who are taking
medication that may lower the seizure threshold, such as MAO inhibiters, SSRIs, and tricyclic
antidepressants. This medication has physically addictive properties and withdrawal may follow abrupt
discontinuation and is not recommended for patients with prior opoid addiction.
(1) Optimal Duration: 3 to 7 days
(2) Maximum Duration: 2 weeks. Use beyond 2 weeks is acceptable in appropriate cases.
h. Topical Drug Delivery
Topical drug delivery may be an alternative treatment of localized musculoskeletal disorders. It is
necessary that all topical agents be used with strict instructions for application as well as maximum
number of applications per day to obtain the desired benefit and avoid potential toxicity. As with all
medications, patient selection must be rigorous to select those patients with the highest probability of
compliance. Refer to “Iontophoresis” in the Passive Therapy section for information regarding topical
iontophoretic agents.
1) Topical Salicylates and Nonsalicylates
Topical salicylates and nonsalicylates have been shown to be effective in relieving pain in acute
and chronic musculoskeletal conditions. Topical salicylate and nonsalicylates achieve tissue
levels that are potentially therapeutic, at least with regard to COX inhibition. Other than local skin
reactions, the side effects of therapy are minimal, although not nonexistent, and the usual
contraindications to use of these compounds needs to be considered. Local skin reactions are
rare and systemic effects were even less common. Their use in patients receiving warfarin
therapy may result in alterations in bleeding time. Overall, the low level of systemic absorption
can be advantageous; allowing the topical use of these medications when systemic
administration is relatively contraindicated such as is the case in patients with hypertension,
cardiac failure, or renal insufficiency.
(1) Optimal duration: 1 week
(2) Maximal duration: 2 weeks per episode
2) Capsaicin
Capsaicin is another medication option for topical drug use in lower extremity injury. Capsaicin
offers a safe and effective alternative to systemic NSAID therapy. Although it is quite safe,
effective use of capsaicin is limited by the local stinging or burning sensation that typically
dissipates with regular use, usually after the first 7 to 10 days of treatment. Patients should be
advised to apply the cream on the affected area with a plastic glove or cotton applicator and to
avoid inadvertent contact with eyes and mucous membranes.
(1) Optimal duration: 1 week
(2) Maximal duration: 2 weeks per episode
3) Other Agents
Other topical agents, including prescription drugs (i.e., lidocaine), prescription compound agents,
and prescribed over-the-counter medications (i.e., blue ice), may be useful for pain and
inflammation. These drugs should be used according to patient needs.
(1) Optimal duration: varies with drug or compound
(2) Maximal duration: varies with drug or compound
4) Iontophoretic Agents - Refer to “Iontophoresis,” under Passive Therapy section.
5. Occupational Rehabilitation Programs
a. 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.
1) Work Conditioning
These programs are usually initiated once reconditioning has been completed but may be offered
at any time throughout the recovery phase. It 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.
(1) Length of visit: 1 to 2 hours per day
(2) Frequency: 2 to 5 visits per week
(3) Optimum duration: 2 to 4 weeks
(4) Maximum duration: 6 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.
2) Work Simulation
Work simulation is a program where an individual completes specific work-related tasks for a
particular job and return to work. Use of this program is appropriate when modified duty can only
be partially accommodated in the work place, when modified duty in the work place is
unavailable, or when the patient requires more structured supervision. The need for work place
simulation should be based upon the results of a Functional Capacity Evaluation and or Jobsite
Analysis.
(1) Length of visit: 2 to 6 hours per day
(2) Frequency: 2 to 5 visits per week
(3) Optimum duration: 2 to 4 weeks
(4) Maximum duration: 6 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.
b. Interdisciplinary
Interdisciplinary programs are characterized by a variety of disciplines that participate in the assessment,
planning, and/or implementation of an injured workers program with the goal for patients to gain full or
optimal function and return to work. There should be close interaction and integration among the
disciplines to ensure that all members of the team interact to achieve team goals. These programs are for
patients with greater levels of perceived disability, dysfunction, deconditioning and psychological
involvement. For patients with chronic pain, refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder
Medical Treatment Guideline.
1) Work Hardening
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, psychological, 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, or vocational specialist.
(1) Length of visit: Up to 8 hours each day
(2) Frequency: 2 to 5 visits per week
(3) Optimum duration: 2 to 4 weeks
(4) Maximum duration: 6 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. Orthotics and Prosthetics
a. Fabrication/Modification of Orthotics
Fabrication/modification of orthotics would be used when there is need to normalize weight-bearing,
facilitate better motion response, stabilize a joint with insufficient muscle or proprioceptive/reflex
competencies, to protect subacute conditions as needed during movement, and correct biomechanical
problems. For specific types of orthotics/prosthetics see Section IV, “Specific Diagnosis, Testing and
Treatment Procedures.”
(1) Time to produce effect: 1 to 3 sessions (includes wearing schedule evaluation)
(2) Frequency: 1 to 2 times per week
(3) Optimum/maximum duration: 4 sessions of evaluation, casting, fitting, and re-evaluation
b. Orthotic/Prosthetic Training
Orthotic/prosthetic training is the skilled instruction (preferably by qualified providers) in the proper use of
orthotic devices and/or prosthetic limbs including stump preparation, donning and doffing limbs,
instruction in wearing schedule and orthotic/prosthetic maintenance training. Training can include gait,
mobility, transfer and self-care techniques.
(1) Time to produce effect: 2 to 6 sessions
(2) Frequency: 3 times per week
(3) Optimum/maximum duration: 2 to 4 months
c. Splints or Adaptive Equipment
Splints or adaptive equipment design, fabrication and/or modification indications include the need to
control neurological and orthopedic injuries for reduced stress during functional activities and modify tasks
through instruction in the use of a device or physical modification of a device, which reduces stress on the
injury. Equipment should improve safety and reduce risk of re-injury. This includes high and low
technology assistive options such as workplace modifications, computer interface or seating, crutch or
walker training, and self-care aids.
(1) Time to produce effect: Immediate
(2) Frequency: 1 to 3 sessions or as indicated to establish independent use
(3) Optimum/maximum duration: 1 to 3 sessions
7. Patient Education
No treatment plan is complete without addressing issues of individual and/or group patient 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 be encouraged to take an active role in the
establishment of functional outcome goals. They should be educated on their specific injury, assessment
findings, and plan of treatment. Instruction on proper body mechanics and posture, positions to avoid,
self-care for exacerbation of symptoms, and home exercise should also be addressed.
(1) Time to produce effect: Varies with individual patient
(2) Frequency: Should occur at each visit
8. Personalitv/Psychological/Psvchosocial Intervention
Psychosocial treatment is generally accepted, widely used and well established intervention. This group
of therapeutic and diagnostic modalities includes, but is not limited to, individual counseling, group
therapy, stress management, psychosocial crises intervention, hypnosis and meditation. Any screening or
diagnostic workup should clarify and distinguish between preexisting versus aggravated versus purely
causative psychological conditions. Psychosocial intervention is recommended as an important
component in the total management program that should be implemented as soon as the problem is
identified. This can be used alone or in conjunction with other treatment modalities. Providers treating
patients with chronic pain should refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder Medical
Treatment Guideline.
(1) Time to produce effect: 2 to 4 weeks
(2) Frequency: 1 to 3 times weekly for the first 4 weeks (excluding hospitalization, if required), decreasing
to 1 to 2 times per week for the second month. Thereafter, 2 to 4 times monthly.
(3) Optimum duration: 6 weeks to 3 months
(4) Maximum duration: 3 to 12 months. Counseling is not intended to delay but to enhance functional
recovery. For select patients, longer supervised treatment may required, and if further counseling
beyond 3 months is indicated, documentation addressing which pertinent issues are preexisting
versus aggravated versus causative, as well as projecting a realistic functional prognosis, should
be provided by the authorized treating provider every 4 to 6 weeks during treatment.
9. Restriction of Activity
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 lower extremity injuries.
10. Return-To-Work
Early return-to-work should be a prime goal in treating occupational injuries given the poor return-to-work
prognosis for an injured worker who has been out of work for more than six months. It is imperative that
the patient be educated regarding the benefits of return-to-work, restrictions, and follow-up if problems
arise. When attempting to return a patient to work after a specific injury, clear objective restrictions of
activity level should be made. An accurate job description may be necessary to assist the physician in
making return-to-work recommendations.
Retum-to-work is defined as any work or duty that the patient is able to perform safely, and it may not be
the patient's regular work. Due to the large spectrum of injuries of varying severity and varying physical
demands in the work place, it is not possible to make specific return-to-work guidelines for each injury.
Therefore, the Division recommends the following:
a. Establishment of A Return-To-Work Status
Ascertaining a return-to-work status is part of medical care, should be included in the treatment and
rehabilitation plan, and addressed at every visit. A description of daily activity limitations is part of any
treatment plan and should be the basis for restriction of work activities. In most cases the patient should
be able to return to work in some capacity or in an alternate position consistent with medical treatment
within two weeks unless there are extenuating circumstances. Injuries requiring more than two weeks off
work should be thoroughly documented. (Some of these diagnoses are listed in Section IV, “Specific
Diagnosis, Testing, and Treatment”).
b. Establishment of Activity Level Restrictions
Communication is essential between the patient, employer and provider to determine appropriate
restrictions and return-to-work dates. It is the responsibility of the physician to provide clear concise
restrictions, and it the employer's responsibility to determine if temporary duties can be provided within
the restrictions. For lower extremity injuries, the following should be addressed when describing the
patient's activity level:
1) Lower body postures such as squatting, kneeling, crawling, stooping, or climbing should include
duration and frequency.
2) Ambulatory level for distance, frequency and terrain should be specified.
3) Standing duration and frequency with regard to balance issues.
4) Use of adaptive devices or equipment for proper ergonomics to enhance capacities can be included.
c. Compliance with Activity Restrictions
In some cases, compliance with restriction of activity levels may require a complete jobsite evaluation, a
functional capacity evaluation (FCE), or other special testing. Refer to the “Special Tests” section of this
guideline.
11. Therapy — Active
Most of the following active therapies have some evidence and are widely used and accepted methods of
care for a variety of work-related injuries. They are based on the philosophy that therapeutic exercise
and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion, and
can alleviate discomfort. Active therapy requires an internal effort by the individual to complete a specific
exercise or task. This form of therapy requires supervision from a therapist or medical provider such as
verbal, visual and/or tactile instruction(s). At times, the provider may help stabilize the patient or guide the
movement pattern but the energy required to complete the task is predominately executed by the patient.
Patients should be instructed to continue active therapies at home as an extension of the treatment
process in order to maintain improvement levels. Home exercise can include exercise with or without
mechanical assistance or resistance and functional activities with assistive devices.
The following active therapies are listed in alphabetical order:
a. Activities of Daily Living (ADL)
Activities of daily living are instruction, active-assisted training and/or adaptation of activities or equipment
to improve a person's capacity in normal daily activities such as self-care, work re-integration training,
homemaking and driving.
(1) Time to produce effect: 4 to 5 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 weeks
b. Functional Activities
Functional activities are the use of therapeutic activity to enhance mobility, body mechanics,
employability, coordination, and sensory motor integration.
(1) Time to produce effect: 4 to 5 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 weeks
c. Functional Electrical Stimulation
Functional electrical stimulation is the application of electrical current to elicit involuntary or assisted
contractions of atrophied and/or impaired muscles. Indications include muscle atrophy, weakness, and
sluggish muscle contraction secondary to pain, injury, neuromuscular dysfunction or peripheral nerve
lesion.
(1) Time to produce effect: 2 to 6 treatments
(2) Frequency: 3 times per week
(3) Optimum duration: 8 weeks.
(4) Maximum duration: 8 weeks. If beneficial, provide with home unit.
d. Gait Training
Gait training is crutch walking, cane or walker instruction to a person with lower extremity injury or
surgery. Indications include the need to promote normal gait pattern with assistive devices; instruct in the
safety and proper use of assistive devices; instruct in progressive use of more independent devices (i.e.,
platform-walker, to walker, to crutches, to cane); instruct in gait on uneven surfaces and steps (with and
without railings) to reduce risk of fall, or loss of balance; and or instruct in equipment to limit weightbearing for the protection of a healing injury or surgery.
(1) Time to produce effect: 2 to 6 treatments
(2) Frequency: 2 to 3 times per week
(3) Optimum duration: 2 weeks
(4) Maximum duration: 2 weeks
e. Neuromuscular Re-Education
Neuromuscular 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.
(1) Time to produce effect: 2 to 6 treatments
(2) Frequency: 3 times per week
(3) Optimum duration: 4 to 8 weeks
(4) Maximum duration: 8 weeks
f. Therapeutic Exercise
Therapeutic exercise, with or without mechanical assistance or resistance, may include isoinertial,
isotonic, isometric and isokinetic types of exercises. Indications include the need for cardiovascular
fitness, reduced edema, improved muscle strength, improved connective tissue strength and integrity,
increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle
recruitment, increased range-of-motion and are used to promote normal movement patterns. Can also
include complementary/alternative exercise movement therapy.
(1) Time to produce effect: 2 to 6 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 4 to 8 weeks
(4) Maximum duration: 8 weeks
g. Wheelchair Management and Propulsion
Wheelchair management and propulsion are the instruction and training of self-propulsion and proper use
of a wheelchair. This includes transferring and safety instruction. This is indicated in individuals who are
not able to ambulate due to bilateral lower extremity injuries, inability to use ambulatory assistive devices,
and in cases of multiple traumas.
(1) Time to produce effect: 2 to 6 treatments
(2) Frequency: 2 to 3 times per week
(3) Optimum duration: 2 weeks
(4) Maximum duration: 2 weeks
12. Therapy — Passive
Most of the following passive therapies and modalities are generally well-accepted methods of care for a
variety of work-related injuries. Passive therapy includes those treatment modalities that do not require
energy expenditure on the part of the patient. They are principally effective during the early phases of
treatment and are directed at controlling symptoms such as pain, inflammation and swelling and to
improve the rate of healing soft tissue injuries. They should be use adjunctively 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.
While protocols for specific diagnoses and post-surgical conditions may warrant durations of treatment
beyond those listed as “maximum,” factors such as exacerbation of symptoms, re-injury, interrupted
continuity of care, and comorbidities may extend durations of care. Having specific goals with objectively
measured functional improvement during treatment can support extended durations of care. It is
recommended that if after 6 to 8 visits no treatment effect is observed, alternative treatment interventions,
further diagnostic studies or further consultations should be pursued.
The following passive therapies and modalities are listed in alphabetical order.
a. Continuous Passive Movement (CPM)
CPM is a form of passive motion using specialized machinery that acts to move a joint and may also
pump blood and edema fluid away from the joint and periarticular tissues. CPM is effective in preventing
the development of joint stiffness if applied immediately following surgery. It should be continued until the
swelling that limits motion of the joint no longer develops. ROM for the joint begins at the level of patient
tolerance and is increased twice a day as tolerated. Use of this equipment may require home visits.
(1) Time to produce effect: Immediate
(2) Frequency: Up to 4 times a day
(3) Optimum duration: Up to 3 weeks post surgical
(4) Maximum duration: 3 weeks
b. Contrast Baths
Contrast baths can be used for alternating immersion of extremities in hot and cold water. Indications
include edema in the sub-acute stage of healing, the need to improve peripheral circulation and decrease
joint pain and stiffness.
(1) Time to produce effect: 3 treatments
(2) Frequency: 3 times per week
(3) Optimum duration: 4 weeks
(4) Maximum duration: 1 month
c. Electrical Stimulation (Unattended)
Electrical stimulation, once applied, requires minimal on-site supervision by the physician or nonphysician provider. Indications include pain, inflammation, muscle spasm, atrophy, decreased circulation,
and the need for osteogenic stimulation.
(1) Time to produce effect: 2 to 4 treatments
(2) Frequency: Varies, depending upon indication, between 2 to 3 times per day to 1 time a week.
Provide home unit if frequent use.
(3) Optimum duration: 1 to 3 months
(4) Maximum duration: 3 months
d. Fluidotherapy
Fluidotherapy employs a stream of dry, heated air that passes over the injured body part. The injured
body part can be exercised during the application of dry heat. Indications include the need to enhance
collagen extensibility before stretching, reduce muscle guarding or reduce inflammatory response.
(1) Time to produce effect: 1 to 4 treatments
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 4 weeks
(4) Maximum duration: 1 month
e. Infrared Therapy
Infrared therapy is a radiant form of heat application. Indications include the need to elevate the pain
threshold before exercise and to alleviate muscle spasm to promote increased movement.
(1) Time to produce effect: 2 to 4 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 3 weeks as primary, or up to 2 months if used intermittently as an adjunct to other
therapeutic procedures
(4) Maximum duration: 2 months
f. Iontophoresis
Iontophoresis is the transfer of medication, including, but not limited to, steroidal anti-inflammatory 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).
(1) Time to produce effect: 1 to 4 treatments
(2) Frequency: 3 times per week with at least 48 hours between treatments
(3) Optimum duration: 8 to 10 treatments
(4) Maximum duration: 10 treatments
g. Manipulation
Manipulation is manual therapy that moves a joint beyond the physiologic range-of-motion but not beyond
the anatomic range-of-motion. It is indicated for pain and adhesions.
(1) Time to produce effect: Immediate or up to 10 treatments
(2) Frequency: 1 to 5 times per week as indicated by the severity of involvement and the desired effect
(3) Optimum duration: 10 treatments
(4) Maximum duration: 10 treatments
h. Manual Electrical Stimulation
Manual electrical stimulation is used for peripheral nerve injuries or pain reduction that require continuous
application, supervision, or involve extensive teaching. Indications include muscle spasm (including
TENS), atrophy, decreased circulation, osteogenic stimulation, inflammation, and the need to facilitate
muscle hypertrophy, muscle strengthening, muscle responsiveness in SCI/BI, and peripheral
neuropathies.
(1) Time to produce effect: Variable, depending upon use.
(2) Frequency: 3 to 7 times per week
(3) Optimum duration: 8 weeks
(4) Maximum duration: 2 months
i. Massage — 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
practitioners hands. Indications include edema (peripheral or hard and non-pliable edema), muscle
spasm, adhesions, the need to improve peripheral circulation and range-of-motion, or to increase muscle
relaxation and flexibility prior to exercise. In cases with edema, deep vein thrombosis should be ruled out
prior to treatment.
(1) Time to produce effect: Immediate
(2) Frequency: 1 to 2 times per week
(3) Optimum duration: 6 weeks
(4) Maximum duration: 2 months
j. Mobilization (Joint)
Mobilization is passive movement, which may include passive range of motion performed in such a
manner (particularly in relation to the speed of the movement) that it is, at all times, within the ability of the
patient to prevent the movement if they so choose. 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/maltraction.
(1) Time to produce effect: 6 to 9 treatments
(2) Frequency: 3 times per week
(3) Optimum duration: 6 weeks
(4) Maximum duration: 2 months
k. Mobilization (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.
(1) Time to produce effect: 2 to 3 weeks
(2) Frequency: 2 to 3 times per week
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 weeks
l. Paraffin Bath
A paraffin bath is a superficial heating modality that uses melted paraffin (candle wax) to treat irregular
surfaces such as the foot or ankle. Indications include the need to enhance collagen extensibility before
stretching, reduce muscle guarding, or reduce inflammatory response.
(1) Time to produce effect: 1 to 4 treatments
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 4 weeks
(4) Maximum duration: 1 month
m. Superficial Heat And Cold Therapy
Superficial heat and cold therapies are thermal agents applied in various manners that lower or raise the
body tissue temperature for the reduction of pain, inflammation, and/or effusion resulting from injury or
induced by exercise. It may be used acutely with compression and elevation. Indications include acute
pain, edema and hemorrhage, need to increase pain threshold, reduce muscle spasm and promote
stretching/flexibility. Includes portable cryotherapy units and application of heat just above the surface of
the skin at acupuncture points.
(1) Time to produce effect: immediate
(2) Frequency: 2 to 5 times per week
(3) Optimum duration: 3 weeks as primary, or up to 2 months if used intermittently as an adjunct to other
therapeutic procedures
(4) Maximum duration: 2 months
n. Short-wave Diathermy
Short-wave diathermy involves the use of equipment that exposes soft tissue to a magnetic or electrical
field. Indications include enhanced collagen extensibility before stretching, reduced muscle guarding,
reduced inflammatory response and enhanced reabsorption of hemorrhage, hematoma, or edema.
(1) Time to produce effect: 2 to 4 treatments
(2) Frequency: 2 to 3 times per week up to 3 weeks
(3) Optimum duration: 3 to 5 weeks
(4) Maximum duration: 5 weeks
o. Traction
Manual traction is an integral part of manual manipulation or joint mobilization. Indications include
decreased joint space, muscle spasm around joints, and the need for increased synovial nutrition and
response.
(1) Time to produce effect: 1 to 3 sessions
(2) Frequency: 2 to 3 times per week
(3) Optimum duration: 30 days
(4) Maximum duration: 1 month
p. Transcutaneous Electrical Nerve Stimulation (TENS)
TENS should include least one instructional session for proper application and use. Indications include
muscle spasm, atrophy, and decreased circulation and pain control. Minimal TENS unit parameters
should include pulse rate, pulse width and amplitude modulation.
(1) Time to produce effect: Immediate
(2) Frequency: Variable
(3) Optimum duration: 3 sessions
(4) Maximum duration: 3 sessions. If beneficial, provide with home unit or purchase if effective.
q. Ultrasound
Ultrasound includes: Ultrasound with electrical stimulation and Phonophoresis. Ultrasound uses sonic
generators to deliver acoustic energy for therapeutic thermal and/or non-thermal soft tissue effects.
Indications include scar tissue, adhesions, collagen fiber and muscle spasm, and the need to extend
muscle tissue or accelerate the soft tissue healing.
Ultrasound with electrical stimulation is concurrent delivery of electrical energy that involves a 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 antiinflammatory and anesthetics.
(1) Time to produce effect: 6 to 15 treatments
(2) Frequency: 3 times per week
(3) Optimum duration: 4 to 8 weeks
(4) Maximum duration: 2 months
r. Vasopneumatic Devices
Vasopneumatic devices are mechanical compressive devices used in both in-patient and outpatient
settings to reduce various types of edema. Indications include pitting edema, lymphedema and
venostasis. Maximum compression should not exceed minimal diastolic blood pressure. Use of a unit at
home should be considered if expected treatment is greater than two weeks.
(1) Time to produce effect: 1 to 3 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 1 month
(4) Maximum duration: 1 month. If beneficial, provide with home unit.
s. Whirlpool/Hubbard Tank
The whirlpool/Hubbard Tank is conductive exposure to water at temperatures that best elicits the desired
effect (cold vs. heat). It generally includes massage by water propelled by a turbine or Jacuzzi jet system
and has the same thermal effects as hot packs if higher than tissue temperature. It has the same thermal
effects as cold application if comparable temperature water used. Indications include the need for
analgesia, relaxing muscle spasm, reducing joint stiffness, enhancing mechanical debridement and
facilitating and preparing for exercise.
(1) Time to produce effect: 2 to 4 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 3 weeks as primary, or up to 2 months if used intermittently as an adjunct to other
therapeutic procedures
(4) Maximum duration: 2 months
13. Vocational Rehabilitation
Vocational rehabilitation is a generally accepted intervention, but Colorado limits its use as a result of
Senate Bill 87-79. Initiation of vocational rehabilitation requires adequate evaluation of patients for
quantification 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.
G. THERAPEUTIC PROCEDURES — OPERATIVE
All operative interventions must be based upon positive correlation of clinical findings, clinical course and
diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with
positive identification of pathologic condition(s). It is imperative to rule out non-physiologic modifiers of
pain presentation or non-operative conditions mimicking radiculopathy or instability (e.g., peripheral
neuropathy, piriformis syndrome, myofascial pain, scleratogenous or sympathetically mediated pain
syndromes, sacroiliac dysfunction, psychological conditions, etc.) prior to consideration of elective
surgical intervention.
In addition, operative treatment is indicated when the natural history of surgically treated lesions is better
than the natural history for non-operatively treated lesions. All patients being considered for surgical
intervention should first undergo a comprehensive neuromusculoskeletal examination to identify
mechanical pain generators that may respond to non-surgical techniques or may be refractory to surgical
intervention.
Structured rehabilitation interventions should be strongly considered post-operative in any patient not
making expected functional progress within three weeks post-operative.
Return to work restrictions should be specific according to the recommendation in the section “Return to
Work” under Therapeutic Procedures – Non-Operative.
a. Ankle and Subtalar Fusion
1) Description/Definition — Surgical fusion of the ankle or subtalar joint.
2) Occupational Relationship — Usually post-traumatic arthritis or residual deformity.
3) Specific Physical Findings — Painful, limited range of motion of the joint(s). Possible fixed deformity.
4) Diagnostic Testing Procedures — Radiographs. Sometimes tomography, CT scan, bone scan.
5) Non-Operative Treatment — Active and/or passive therapy for bracing, NSAIDs.
6) Surgical Indications — All reasonable conservative measures have been exhausted and other
reasonable surgical options have been seriously considered or implemented. Patient has
disabling pain or deformity.
7) Operative Treatment — Usually open reduction, grafting and internal fixation. External fixation may be
used in some cases.
8) Post-Operative Therapy — Protected weight-bearing. Active and/or passive therapy for gait training,
ADLs. May require nonweight-bearing and modified duty up to 4 to 6 months.
b. Knee Fusion
1) Description/Definition — Surgical fusion of femur to tibia at the knee joint.
2) Occupational Relationship — Usually from post-traumatic arthritis or deformity.
3) Specific Physical findings — Stiff, painful, sometime deformed limb at the knee joint.
4) Diagnostic Testing Procedures — Radiographs.
5) Non-Operative Treatment — Active and/or passive therapy for weight sharing braces, NSAIDs.
6) Surgical Indications — All reasonable conservative measures have been exhausted and other
reasonable surgical options have been seriously considered or implemented. Fusion is a
consideration particularly in the young patient who desires a lifestyle that would subject the knee
to high mechanical stresses.
7) Operative Treatment — Usually open reduction, grafting, internal fixation. External fixation or
intramedullary rodding may also be used.
8) Post-Operative Therapy — Active and/or passive therapy for protected weight-bearing.
c. Total Knee Replacement
1) Description/Definition — Prosthetic replacement of the articulating surfaces of the knee joint.
2) Occupational Relationship — Usually from post-traumatic arthritis.
3) Specific Physical Findings — Stiff, painful knee.
4) Diagnostic Testing Procedures — Radiographs.
5) Non-Operative Treatment — Active and/or passive therapy, NSAIDs.
6) Surgical Indications — Severe arthritis plus all reasonable conservative measures have been
exhausted and other reasonable surgical options have been considered or implemented.
7) Operative Treatment — Prosthetic replacement of the articular surfaces of the knee.
8) Post-Operative Therapy — Active and/or passive therapy for graduated weight-bearing, range-ofmotion.
d. Total Hip Replacement
1) Description/Definition — Prosthetic replacement of the articulating surfaces of the hip joint.
2) Occupational Relationship — Usually from post-traumatic arthritis. Patients with intracapsular femoral
fractures have a risk of developing avascular necrosis of the femoral head requiring treatment
months to years after the initial injury.
3) Specific Physical Findings — Stiff, painful hip.
4) Diagnostic Testing Procedures — Radiographs.
5) Non-Operative Treatment — Active and/or passive therapy, NSAIDs.
6) Surgical Indications — All reasonable conservative measures have been exhausted and other
reasonable surgical options have been seriously considered or implemented. Severe arthritis.
7) Operative Treatment — Prosthetic replacement of the articular surfaces of the hip.
8) Post-Operative Therapy — Active and/or passive therapy for graduated weight-bearing, range of
motion.
e. Amputation
1) Description/Definition — Surgical removal of a portion of the lower extremity.
2) Occupational Relationship — Usually secondary to post traumatic bone, soft tissue, vascular or
neurologic compromise of part of the extremity.
3) Specific Physical Findings — Non-useful or non-viable portion of the lower extremity.
4) Diagnostic Testing Procedures — Radiographs, vascular studies.
5) Non-Operative Treatment — None.
6) Surgical Indications — Non-useful or non-viable portion of the extremity.
7) Operative Treatment — Amputation.
8) Post-Operative Therapy — Active and/or passive therapy for prosthetic fitting, construction and
training, protected weight-bearing.
f. Manipulation Under Anesthesia
1) Description/Definition — Passive range of motion of a joint under anesthesia.
2) Occupational Relationship — Joint stiffness that usually results from a traumatic injury, compensation
related surgery, or other treatment.
3) Specific Physical Findings — Joint stiffness in both active and passive modes.
4) Diagnostic Testing Procedures — Radiographs.
5) Non-Operative Treatment — Active and/or passive therapy for active and passive range of motion
exercises.
6) Surgical Indications — Consider if routine therapeutic modalities, including physical therapy and/or
dynamic bracing, do not restore the degree of motion that should be expected after a reasonable
period of time, usually at least 12 weeks.
7) Operative Treatment — Not applicable.
8) Post-Operative Therapy — Active and/or passive therapy for active and passive range of motion.
g. Bursectomy
1) Description/Definition — Surgical removal of peri-articular bursa.
2) Occupational Relationship — Usually a traumatic local injury or repetitive minor local irritation.
3) Specific Physical Findings — Swelling, tenderness over the bursa.
4) Diagnostic Testing Procedures — Radiographs.
5) Non-Operative Treatment — Active and/or passive therapy for splinting, rest, NSAIDs, steroid
injection.
6) Surgical Indications — Persistent pain, swelling despite treatment.
7) Operative Treatment — Surgical removal of the bursa.
8) Post-Operative Therapy — Active and/or passive therapy for graduated range-of-motion exercises.
h. Osteotomy
1) Description/Definition — A reconstructive procedure involving the surgical cutting of bone for
realignment and is useful in patients that would benefit from realignment in lieu of total joint
replacement.
2) Occupational Relationship — Post-traumatic arthritis or deformity.
3) Specific Physical Findings — Painful decreased range of motion and/or deformity.
4) Diagnostic Testing Procedures — Radiographs, MRI scan, CT scan.
5) Non-Operative Treatment — Active and/or passive therapy for activity modification, bracing, NSAIDs.
6) Surgical Indications — Failure of non-surgical treatment. Avoidance of total joint arthroplasty desirable.
7) Operative Treatment — Peri-articular opening or closing wedge of bone, usually with grafting and
internal or external fixation.
8) Post-Operative Therapy — Active and/or passive therapy for protected weight-bearing, progressive
range-of-motion.
i. Hardware Removal
1) Description/Definition — Surgical removal of internal or external fixation device.
2) Occupational Relationship — Usually following healing of a post-traumatic injury that required fixation
or reconstruction using instrumentation.
3) Specific Physical Findings — Local pain to palpation, swelling, erythema.
4) Diagnostic Testing Procedures — Radiographs, tomography, CT scan, MRI.
5) Non-Operative Treatment — Active and/or passive therapy for local modalities, activity modification.
NSAIDs.
6) Surgical Indications — Persistent local pain, irritation around hardware.
7) Operative Treatment — Removal of instrumentation. Some instrumentation (e.g., Ilizarof) may be
removed in the course of standard treatment without local irritation.
8) Post-Operative Therapy — Active and/or passive therapy for progressive weight-bearing, range of
motion.
j. Release of Contracture
1) Description/Definition — Surgical incision or lengthening of contracted tendon or peri-articular soft
tissue.
2) Occupational Relationship — Usually following a posttraumatic injury.
3) Specific Physical Findings — Shortened tendon or stiff joint.
4) Diagnostic Testing Procedures — Radiographs, CT scan, MRI scan.
5) Non-Operative Treatment — Active and/or passive therapy for stretching, range of motion exercises.
6) Surgical Indications — Persistent shortening or stiffness associated with pain and/or altered function.
7) Operative Treatment — Surgical incision or lengthening of involved soft tissue.
8) Post-Operative Therapy — Active and/or passive therapy for stretching, range-of-motion exercises.
RULE XVII, EXHIBIT D Complex Regional Pain Syndrome/ Reflex Sympathetic Dystrophy Medical
Treatment Guidelines July 30, 2003 (Previously Adopted December 30, 1996 and Revised
March 15, 1998)
Presented By: State of Colorado Department of Labor and Employment DIVISION OF WORKERS'
COMPENSATION
TABLE OF CONTENTS
A. INTRODUCTION
B. GENERAL GUIDELINE PRINCIPLES
1. APPLICATION OF GUIDELINES
2. EDUCATION
3. TREATMENT PARAMETER DURATION
4. ACTIVE INTERVENTIONS
5. ACTIVE THERAPEUTIC EXERCISE PROGRAM
6. POSITIVE PATIENT RESPONSE
7. RE-EVALUATION TREATMENT EVERY 3 TO 4 WEEKS
8. SURGICAL INTERVENTIONS
9. SIX-MONTH TIME FRAME
10. RETURN-TO-WORK
11. DELAYED RECOVERY
12. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE
13. TREATMENT OF PREEXISTING CONDITIONS
C. INTRODUCTION TO COMPLEX REGIONAL PAIN SYNDROME
D. DEFINITIONS
E. INITIAL EVALUATION
1. HISTORY AND PHYSICAL EXAMINATION (HX & PE)
F. DIAGNOSTIC PROCEDURES
1. DIAGNOSTIC IMAGING
2. INJECTIONS — DIAGNOSTIC SYMPATHETIC
3. THERMOGRAPHY (INFRARED STRESS THERMOGRAPHY)
4. AUTONOMIC TEST BATTERY
5. OTHER DIAGNOSTIC TESTS NOT SPECIFIC FOR CRPS
G. DIAGNOSIS OF CRPS
1. DIAGNOSTIC COMPONENTS OF CRPS-I (RSD):
2. DIAGNOSTIC CRITERIA FOR CRPS
H. THERAPEUTIC PROCEDURES – NON-OPERATIVE
1. ACUPUNCTURE
2. BIOFEEDBACK
3. COMPLEMENTARY ALTERNATIVE MEDICINE (CAM)
4. SLEEP DISTURBANCES
5. INJECTIONS — THERAPEUTIC
a. Sympathetic Injections
b. Trigger Point Injections
c. Peripheral Nerve Blocks
d. Intravenous Lidocaine
6. INTERDISCIPLINARY REHABILITATION PROGRAMS
7. MEDICATIONS
a. Anticonvulsants
b. Antidepressants
c. Hypnotics and Sedatives
d. Opioids
e. Topical Drug Delivery
f. Other Agents
8. ORTHOTICS/PROSTHETICS/EQUIPMENT
9. PATIENT EDUCATION
10. PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION
11. RESTRICTION OF ACTIVITIES
12. RETURN-TO-WORK
13. THERAPY — ACTIVE
a. Activities of Daily Living (ADL)
b. Aquatic Therapy
c. Gait Training
d. Neuromuscular Re-education
e. Stress Loading
f. Therapeutic Exercise
14 THERAPY — PASSIVE
a. Continuous Passive Motion
b. Fluidotherapy
c. Orthotics/Splinting
d. Paraffin Bath
e. Desensitization
f. Superficial Heat Therapy
I. THERAPEUTIC PROCEDURES – OPERATIVE
1. INTRATHECAL DRUG DELIVERY
2. NEUROSTIMULATION
3. SYMPATHECTOMY
J. MAINTENANCE MANAGEMENT
1. HOME EXERCISE PROGRAMS AND EXERCISE EQUIPMENT
2. EXERCISE PROGRAMS REQUIRING SPECIAL FACILITIES
3. PATIENT EDUCATION MANAGEMENT
4. PSYCHOLOGICAL MANAGEMENT
5. NON-NARCOTIC MEDICATION MANAGEMENT
6. NARCOTIC MEDICATION MANAGEMENT
7. THERAPY MANAGEMENT
8. INJECTION THERAPY
9. PURCHASE OR RENTAL OF DURABLE MEDICAL EQUIPMENT
A. INTRODUCTION
This document has been prepared by the Colorado Department of Labor and Employment, Division of
Workers' Compensation (Division) and should be interpreted within the context of guidelines for
physicians/providers treating individuals qualifying under Colorado's Workers' Compensation Act as
injured workers with Complex Regional Pain Syndrome (CRPS), formerly known as Reflex Sympathetic
Dystrophy (RSD).
Although the primary purpose of this document is advisory and educational, these guidelines are
enforceable under the Workers' Compensation Rules of Procedure, 7 CCR 1101-3. The Division
recognizes that acceptable medical practice may include deviations from these guidelines, as individual
cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of
professional care.
To properly utilize this document, the reader should not skip nor overlook any sections.
B. GENERAL GUIDELINE PRINCIPLES
The principles summarized in this section are key to the intended implementation of all Division of
Workers' Compensation guidelines and critical to the reader's application of the guidelines in this
document.
1. Application of Guidelines
The Division provides procedures to implement medical treatment guidelines and to foster communication
to resolve disputes among the provider, payer and patient through the Worker's Compensation Rules of
Procedure, Rule XVII and Rule VIII. In lieu of more costly litigation, parties may wish to seek
administrative dispute resolution services through the Division.
2. Education
Education of the patient and family, as well as the employer, insurer, policy makers and the community
should be the primary emphasis in the treatment of chronic pain spine injuries and disability. Currently,
practitioners often think of education last, after medications, manual therapy and surgery. Practitioners
must develop and implement an effective strategy and skills to educate patients, employers, insurance
systems, policy makers and the community as a whole. An education-based paradigm should always start
with inexpensive communication providing reassuring information to the patient. More in-depth education
currently exists within a treatment regime employing functional restorative and innovative programs of
prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or
group patient education as a means of facilitating self-management of symptoms and prevention.
3. Treatment Parameter Duration
Time frames for specific interventions commence once treatments have been initiated, not on the date of
injury. Obviously, duration will be impacted by patient compliance, as well as availability of services.
Clinical judgment may substantiate the need to accelerate or decelerate the time frames discussed in this
document.
4. Active Interventions
Interventions emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment,
are generally emphasized over passive modalities, especially as treatment progresses. Generally,
passive interventions are viewed as a means to facilitate progress in an active rehabilitation program with
concomitant attainment of objective functional gains.
5. Active Therapeutic Exercise Program
Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and
education. This includes functional application in vocational or community settings.
6. Positive Patient Response
Positive results are defined primarily as functional gains that can be objectively measured. Objective
functional gains include, but are not limited to, positional tolerances, range-of-motion, strength,
endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures
that can be quantified. Subjective reports of pain and function should be considered and given relative
weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on
objective findings.
7. Re-Evaluation Treatment Every 3 to 4 Weeks
If a given treatment or modality is not producing positive results within 3 to 4 weeks, the treatment should
be either modified or discontinued. Reconsideration of diagnosis should also occur in the event of poor
response to a seemingly rational intervention.
8. Surgical Interventions
Surgery should be contemplated within the context of expected functional outcome and not purely for the
purpose of pain relief. The concept of “cure” with respect to surgical treatment by itself is generally a
misnomer. All operative interventions must be based upon positive correlation of clinical findings, clinical
course and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific
diagnosis with positive identification of pathologic conditions.
9. Six-Month Time Frame
The prognosis drops precipitously for returning an injured worker to work once he/she has been
temporarily totally disabled for more than six months. The emphasis within these guidelines is to move
patients along a continuum of care and return-to-work within a six-month time frame, whenever possible.
It is important to note that time frames may not be pertinent to injuries that do not involve work-time loss
or are not occupationally related.
10. Return-to-Work
Return-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 written physical limitations and the patient should
never be released to “sedentary” or “light duty.” The following physical limitations should be considered
and modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, overhead work,
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 consider all of the physical demands of the patient's job position before returning
the patient to full duty and should request clarification of the patient's job duties. Clarification should be
obtained from the employer or, if necessary, including, but not limited to, an occupational health nurse,
occupational therapist, vocational rehabilitation specialist, or an industrial hygienist.
11. Delayed Recovery
Strongly consider a psychological evaluation, if not previously provided, as well as initiating
interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to
make expected progress 6 to 12 weeks after an injury. The Division recognizes that 3 to 10% of all
industrially injured patients will not recover within the timelines outlined in this document despite optimal
care. Such individuals may require treatments beyond the limits discussed within this document, but such
treatment will require clear documentation by the authorized treating practitioner focusing on objective
functional gains afforded by further treatment and impact upon prognosis.
12. Guideline Recommendations and Inclusion of Medical Evidence
Guidelines are recommendations based on available evidence and/or consensus recommendations.
When possible, guideline recommendations will note the level of evidence supporting the treatment
recommendation. When interpreting medical evidence statements in the guideline, the following apply:
Consensus means the opinion of experienced professionals based on general medical principles.
Consensus recommendations are designated in the guideline as “generally well accepted,”
“generally accepted,” “acceptable,” or “well established.”
“Some” means the recommendation considered at least one adequate scientific study, which
reported that a treatment was effective.
“Good” means the recommendation considered the availability of multiple adequate scientific
studies or at least one relevant high-quality scientific study, which reported that a treatment was
effective.
“Strong” means the recommendation considered the availability of multiple relevant and high
quality scientific studies, which arrived at similar conclusions about the effectiveness of a
treatment.
All recommendations in the guideline are considered to represent reasonable care in appropriately
selected cases, regardless of the level of evidence attached to it. Those procedures considered
inappropriate, unreasonable, or unnecessary are designated in the guideline as “not recommended.”
13. Treatment of Preexisting Conditions
Conditions that preexisted the work injury/disease will need to be managed under two circumstances: (a)
A preexisting condition exacerbated by a work injury/disease should be treated until the patient has
returned to their prior level of functioning or MMI; and (b) A preexisting condition not directly caused by a
work injury/disease but which may prevent recovery from that injury should be treated until its negative
impact has been controlled. The focus of treatment should remain on the work injury/disease.
The remainder of this document should be interpreted within the parameters of these guideline principles
that may lead to more optimal medical and functional outcomes for injured workers.
C. INTRODUCTION TO COMPLEX REGIONAL PAIN SYNDROME
Complex Regional Pain Syndrome (CRPS Types I and II) describes painful syndromes, which were
formerly referred to as Reflex Sympathetic Dystrophy (RSD) and causalgia. CRPS conditions usually
follow injury that appears regionally and have a distal predominance of abnormal findings, exceeding the
expected clinical course of the inciting event in both magnitude and duration and often resulting in
significant impairment of limb function.
CRPS-I (RSD) is a syndrome that usually develops after an initiating noxious event, is not limited to the
distribution of a single peripheral nerve, and is apparently disproportionate to the inciting event. It is
associated at some point with evidence of edema, changes in skin blood flow, abnormal sudomotor
activity in the region of the pain, allodynia or hyperalgesia. The site is usually in the distal aspect of an
affected extremity or with a distal to proximal gradient. The peripheral nervous system and possibly the
central nervous system are involved.
CRPS-II (Causalgia) is the presence of burning pain, allodynia, and hyperpathia usually in the hand or
foot after partial injury to a nerve or one of its major branches. Pain is within the distribution of the
damaged nerve but not generally confined to a single nerve.
Stages seen in CRPS-I are not absolute and in fact, may not all be observed in any single patient. In
some patients, stages may be missed or the patient may remain for long periods of time in one stage.
Stage 1 – Acute (Hyperemic)
Starts at the time of injury or even weeks later. Associated with spontaneous pain, aching, burning.
Typically restricted to the distal extremity. Hyperpathia, allodynia, hypoesthesia or hyperesthesia may be
present. Initially, hair and nail growth may be increased but later decrease. Skin may be warm or cold.
Stage 2 – Dystrophic (Ischemic)
Spontaneous burning and/or aching pain, more pronounced hyperpathia and or allodynia. Signs of
chronic sympathetic overactivity include (a) reduced blood flow; (b) sudomotor changes; (c) increased
edema; (d) cyanotic skin; (e) muscle wasting; (f) decreased hair and nail growth; and (g) osteoporosis.
Stage 3 – Atrophic
Signs and symptoms of this stage include (a) pain may be less prominent; (b) decreased hyperpathia
and/or allodynia; (c) reduction in blood flow; (d) skin temperature and sweating may be increased or
decreased; (e) irreversible trophic changes in skin and integument; and (f) pronounced muscle atrophy
with contractures.
D. DEFINITIONS
1. After sensation – Refers to the abnormal persistence of a sensory perception, provoked by a stimulus
even though the stimulus has ceased.
2. Allodynia – Pain due to a non-noxious stimulus that does not normally provoke pain.
Mechanical Allodynia – Refers to the abnormal perception of pain from usually non-painful
mechanical stimulation.
Static Mechanical Allodynia – Refers to pain obtained by applying a single stimulus such as light
pressure to a defined area.
Dynamic Mechanical Allodynia – Obtained by moving the stimulus such as a brush or cotton tip
across the abnormal hypersensitive area.
Thermal Allodynia – Refers to the abnormal sensation of pain from usually non-painful thermal
stimulation such as cold or warmth.
3. Central Pain – Pain initiated or caused by a primary lesion or dysfunction in the central nervous
system.
4. Central Sensitization – The experience of pain evoked by the excitation of non-nociceptive neurons or
of nerve fibers that normally relay non-painful sensations to the spinal cord. This result when nonnociceptive afferent neurons act on a sensitized CNS.
5. Dystonia – State of abnormal (hypo or hyper) tonicity in any of the tissues.
6. Hyperalgesia – Refers to an exaggerated pain response from a usually painful stimulation.
7. Hyperemia – Presence of increased blood in a part or organ.
8. Hyperesthesia (Positive Sensory Phenomenon) – Includes allodynia, hyperalgesia, and hyperpathia.
Elicited by light touch, pin prick, cold, warm vibration, joint position sensation or two-point
discrimination, which is perceived as increased or more.
9. Hyperpathia – Refers to an abnormally painful and exaggerated reaction to stimulus, especially to a
repetitive stimulus, in a patient who perceives the stimulus as less intense because of an
increased threshold.
10. Hypoesthesia – (also hypesthesia), diminished sensitivity to stimulation.
11. Pain Behavior – The nonverbal actions (such as grimacing, groaning, limping, using visible pain
relieving or support devices and requisition of pain medications, among others) that are outward
manifestations of pain, and through which a person may communicate that pain is being
experienced.
12. Sudomotor Changes – Alteration in function of sweat glands; sweat output may increase or decrease
due to changes in autonomic input to the gland.
13. Sympathetically Maintained Pain – A pain that is maintained by sympathetic efferent innervations or
by circulating catecholalmines.
14. Trophic Changes – Tissue alterations due to interruption of nerve or blood supply; may include
changes in hair growth and texture of skin.
15. Vasomotor Changes – Alteration in regulation of dilation or constriction of blood vessels.
E. INITIAL EVALUATION
All potential pain generators should be thoroughly investigated by complete neurologic and
musculoskeletal exam and diagnostic procedures. Because CRPS-I is commonly associated with other
injuries, it is essential that all related diagnoses are defined and treated. These disturbances are typically
restricted to one extremity, usually distally, but are variable in their expression.
1. History and Physical Examination (Hx & Pe)
The history and physical exam establish the basis for subsequent diagnostic and therapeutic procedures.
When clinical evaluation findings do not complement the findings of other diagnostic procedures, clinical
findings should have preference. Before the diagnosis of CRPS-I or CRPS-II is established, an
experienced practitioner must perform a detailed neurological and musculoskeletal exam to exclude other
potentially treatable pain generators or neurological lesions.
a. Medical History
As in other fields of medicine, a thorough patient history is an important part of the evaluation of
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. History should ascertain
the following elements:
1) Causality: How did this injury occur? Was the problem initiated by a work-related injury or
exposure?
2) Presenting symptoms:
a) Severe, generally unremitting burning and/or aching pain, and/or allodynia;
b) Swelling of the involved area;
c) Changes in skin color;
d) Asymmetry in nail and/or hair growth;
e) Abnormal sweat patterns of the involved extremity;
f) Dystonia; and/or
g) Subjective temperature changes of the affected area.
b. Pain History
The patient's description of and response to pain is one of the key elements in treatment.
Characterization of the patient's pain and of the patient's response to pain is one of the key
elements in treatment.
1) Site of Pain – localization and distribution of the pain help determine the type of pain the
patient has (i.e., central versus peripheral).
2) Pain Drawing/Visual Analog Scale (VAS)
3) Duration
4) Place of onset
5) Pain Characteristics – time of pain occurrence as well as intensity, quality and radiation give
clues to the diagnosis and potential treatment.
6) Response of Pain to Activity
7) Associated Symptoms – Does the patient have numbness or paresthesia, dysesthesia,
weakness, bowel or bladder dysfunction, decreased temperature, increased sweating,
cyanosis or edema? Is there local tenderness, allodynia, hyperesthesia or hyperalgesia?
c. Substance Use/Abuse
1) Alcohol use
2) Smoking History
3) History of drug use and abuse.
4) Caffeine or caffeine-containing beverages.
d. Other Factors Affecting Treatment Outcome
1) Compensation/Disability/Litigation
2) Treatment Expectations – What does the patient expect from treatment: complete relief of pain
or reduction to a more tolerable level?
e. Medical Management History
Refer to the Chronic Pain guideline for detailed elements when performing a review of prior
medical management. In addition, history may include:
1) Chronological review of medical records including previous medical evaluations and response
to treatment interventions;
2) History of diagnostic tests and results including but not limited to any response to sympathetic
nerve blocks, results of general laboratory studies, EMG and nerve conduction studies,
radiological examinations, including triple phase bone scan or thermography with
autonomic stress testing.
3) Medications, including prescription, over-the-counter and herbal/dietary supplements.
4) Review of Systems Check List – Determine if there is any interplay between the pain
complaint and other medical conditions.
5) 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. It is recommended that patients diagnosed with CRPS be
referred for a psychosocial evaluation. All patients with CRPS have Chronic Pain, and are
likely to suffer psychosocial consequences.
6) Preexisting Conditions – Treatment of these conditions is appropriate when the preexisting
condition affects recovery from chronic pain.
f. Physical Examination
Physical Examination should include examination techniques applicable to those portions of the
body in which the patient is experiencing subjective symptomatology and should include:
1) Inspection – Changes in appearance of the involved area, to include trophic changes,
changes in hair and nail growth, muscular atrophy, changes in skin turgor, swelling and
color changes.
2) Temperature Evaluation – Palpable temperature changes may not be detectable in early
disease stages, and the examiner will generally only be able to appreciate significant
temperature variations. Thermography, or other objective testing may be necessary to
display temperature asymmetries.
3) Motor Evaluation – Involuntary movements, dystonia or muscle weakness in the involved
limb(s).
4) Sensory Evaluation – A detailed sensory examination is crucial in evaluating a patient with
chronic pain complaints. Presence of allodynia. Anatomic pattern of any associated
sensory abnormalities to light touch, deep touch, pain and thermal stimulation.
Quantitative sensory testing may be useful.
5) Musculoskeletal Evaluation –Presence of associated myofascial problems, such as
contractures, ROM or trigger points.
6) Evaluation of Nonphysiologic Findings – Determine the presence of the following: Variabilities
on formal exam including variable sensory exam, inconsistent tenderness, and or
swelling secondary to extrinsic sources; Inconsistencies between formal exam and
observed abilities of range-of-motion, motor strength, gait and cognitive/emotional state;
and/or, observation of consistencies between pain behavior, affect and verbal pain rating,
and affect and physical re-examination.
F. DIAGNOSTIC PROCEDURES
The Division 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 are listed below in order of their suggested usefulness. In
addition, it is recommended that all patients diagnosed with CRPS have a full psychosocial evaluation.
1. Diagnostic Imaging
Imaging 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
Division guidelines for specific information about specific testing procedures.
a. Plain Film Radiography
Description - A radiological finding in CRPS may be unilateral osteoporosis; however,
osteoporosis may be absent in many cases. In CRPS-I, the osteoporosis may be rapid in
progression. The disorder typically affects the distal part of an extremity such as a hand or foot,
yet intermediate joints such as the knee or elbow may be involved.
Results - The radiological appearance of osteoporosis has been characterized as spotty or
patchy. Although CRPS-I may exist in the absence of osteoporosis, the diagnosis of CRPS-I
cannot be made solely on the basis of radiographic appearance or the osteoporosis alone.
b. Triple Phase Bone Scan
Description - Radionucleotide imaging scintigraphy employing radio-pharmaceutical technetium
coupled to a phosphate complex has been used to help facilitate the diagnosis of CRPS-1. It was
hoped that a three-phase radionucleotide study would be selective in the face of demineralization
of the bone as seen in CRPS-I. However there are many different types of conditions that can
produce osteoporosis, and a triple-phase bone scan does not distinguish between the causes of
bone demineralization.
Results - Clinical information can be derived from each of the three phases of the bone scan
following injection. In the early course of CRPS-I, there is an increased uptake seen during Phase
1. However, in the late course of the disease process, there can actually be a decreased uptake
seen. In Phase 2, which reflects the soft tissue vascularity, an increased diffuse uptake may be
appreciated during the early course of CRPS-I. During Phase 3, one will see a diffuse uptake of
multiple bone involvement of the involved limb, reflecting the bone turnover secondary to
osteoporosis. Negative bone scans may be found in up to 40 percent of patients clinically
diagnosed with CRPS-I; however when positive it may help to confirm the diagnosis of CRPS-I.
2. Injections – Diagnostic Sympathetic
Description — Diagnostic sympathetic injections are generally accepted procedures to aid in the
diagnosis of CRPS I & II and SMP. Sympathetic blocks lack specificity for CRPS I & II. Each diagnostic
injection has inherent risk and risk versus benefit should always be evaluated when considering injection
therapy. Since these procedures are invasive, less invasive or non-invasive procedures should be
considered first. Selection of patients, choice of procedure, and localization of the level for injection
should be determined by clinical information.
Special Considerations – Injections with local anesthetics of differing duration are required to confirm a
diagnosis. In some cases, injections at multiple levels may be required to accurately diagnose pain. Refer
to “Injections – Therapeutic” for information on specific injections.
Since fluoroscopic and/or CT guidance during procedures is recommended to document technique and
needle placement, an experienced physician should perform the procedure. The practitioner should have
experience in ongoing injection training workshops provided by organizations such as the International
Spinal Injection Society (ISIS) and be knowledgeable in radiation safety. In addition, practitioners should
obtain fluoroscopy training and radiation safety credentialing from their Departments of Radiology, as
applicable.
Complications – Complications may include transient neurapraxia, nerve injury, inadvertent spinal
injection, infection, venous or arterial vertebral puncture, laryngeal paralysis, respiratory arrest, vasovagal
effects, as well as permanent neurologic damage.
Contraindications – Absolute contraindications of diagnostic injections include: (a) bacterial infection –
systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d)
possible pregnancy. Relative contraindications of diagnostic injections may include: ASA/antiplatelet
therapy (drug may be held for at least 3 days prior to injection).
Test Results – The interpretation of the test result is primarily based upon pain relief of 50 percent or
greater. The diagnostic significance of the test result should be evaluated in conjunction with clinical
information and further information can be obtained from functional reassessment performed by physical
and/or occupational therapy or from results of other diagnostic procedures following a successful block.
Local anesthetics of different durations of action should be considered and could take the place of doing a
“placebo” block (i.e. - procaine, lidocaine, marcaine). Pain relief should be at least 50 percent or greater
for the duration of the local anesthetic. It should be noted that with CRPS-I it is not unusual for the relief to
last longer than the duration of the local anesthetic. If a placebo block is done, the needle should not be
placed down to the sympathetic chain nor should an injection of saline be done around the sympathetic
chain. Contact with the sympathetic nerves by a needle or pressure on the chain by saline can cause a
temporary sympathetic block and give a false positive placebo test. A “sham block” would be preferable to
see if the patient is a placebo responder. Additionally, patients with definite CRPS-I can also be placebo
responders. The fact that the patient responds positively to a placebo does not mean that he/she does not
have CRPS-1. It merely means that the patient is a placebo responder. This increases the value of doing
another confirmatory test
a. Stellate Ganglion Block
For diagnosis and treatment of sympathetic pain involving the face, head, neck, and upper
extremities secondary to CRPS-I and II. This block is commonly used for differential diagnosis
and is the preferred treatment of CRPS-I pain involving the upper extremity. For diagnostic
testing, use three blocks over a 3-14 day period. For a positive response, pain relief should be
50% or greater for the duration of the local anesthetic and pain relief should be associated with
functional improvement.
b. Lumbar Sympathetic Block
Useful for diagnosis and treatment of pain of the pelvis and lower extremity secondary to CRPS-I
and II. This block is commonly used for differential diagnosis and is the preferred treatment of
sympathetic pain involving the lower extremity. For diagnostic testing, use three blocks over a 314 day period. For a positive response, pain relief should be 50% or greater for the duration of the
local anesthetic and pain relief should be associated with functional improvement.
c. Phentolamine Infusion Test
An intravenous infusion of phentoalmine, an alpha 2 blocker, which results in generalized
systemic sympatholysis. The infusion begins with intravenous saline for placebo control. For a
positive response, pain relief should be 50 percent or greater and associated with functional
improvement. This test aids in the diagnosis of SMP.
3. Thermography (Infrared Stress Thermography)
Description – A generally accepted procedure with some evidence to support its limited use. Infrared
thermography may be useful for patients with suspected CRPS-I and II, and Sympathetically Maintained
Pain (SMP). Thermography can distinguish abnormal thermal asymmetry of 1.0 degree Celsius which is
not distinguishable upon physical examination. It may also be useful in cases of suspected small caliber
fiber neuropathy and to evaluate patient response to sympatholytic interventions.
Special Considerations – The practitioner who supervises and interprets the thermographic evaluation
shall follow recognized protocols and be board certified by one of the examining boards of the American
Academy of Medical Infrared Imaging, American Academy of Thermology, or American Chiropractic
College of Thermology.
Medications with anticholinergic activity (tricyclics, cyclobenzaprine, antiemetics, antipsychotics) may
interfere with autonomic testing. The pre-testing protocol which includes cessation of specific medications
therapy must be followed for accurate test results. Results of autonomic testing may be affected by
peripheral polyneuropathy, radiculopathy or peripheral nerve injury, peripheral vascular disease,
generalized autonomic failure, or by Shy-Drager syndrome.
Thermographic Tests – Functional autonomic stress testing may include any of the following methods:
a. Cold Water Stress Test (Cold Pressor Test) – Paroxysmal cooling is strongly suggestive of vasomotor
instability.
b. Warm Water Stress Test – Paroxysmal warming is strongly suggestive of vasomotor instability.
4. Autonomic Test Battery
Description – Resting skin temperature (RST), resting sweat output (RSO), and quantitative sudomotor
axon reflex test (QSART) are a recently developed test battery with some evidence to support its limited
use in the diagnosis of CRPS-I. Prior authorization is required.
Special Considerations - Medications with anticholinergic activity (tricyclics, cyclobenzaprine, antiemetics,
antipsychotics) may interfere with autonomic testing. Results of autonomic testing may be affected by
peripheral polyneuropathy, radiculopathy or peripheral nerve injury, peripheral vascular disease,
generalized autonomic failure, or by Shy-Drager syndrome.
Test Battery – These tests measure asymmetries in physiologic manifestations of autonomic activity
between an affected limb and an unaffected contralateral limb. Skin temperature reflects vasomotor
activity and sweat output measures sudomotor activity. The results of the three test components must be
combined and scored. The battery of tests must include a measurement of each component (RST, RSO,
and QSART).
a. Infrared Resting Skin Temperature (RST) – Provides thermographic measurements between the
affected and unaffected limb. Generally, a 1 degree Celsius difference is significant.
b. Resting Sweat Output (RSO) – Measures an increase or reduction of 50 percent between the affected
and unaffected limb.
c. Quantitative Sudomotor Axon Reflex Test (QSART) – Measures the sweat output elicited by
iontophoretic application of acetylcholine. An increase or reduction of 50 percent between the
affected and unaffected limb is significant.
5. Other Diagnostic Tests Not Specific for CRPS
The following tests and procedures are not used to establish the diagnosis of CRPS but may provide
additional information. The following are listed in alphabetical order.
a. Electrodiagnostic Procedures
Electromyography (EMG) and Nerve Conduction Studies (NCS) are generally accepted, wellestablished and widely used for localizing the source of the neurological symptoms and
establishing the diagnosis of focal nerve entrapments, such as carpal tunnel syndrome or
radiculopathy, which may contribute to or coexist with CRPS II (causalgia). Traditional
electrodiagnosis includes nerve conduction studies, late responses, (F-Wave, H-reflex) and
electromyographic assessment of muscles with needle electrode examination. As CRPS II occurs
after partial injury to a nerve, the diagnosis of the initial nerve injury can be made by
electrodiagnostic studies. The later development of sympathetically mediated symptomatology
however, has no pathognomonic pattern of abnormality on EMG/NCS. When issues of diagnosis
are in doubt, a referral or consultation with a physiatrist or neurologist trained in electrodiagnosis
is appropriate.
b. Laboratory Tests
Laboratory tests are generally accepted well established and widely used procedures and can
provide useful diagnostic and monitoring information.
They may be used when there is suspicion of systemic illness, infection, neoplasia, or underlying
rheumatologic disorder, connective tissue disorder, or based on history and/or physical
examination. Tests include, but are not limited to:
1) CBC with differential can detect infection, blood dyscrasias, and medication side effects;
2) Erythrocyte sedimentation rate, rheumatoid factor, ANA, HLA, and Creactive protein can be
used to detect evidence of a rheumatologic, infection, or connective tissue disorder,
serum protein electrophoresis;
3) Thyroid, glucose and other tests to detect endocrine disorders;
4) Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can
detect metabolic bone disease;
5) Urinalysis for calcium, phosphorus, hydroxyproline, or hematuria;
6) Liver and kidney function may be performed for baseline testing and monitoring of
medications; and
7) Tox Screen and or Blood Alcohol Level if suspected drug or alcohol abuse.
c. Peripheral Blood Flow (Laser Doppler or Xenon Clearance Techniques)
This is currently being evaluated as a diagnostic procedure in CRPS-I and is not recommended
by the Division at this time.
d. Personality/Psychosocial/Psychological Evaluation
Psychosocial assessment requires consideration of variations in pain experience and expression
because of factors such as gender, age, race, ethnicity, national origin, religion, sexual
orientation, disability, language or socioeconomic status. Psychometric Testing is a valuable
component of a consultation to assist the physician in making a more effective treatment plan.
There is strong evidence that psychometric testing provides unique and useful information, and
that the validity of such tests is comparable to the validity of medical tests. All patients who are
diagnosed as having chronic pain should be referred for a Psychosocial Evaluation as well as
concomitant interdisciplinary rehabilitation treatment whenever appropriate.
1) Qualifications
a) A psychologist with a PhD, PsyD, 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 in injured workers.
b) Psychometric tests may be administered by psychologists with a PhD, PsyD, or EdD,
or by physicians with appropriate training.
2) Clinical Evaluation – All chronic pain patients should have a clinical evaluation that addresses
the following areas:
a) 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.
(1) Nature of injury
(2) Psychosocial circumstances of the injury
(3) Current symptomatic complaints
(4) Extent of medical corroboration
(5) Treatment received and results
(6) Compliance with treatment
(7) Coping strategies used, including perceived locus of control
(8) Perception of medical system and employer
(9) History of response to prescription medications
b) Health History
(1) Nature of injury
(2) Medical history
(3) Psychiatric history
(4) History of alcohol or substance abuse
(5) Activities of daily living
(6) Mental status exam
(7) Previous injuries, including disability, impairment, and compensation
c) Psychosocial history
(1) Childhood history, including abuse
(2) Educational history
(3) Family history, including disability
(4) Marital history and other significant adulthood activities and events
(5) Legal history, including criminal and civil litigation
(6) Employment and military history
(7) Signs of pre-injury psychological dysfunction
(8) Current interpersonal relations, support, living situation
(9) Financial history
d) Psychological test results, if performed
e) Danger to self or others.
f) Current psychiatric diagnosis consistent with the standards of the American Psychiatric
Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).
g) Preexisting psychiatric conditions. Treatment of these conditions is appropriate when
the preexisting condition affects recovery from chronic pain.
h) Causality (to address medically probable cause and effect, distinguishing pre-existing
psychological symptoms, traits and vulnerabilities from current symptoms).
i) Treatment recommendations with respect to specific goals, frequency, timeframes, and
expected outcomes.
3) 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 6th grade reading level. Special Tests
e. Special Tests
Special tests are generally well-accepted tests and are performed as part of a skilled assessment
of the patients' capacity to return to work, strength capacity, and or physical work demands
classifications and tolerance. Tests include Computer-Enhanced Evaluations, Functional Capacity
Evaluation (FCE), Jobsite Evaluation, Vocational Assessment, and Work Tolerance Screening.
Refer to the Chronic Pain guideline for detailed information and frequency of each special testing
procedure.
G. DIAGNOSIS OF CRPS
1. Diagnostic Components of CRPS-I (RSD):
a. Subjective Complaints
Complaint of pain, usually burning or aching pain and out of proportion to identified pathology.
May be sharp or lancinating. Frequently is present without provocation or movement.
b. Physical Findings
1) Swelling, generally unilateral and variable in presentation.
2) Vasomotor signs – Unilateral. Initial extremity warming early on, coldness of extremity as
condition progresses. Discoloration of skin usually darker blue or purple, may be mottled,
may be paler.
3) Sudomotor sign – Increased sweating of the involved extremity.
4) Trophic Changes – Coarse, thick hair, later may be sparse; nails brittle, ridged, may grow
faster initially, later grow more slowly; skin is smooth, shiny; digits tapered (pencil
pointing); joints stiff with decreased ROM; muscle wasting; motor disturbances; increased
physiological tremor, dystonia.
c. Diagnostic Testing Procedures
1) X-rays of both extremities;
2) Triple Phase Bone Scan;
3) Sympathetic Blocks
4) Infrared Thermogram;
5) Autonomic Test Battery
2. Diagnostic Criteria for CRPS
a. CRPS-I (RSD)
1) Patient complains of pain, usually diffuse burning or aching;
2) Patient has physical findings on examination of at least vasomotor and/or sudomotor signs.
Allodynia and/or trophic changes add strength to the diagnosis of CRPS-I; and
3) At least two diagnostic testing procedures are positive. Even the most sensitive tests can have
false negatives. The patient can still have CRPS-I, if clinical signs are strongly present. In
patients with continued signs and symptoms of CRPS-I, further diagnostic testing may be
appropriate.
b. CRPS-II (causalgia)
1) Patient complains of pain;
2) Documentation of peripheral nerve injury with pain initially in the distribution of the injured
nerve;
3) Patient has physical findings on examination of at least vasomotor and/or sudomotor signs.
Allodynia and/or trophic changes add strength to the diagnosis of CRPS-II; and
4) At least two diagnostic testing procedures are positive. Even the most sensitive tests can have
false negatives. The patient can still have CRPS-II, if clinical signs are strongly present.
In patients with continued signs and symptoms of CRPS-II, further diagnostic testing may
be appropriate.
c. Sympathetically Mediated Pain (SMP)
1) Patient complains of pain;
2) Usually does not have clinically detectable vasomotor or sudomotor signs; and
3) Has pain relief with sympathetic blocks.
d. Not CRPS
1) Patient complains of pain;
2) May or may not have vasomotor or sudomotor signs;
3) No relief with sympathetic blocks; and
4) No more than one other diagnostic test procedure is positive.
H. THERAPEUTIC PROCEDURES – NON-OPERATIVE
Non-operative therapeutic rehabilitation is applied to patients with CRPS or SMP who experience chronic
and complex problems of deconditioning and functional disability. Treatment modalities may be utilized
sequentially or concomitantly depending on chronicity and complexity of the problem, and treatment plans
should always be based on a diagnosis utilizing appropriate diagnostic procedures.
Before initiation of any therapeutic procedure, the authorized treating physician, employer and insurer
must consider these important issues in the care of the injured worker:
a. 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.
b. Reassessment of the patient's status in terms of functional improvement should be documented after
each treatment. If patients are not responding within the recommended time periods, alternative
treatment interventions, further diagnostic studies or consultations should be pursued. Continued
treatment should be monitored using objective measures such as:
1) Return to work or maintaining work status.
2) Fewer restrictions at work or performing or limitations in activities of daily living (ADL).
3) Decrease in usage of medications.
4) Measurable functional gains, such as increased range of motion or documented increase in
strength.
c. Clinicians 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.
d. Psychological or psychosocial screening should be performed on all chronic pain patients.
The following procedures are listed in alphabetical order.
1. Acupuncture
Acupuncture is an accepted and widely used procedure for the relief of pain and inflammation and there is
some scientific evidence to support its use. Credentialed practitioners must perform acupuncture
evaluations, with experience in evaluation and treatment of chronic pain patients. 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. It is commonly used when pain medication is reduced or not tolerated. It may be used
as an adjunct to physical rehabilitation, surgical intervention, and or as part of multidisciplinary treatment
to hasten the return of functional activity. Acupuncture should be performed by licensed practitioners.
Refer to the Chronic Pain guideline for detailed information on acupuncture and timeframe parameters.
2. Biofeedback
Biofeedback is a generally well-accepted form of behavioral medicine that helps patients learn selfawareness and self-regulation skills for the purpose of gaining greater control of their physiology.
Biofeedback treatment is intended to assist patients in managing stress-related psychophysiological
reactions that may arise as a reaction to organic pain, or which may cause pain. The biofeedback
specialist may utilize a variety of interventions for teaching physiological self-management. Biological
feedback may then be provided through mechanisms ranging from simple devices to electronic
instrumentation, and displayed or fed back to the patient visually, auditorially, or tactilely. This enables the
patient to identify and refine effective interventions.
The application of biofeedback to patients with CRPS is not well researched. However, based on CRPS
symptomology, temperature or skin conductance feedback modalities may be of particular interest. Refer
to the Chronic Pain Guideline for detailed information on biofeedback and time parameters.
3. Complementary Alternative Medicine (CAM)
CAM is a term used to describe a broad range of treatment modalities, a number of which are generally
accepted and supported by some scientific evidence, and others which still remain outside the generally
accepted practice of conventional Western Medicine. In many of these approaches, there is attention
given to the relationship between physical, emotional, and spiritual well-being. While CAM may be
performed by a myriad of both licensed and non-licensed health practitioners with training in one or more
forms of therapy, credentialed practitioners should be used when available or applicable.
Refer to Chronic Pain guideline for detailed information on CAM and timeframe parameters.
4. Sleep Disturbances
Disturbances of sleep are common in chronic pain. Although primary insomnia may accompany pain as
an independent comorbid 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
slowwave sleep and increase in light sleep occur and sleep efficiency, the proportion of time in bed spent
asleep, is decreased. These changes are associated with patient reports of non-restorative sleep.
Many chronic pain patients develop behavioral habits that exacerbate and maintain sleep disturbances.
Excessive time in bed, irregular sleep routine, napping, low activity and worrying in bed are all
maladaptive responses that can arise in the absence of any psychopathology. There is some evidence
that behavioral modification, such as patient education and group or individual counseling, can be
effective in reversing the effects of insomnia. Behavioral modifications are easily implemented and can
include:
a. Maintaining a regular sleep schedule, retiring and rising at approximately the same time on weekdays
and weekends.
b. Avoiding daytime napping.
c. Avoiding caffeinated beverages after lunchtime
d. Making the bedroom quiet and comfortable, eliminating disruptive lights, sounds television sets, and
keeping a bedroom temperature of about 65°;F.
e. Avoiding alcohol or nicotine within two hours of bedtime.
f. Avoiding large meals within two hours of bedtime.
g. Exercising vigorously during the day, but not within two hours of bedtime, since this may raise core
temperature and activate the nervous system.
h. Associating the bed with sleep and sexual activity only, using other parts of the home for television,
reading and talking on the telephone.
i. Leaving the bedroom when unable to sleep for more than 20 minutes, retuning to the bedroom when
ready to sleep again.
These modifications should be undertaken before sleeping medication is prescribed.
5. Injections — Therapeutic
When considering the use of injections in CRPS management, the treating physician must carefully
consider the inherent risks and benefits. First, it is understood that these injections are seldom meant to
be “curative” but may have diagnostic or prognostic qualities and when used for therapeutic purposes
they are employed in conjunction with other treatment modalities for maximum benefit. Second, education
of the patient should include the proposed goals of the injections, expected gains, risks or complications,
and alternative treatment. Lastly, reassessment of the patient's status in terms of functional improvement
should be documented after each injection and/or series of injections. Any continued use of injections
should be monitored using objective measures such as:
(1) Return to work or maintaining work status.
(2) Fewer restrictions at work or when performing activities of daily living (ADL).
(3) Decrease in usage of medications.
(4) Measurable functional gains, such as increased range of motion or documented increase in strength.
Visual analog scales (VAS) provide important subjective data but are not an appropriate measure of
function.
The physician must be aware of the possible placebo effect as well as the long-term effects of injections
related to the patient's physical and mental status. Strict adherence to contraindications, both absolute
and relative, may prevent potential complications. Subjecting the patient to potential risks, i.e., needle
trauma, infection, nerve injury, or systemic effects of local anesthetics and corticosteroids, must be
considered before the patient consents to such procedures.
a. Sympathetic Injections
Description – Sympathetic injections are generally accepted, well-established procedures. They include
stellate ganglion blocks, lumbar sympathetic, and intravenous regional (Bier) blocks. Regional blocks
frequently use bretylium with additional agents (narcotics and or anti-inflammatory drugs). There is some
evidence that bretylium reduces pain intensity. It is recommended that all patients receiving therapeutic
blocks participate in an appropriate exercise program that may include a functionally directed
rehabilitation program.
Indications – Pain relief and functional improvement from previous diagnostic or therapeutic blocks.
Special Considerations – Except for Bier blocks, fluoroscopic and/or CT guidance during procedures is
recommended to document technique and needle placement; an experienced physician should perform
the procedure. The practitioner should participate in ongoing injection training workshops provided by
organizations such as the International Spinal Injection Society (ISIS) and be knowledgeable in radiation
safety. In addition, practitioners should obtain fluoroscopy training and radiation safety credentialing from
their Departments of Radiology, as applicable.
Complications – Complications may include transient neurapraxia, nerve injury, inadvertent spinal
injection, infection, venous or arterial vertebral puncture, laryngeal paralysis, respiratory arrest, vasovagal
effects, as well as permanent neurologic damage.
Contraindications – Absolute contraindications of therapeutic injections include: (a) bacterial infection –
systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d)
possible pregnancy. Relative contraindications of therapeutic injections may include: ASA/antiplatelet
therapy (drug may be held for at least 3 days prior to injection).
Treatment Parameters – To be effective as a treatment modality, the patient should be making
measurable progress in their rehabilitation program and should be achieving an increasing or sustained
duration of relief between blocks. If appropriate outcomes are not achieved, changes in treatment should
be undertaken.
(1) Time to produce effect: 1 to 3 blocks
(2) Frequency: Variable, depending upon duration of pain relief and functional gains. During the first two
weeks of treatment, blocks may be provided every 3 to 5 days, based on patient response. After
the first two weeks, blocks may be given weekly with tapering for a maximum of 7 injections over
6 weeks.
(3) Optimum duration: 3 months.
(4) Maximum duration: 3 to 4 months for initial treatment. For the use of blocks during maintenance care,
refer to the Maintenance Care section for treatment parameters.
b. Trigger Point Injections
May be appropriate when myofascial trigger points are present on examination. Refer to chronic pain
guidelines for treatment parameters.
c. Peripheral Nerve Blocks
May be appropriate when peripheral nerve pathology is identified. Refer to chronic pain guidelines for
treatment parameters.
d. Intravenous Lidocaine
May be used as a prognostic indicator for the use of mexilitine. It is infrequently used as a therapeutic
treatment.
6. Interdisciplinary Rehabilitation Programs
Interdisciplinary Rehabilitation Programs are the gold standard of treatment for individuals with chronic
pain who have not responded to less intensive modes of treatment. In addition, there are current studies
to support the use of pain programs.
These programs should assess the impact of pain and suffering on the patient's medical, physical,
psychological, social and/or vocational functioning. In general, interdisciplinary programs deal with
irreversible, painful musculoskeletal, neurological, and other chronic painful disorders and psychological
issues, including drug dependence, high levels of stress and anxiety, failed surgery and preexisting or
latent psychopathology. The number of professions involved in the team in chronic pain program may
vary due to the complexity of the needs of the person served. The Division recommends consideration of
referral to an interdisciplinary program within 6 months post-injury in patients with delayed recovery
unless surgical interventions or other medical complications intervene.
Chronic pain patients need to be treated as outpatients within a continuum of treatment intensity.
Outpatient chronic pain programs are available with services provided by a coordinated interdisciplinary
team within the same facility (formal) or as coordinated by the authorized treating physician (informal).
Formal programs are able to provide coordinated, high intensity level of services and are recommended
for most chronic pain patients who have received multiple therapies during acute management, especially
patients with greater levels of perceived disability, dysfunction, deconditioning and psychological
involvement. Informal programs offer a lesser intensity of service and may be considered for patients who
are currently employed, those who cannot attend all day programs, those with language barriers, or those
living in areas not offering formal programs. An informal interdisciplinary program is one in which the
authorized treating physician coordinates all aspects of care.
Refer to the Chronic Pain guideline for detailed information about these programs and timeframe
parameters. Before treatment has been initiated, the patient, physician, and insurer should agree on
treatment approach, methods and goals. Generally the type of outpatient program needed will depend on
the degree of impact the pain has had on the patient's medical, physical, psychological, social and/or
vocational functioning.
When referring a patient for formal outpatient interdisciplinary pain rehabilitation or Work Hardening
programs, the Division recommends the programs be Commission on Accreditation of Rehabilitation
Facilities (CARF) eligible and/or certified. CARF eligibility or certification ensures that programs meet
specific care standards of design and efficacy.
Inpatient Pain Rehabilitation Programs are rarely needed but may be necessary for certain patients. Refer
to Chronic Pain guideline for detailed conditions that may require inpatient pain rehabilitation.
Outpatient interdisciplinary pain programs, whether formal or informal, should be comprised of the
following dimensions:
a. Communication – To ensure positive functional outcomes, communication between the patient, insurer
and all professionals involved must be coordinated and consistent. Any exchange of information
must be provided to all professionals, including the patient. Care decisions would be
communicated to all.
b. Documentation – Through documentation by all professionals involved and or discussions with the
patient, it should be clear that functional goals are being actively pursued and measured on a
regular basis to determine their achievement or need for modification.
c. Treatment Modalities – Use of modalities may be necessary early in the process to facilitate
compliance with and tolerance to therapeutic exercise, physical conditioning, and increasing
functional activities. Active treatments should be emphasized over passive treatments. Active
treatments should encourage self-coping skills and management of pain, which can be continued
independently at home or at work. Treatments that can foster a sense of dependency by the
patient on the caregiver should be avoided. Treatment length should be decided based upon
observed functional improvement. For a complete list of Active and Passive Therapies, refer to
the Therapy sections of this guideline. All treatment timeframes may be extended, based upon
the patient's positive functional improvement.
d. Therapeutic Exercise Programs – There is strong evidence that these programs, including aerobic
conditioning and strengthening, are superior to treatment programs that do not include exercise.
There is no sufficient evidence to support the recommendation of any particular exercise regimen
over any other exercise regimen. A Therapeutic Exercise program should be initiated at the start
of any treatment rehabilitation. Such programs should emphasize education, independence, and
the importance of an on-going exercise regime.
e. Return to Work – The authorized treating physician should continually evaluate the patient for their
potential to return to work. When return to work is an option, it may be appropriate to implement a
Work Hardening Program (as described in this section). For patients currently employed, efforts
should be aimed at keeping them employed. For more specific information regarding return to
work, refer to the Return To Work section in this guideline.
f. Patient Education – Patients with pain need to re-establish a healthy balance in lifestyle. All providers
should educate patients on how to overcome barriers to resuming daily activity, including pain
management, decreased energy levels, financial constraints, decreased physical ability and
change in family dynamics.
g. Psychosocial Evaluation and Treatment – Psychosocial evaluation should be initiated, if not previously
done. Providers of care should have a thorough understanding of the patient's personality profile;
especially if dependency issues are involved. Psychosocial treatment may enhance the patient's
ability to participate in pain treatment rehabilitation, manage stress, and increase their problemsolving and self-management skills.
h. Vocational Assistance – Vocational assistance can define future employment opportunities or assist
patients in obtaining future employment. Refer to Return to Work section for detailed information.
7. Medications
There is no single formula for pharmacological treatment of patients with chronic nonmalignant pain. A
thorough medication history, including use of alternative and over the counter medications, should be
performed at the time of the initial visit and updated periodically. Appropriate application of
pharmacological agents depends on the patient's age, past history (including history of substance abuse),
drug allergies and the nature of all medical problems. It is incumbent upon the physician to thoroughly
understand pharmacological principles when dealing with the different drug families and their respective
side effect, bioavailability profiles and primary reason for each medication's usage.
Control of chronic non-malignant pain is expected to involve the use of medication. Strategies for
pharmacological control of pain cannot be precisely specified in advance. Rather, drug treatment requires
close monitoring of the patient's response to therapy, flexibility on the part of the prescriber, and a
willingness to change treatment when circumstances change. Many of the drugs discussed in the
medication section were licensed for indications other than analgesia, but are effective in the control of
many types of chronic pain.
All medications should be given an appropriate trial in order to test for therapeutic effect. Trials of
medication requiring specific therapeutic drug levels may take several months to achieve, depending
upon the half-life of the drug. It is recommended that patients with CRPS be maintained on drugs that
have the least serious side effects. For example, patients need to be tried or continued on acetaminophen
and or antidepressant medications whenever feasible as part of their overall treatment for chronic pain. It
is recommended that use of opioid analgesic and sedative hypnotic medications in chronic pain patients
be used in a very limited manner, with total elimination desirable whenever clinically feasible.
For the clinician to interpret the following material, it should be noted that: (1) drug profiles listed are not
complete; (2) dosing of drugs will depend upon the specific drug, especially for off-label use; and (3) not
all drugs within each class are listed, and other drugs within the class may be appropriate. Clinicians
should refer to informational texts or consult a pharmacist before prescribing unfamiliar medications or
when there is a concern regarding drug interactions.
The following drug classes are listed in alphabetical order, not in order of suggested use.
a. Anticonvulsants
Although the mechanism of action of anticonvulsant drugs in neuropathic pain states remains to be fully
defined, they appear to act as nonselective sodium channel blocking agents. A large variety of sodium
channels are present in nervous tissue, and some of these are important mediators of nociception, as
they are found primarily in unmyelinated fibers and their density increases following nerve injury. While
the pharmacodynamic effects of the various anticonvulsant drugs are similar, the pharmacokinetic effects
differ significantly. Carbamazepine has important effects as an inducer of hepatic enzymes and may
influence the metabolism of other drugs enough to present problems in patients taking more than one
drug. Gabapentin and oxcarbazepine, by contrast, are relatively non-significant enzyme inducers, creating
fewer drug interactions. Because anticonvulsant drugs may have more problematic side-effect profiles,
their use should usually be deferred until antidepressant drugs have failed to relieve pain.
1) Gabapentin (Neurontin)
a) Description – Structurally related to GABA but does not interact with GABA receptors.
b) Indications – Neuropathic pain.
c) Relative Contraindications – Renal insufficiency.
d) Dosing and Time to Therapeutic Effect – Dosage may be increased over several days.
e) Major Side Effects – Confusion, sedation.
f) Drug Interactions – Oral contraceptives, cimetidine, antacids.
g) Recommended Laboratory Monitoring – Renal function.
b. Antidepressants
Antidepressants are classified into a number of categories based on their chemical structure and their
effects on neurotransmitter systems. Their effects on depression are attributed to their actions on
disposition of norepinephrine and serotonin at the level of the synapse; although these synaptic actions
are immediate, the symptomatic response in depression is delayed by several weeks. When used for
chronic pain, the effects may in part arise from treatment of underlying depression, but may also involve
additional neuromodulatory effects on endogenous opioid systems, raising pain thresholds at the level of
the spinal cord.
Pain responses may occur at lower drug doses with shorter times to symptomatic response than are
observed when the same compounds are used in the treatment of mood disorders. Neuropathic pain,
diabetic neuropathy, post-herpetic neuralgia, and cancer-related pain may respond to antidepressant
doses low enough to avoid adverse effects that often complicate the treatment of depression.
1) Tricyclics (e.g., amitruptiline [Elavil], nortriptyline [Pamelor, Aventyl], doxepin [Sinequan, Adapin])
a) Description – Serotonergics, typically tricyclic antidepressants (TCAs), are utilized for their
serotonergic properties as increasing CNS serotonergic tone can help decrease pain
perception in nonantidepressant dosages. Amitriptyline is known for its ability to repair
Stage 4 sleep architecture, a frequent problem found in chronic pain patients and to treat
depression, frequently associated with chronic pain.
b) Indications – Chronic musculoskeletal and/or neuropathic pain, insomnia. Second line drug
treatment for depression.
c) Major Contraindications – Cardiac disease or dysrhythmia, glaucoma, prostatic hypertrophy,
seizures, suicide risk.
d) Dosing and Time to Therapeutic Effect – Varies by specific tricyclic. Low dosages are
commonly used for chronic pain and/or insomnia.
e) Major Side Effects – Anticholinergic side effects including, but not limited to, dry mouth,
sedation, orthostatic hypotension, cardiac arrhythmia, weight gain.
f) Drug Interactions – Tramadol (may cause seizures), Clonidine, cimetidine, sympathomimetics,
valproic acid, warfarin, carbamazepine, bupropion, anticholinergics, quinolones.
g) Recommended Laboratory Monitoring – Renal and hepatic function. EKG for those on high
dosages or with cardiac risk.
c. Hypnotics and Sedatives
Sedative and hypnotic drugs decrease activity, induce drowsiness, and moderate agitation. Many drugs
produce these effects incidental to their usual intended effects, similar to the side effects of many
antihistamines and antidepressants. Due to the habit-forming potential of the benzodiazepines and other
drugs found in this class, they are not routinely recommended but may be useful in some patients with
chronic pain.
Most insomnia in chronic pain patients should be managed primarily though behavioral interventions with
medications as secondary measures (refer to “Disturbances of Sleep” section).
1) Zaleplon (Sonata)
a) Description – A nonbenzodiazepine hypnotic.
b) Indications – Insomnia.
c) Dosing and Time to Therapeutic Effect – Time of onset is 30 to 60 minutes. Due to rapid
elimination, may be taken as little as 4 hours before awakening.
d) Major Side Effects – Dizziness, dose-related amnesia.
e) Drug Interactions – Increases sedative effect of other CNS depressant drugs. Use low dose if
on cimetidine.
f) Recommended Laboratory Monitoring – Hepatic function.
2) Zolpidem (Ambien)
a) Description – A nonbenzodiazepine hypnotic, which does not appear to cause rebound
insomnia. It has little respiratory depression and insignificant anxiolytic or muscle relaxant
activity.
b) Indications – Short-term use for insomnia
c) Time to Produce Therapeutic Effect – Onset of action is 30 to 60 minutes
d) Major Side Effects – Dizziness, dose-related amnesia.
e) Drug Interactions – Increases sedative effect of other CNS depressant drugs.
f) Recommended Laboratory Monitoring – Hepatic function.
d. Opioids
Opioids are the most powerful analgesics. Their use in acute pain and moderate to severe cancer pain is
well accepted. Their use in chronic nonmalignant pain, however, is fraught with controversy and lack of
scientific research.
Opioids include some of the oldest and most effective drugs used in the control of severe pain. The
discovery of opioid receptors and their endogenous peptide ligands has led to an understanding of effects
at the binding sites of these naturally occurring substances. Most of their analgesic effects have been
attributed to their modification of activity in pain pathways within the central nervous system; however, it
has become evident that they also are active in the peripheral nervous system. Activation of receptors on
the peripheral terminals of primary afferent nerves can mediate antinociceptive effects, including inhibition
of neuronal excitability and release of inflammatory peptides. Some of their undesirable effects on
inhibiting gastrointestinal motility are peripherally mediated by receptors in the bowel wall.
The central nervous system actions of these drugs account for much of their analgesic effect and for
many of their other actions, such as respiratory depression, drowsiness, mental clouding, reward effects,
and habit formation. With respect to the latter, it is crucial to distinguish between three distinct
phenomena: tolerance, dependence, and addiction.
Tolerance refers to a state of adaptation in which exposure to a drug over time causes higher doses of
that drug to be required in order to produce the same physiologic effect.
Dependence refers to a set of disturbances in body homeostasis that leads to withdrawal symptoms,
which can be produced with abrupt discontinuation, rapid reduction, decreasing blood levels, and /or by
administration of an antagonist.
Addiction is a primary, chronic, neurobiologic disease, with genetic, psychological, and environmental
factors influencing its development and manifestations. It is a behavioral pattern of drug craving and
seeking which leads to a preoccupation with drug procurement and use.
Tolerance and dependence are physiological phenomena, are expected with the continued administration
of opioids, and should not deter physicians from their appropriate use.
The use of opioids is well accepted in treating cancer pain, where nociceptive mechanisms are generally
present due to ongoing tissue destruction, expected survival may be short, and symptomatic relief is
emphasized more than functional outcomes. In chronic non-malignant pain, by contrast, tissue destruction
has generally ceased, meaning that central and neuropathic mechanisms frequently overshadow
nociceptive processes. Expected survival in chronic pain is relatively long and return to a high level of
function is a major goal of treatment. Therefore, approaches to pain developed in the context of malignant
pain may not be transferable to chronic non-malignant pain.
In most cases, analgesic treatment should begin with acetaminophen, aspirin, and NSAIDs. While
maximum efficacy is modest, they may reduce pain sufficiently to permit adequate function. When these
drugs do not satisfactorily reduce pain, opioids for moderate to moderately severe pain may be added to
(not substituted for) the less efficacious drugs.
Consultation or referral to a pain specialist should be considered when the pain persists but the
underlying tissue pathology is minimal or absent and correlation between the original injury and the
severity of impairment is not clear. Consider consultation if suffering and pain behaviors are present and
the patient continues to request medication, or when standard treatment measures have not been
successful or are not indicated.
1) General Indications — There must be a clear understanding that opioids are to be used for a limited
term in the first instance (see trial indications below), that their use is contingent upon certain
obligations or goals being met by the patient, e.g., return to work, and the patient understands
that there may be drug screening to ensure compliance.
2) Therapeutic Trial Indications — A therapeutic trial of opioids should not be employed unless the patient
has begun a rehabilitation program. Once this criterion has been met, opioids would be indicated
when a patient meets the following:
a) The failure of pain management alternatives, including active therapies, cognitive behavioral
therapy, pain self-management techniques, and other appropriate medical techniques.
b) Physical and psychosocial assessment, performed by two specialists with one being the
authorized treating physician.
c) Informed, written, witnessed consent by the patient.
In addition, there should be documentation of sustained improvement of pain control and/or
functional status, including return to work, with use of opioids. Frequent follow-up at least every 2
to 4 weeks may be necessary to titrate dosage and assess clinical efficacy.
3) On-Going, Long-Term Management — Actions Should Include:
a) Prescriptions from a single practitioner,
b) Ongoing review and documentation of pain relief, functional status, appropriate medication
use, and side effects,
c) Ongoing effort to gain improvement of social and physical function as a result of pain relief,
d) Contract detailing reasons for termination of supply, with appropriate tapering of dose,
e) Use of random drug screening, as deemed appropriate by the prescribing physician,
f) Use of more than two opioids: a long acting opioid for maintenance of pain relief and a short
acting opioid for limited rescue use when pain exceeds the routine level. If more than two
opioids are prescribed for long-term use a second opinion from specialist who is Board
Certified in Neurology, Physical Medicine and Rehabilitation, or Anesthesiology with
recognized training and/or certification in pharmacological pain management is strongly
recommended,
g) Use of acetaminophen-containing medications in patients with liver disease should be limited;
and
h) Continuing review of overall situation with regard to nonopioid means of pain control,
i) Inpatient treatment in complex cases. Refer to Interdisciplinary Rehabilitation Programs for
detailed information on in-patient criteria.
4) Relative Contraindications — Extreme caution should be used in prescribing controlled substances for
workers with one or more “relative contraindications”:
a) History of alcohol or other substance abuse, or a history of chronic, high-dose benzodiazepine
use;
b) Off work for more than six months;
c) Severe personality disorder
5) General Contraindications —
a) Active alcohol or other substance abuse.
b) Untreated mood or psychotic disorders (e.g., depression).
c) Decreased physical or mental function with continued opioid use.
d) Addictive behaviors. Warning signs include:
(1) Preoccupation with drugs;
(2) Refusal to participate in medication taper;
(3) Reporting that nothing but a specific opioid works;
(4) Strong preference for short-acting over long-acting opioids;
(5) Use of multiple prescribers and pharmacies;
(6) Use of street drugs or other patients drugs;
(7) Not taking medications as prescribed;
(8) Loss of medications more than once; and/or
(9) Criminal behaviors to obtain drugs, i.e., forged prescriptions.
6) Dosing and Time to Therapeutic Effect — Oral route is the preferred route of analgesic administration
because it is the most convenient and cost-effective method of administration. When patients
cannot take medications orally, rectal and transdermal routes should be considered because they
are also relatively noninvasive.
7) Major Side Effects — There is great individual variation in susceptibility to opioid-induced side effects
and clinicians should monitor for these potential side effects. Common initial side effects include
nausea, vomiting, drowsiness, unsteadiness, and confusion. Occasional side effects include dry
mouth, sweating, pruritus, hallucinations, and myoclonus. Rare side effects include respiratory
depression and psychological dependence. Constipation and nausea/vomiting are common
problems associated with long-term opioid administration and should be anticipated, treated
prophylactically, and monitored constantly.
8) Drug Interactions — Patients receiving opioid agonists should not be given a mixed agonist-antagonist
(pentazocine [Talwin], butorphanol [Stadol]) because doing so may precipitate a withdrawal
syndrome and increase pain.
9) Recommended Laboratory Monitoring — Primary laboratory monitoring is recommended for
acetaminophen/ASA/ibuprofen combinations (renal and liver function, blood dyscrasias). May
perform urine and or blood drug screen if suspect use of other narcotics or lack of compliance
with full medication regimen.
10) Patient Physician Contracts — All patients on chronic opioids should have an informed, written,
witnessed consent. The contract should discuss side effects of opioids, results of use in
pregnancy, inability to refill lost or missing medication, withdrawal symptoms, requirement for
drug testing, and necessity of tapering.
11) Potentiating Agents — Some medications appear to potentiate the analgesic effects of opioids.
Dextromethorphan is available as a nonopioid non-prescription antitussive agent in numerous
cough and cold remedies. It antagonizes n-methyl-d-aspartate receptors involved in central
sensitization of pain pathways. It may exert some morphine sparing effects in patients taking
morphine, but its activity as an analgesic in neuropathic pain is likely to be weak. It is well
tolerated in most patients. Because the patient profiles that might predict response to
dextromethorphan are undefined, its use in chronic pain must be empirically tried on an individual
basis. Diphenhydramine and hydroxyzine (atarax, vistaril) are antihistamines, which act at hl
receptors to alleviate allergic symptoms and produce somnolence. Diphenhydramine is a
component of some non-prescription sleeping preparations. Their use in potentiating the effects
of analgesic drugs is not clearly defined, but it may be used empirically for this purpose.
e. Topical Drug Delivery
1) Description — Topical medications, such as ketamine and capsacin, may be an alternative treatment
for neuropathic disorders and is an acceptable form of treatment in selected patients although
there is no literature addressing its use in patients with CRPS.
2) Indications — Pain. Patient selection must be rigorous to select those patients with the highest
probability of compliance.
3) Dosing and Time to Therapeutic Effect — It is necessary that all topical agents be used with strict
instructions for application as well as maximum number of applications per day to obtain the
desired benefit and avoid potential toxicity.
4) Side Effects — Localized skin reactions may occur, depending on drug.
f. Other Agents
1) Tramadol (Ultram)
a) Description — An opioid partial agonist that is generally well tolerated, does not cause GI
ulceration, or exacerbate hypertension or congestive heart failure.
b) Indications — Mild to moderate pain relief. This drug has been shown to provide pain relief
equivalent to that of commonly prescribed NSAIDs.
c) Contraindications — Use cautiously in patients who have a history of seizures or who are
taking medication that may lower the seizure threshold, such as MAO inhibitors, SSRIs,
and TCAs. Not recommended in those with prior opioid addiction.
d) Side Effects — May cause impaired alertness or nausea. This medication has physically
addictive properties and withdrawal may follow abrupt discontinuation.
e) Drug Interactions — Narcotics, sedating medications.
f) Recommended Laboratory Monitoring — Renal and hepatic function.
2) Agents not listed which may be useful in the treatment of CRPS and SMP include propranolol,
nifedipine, calcitonin, bisphosphonates and short-term oral steroids, during the acute phase of the
disease. Although propranolol, nifedipine, oral steroids, and calcitonin are used in practice, at this
time there is a lack of well-designed studies to support their effectiveness compared to placebo.
In individual patients, they may be effective. There is some evidence to support the use of
intravenous bisphosphonate drugs, currently licensed for use in malignant bone disease and
Paget's disease, in CRPS patients with abnormal bone scans. Oral use of bisphosphonates has
not been studied in CRPS.
8. Orthotics/Prosthetics/Equipment
Devices and adaptive equipment may be necessary in order to reduce impairment and disability, to
facilitate medical recovery, to avoid re-aggravation of the injury, and to maintain maximum medical
improvement. Refer to the Chronic Pain guideline for detailed information on
Orthotics/Prosthetics/Equipment.
9. Patient Education
Patients should be educated on their specific injury, assessment findings, and plan of treatment and
encouraged to take an active role in establishing functional outcome goals. No treatment plan is complete
without addressing issues of individual and/or group patient education as a means of prolonging the
beneficial effects of rehabilitation, as well as facilitating self-management of symptoms and prevention of
secondary disability. There is good evidence that patient education in self-management of asthma,
anticoagulation, and other diseases improves appropriate use of medications, increases patient
satisfaction with care, and reduces unscheduled physician visits for dealing with complications of
treatment.
Patient education is an interactive process that provides an environment where the patient not only
acquires knowledge but also gains an understanding of the application of that knowledge. Therefore,
patients should be able to describe and/or will need to be educated on:
a. The treatment plan;
b. Indications for and potential side effects of medications;
c. Their home exercise program;
d. Expected results of treatment;
e. Tests to be performed, the reasons for them and their results;
f. Activity restrictions and return-to-work status;
g. Home management for exacerbations of pain;
h. Procedures for seeking care for exacerbations after office hours;
i. Home self-maintenance program;
j. Patient responsibility to communicate with all medical providers and the employer; and
k. Patient responsibility to keep appointments.
Educational efforts should also extend to family and other support persons, the case manager, the insurer
and the employer as indicated to optimize the understanding of the patient and the outcome. Professional
translators should be provided for non-English speaking patients to assure optimum communication. All
education, teaching, and instruction given to the patient should be documented in the medical record.
Effects of education weaken over time; continuing patient education sessions will be required to maximize
the patient's function. The effectiveness of educational efforts can be enhanced through attention to the
learning style and receptivity of the patient. Written educational materials may reinforce and prolong the
impact of verbal educational efforts. Overall, patient education should emphasize health and wellness,
return to work and return to a productive life.
(1) Time to produce effect: Varies with individual patient
(2) Frequency: At each visit
10. Personality/Psychological/Psychosocial Intervention
Psychosocial treatment is generally accepted, well-established therapeutic and diagnostic procedure with
selected use in acute pain problems, but with more widespread use in sub-acute and chronic pain
populations. Psychosocial treatment is recommended as an important component in the total
management of a patient with chronic pain and should be implemented as soon as the problem is
identified.
Once a diagnosis consistent with the standards of the American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders (DSM) has been determined, the patient should be evaluated for
the potential need for psychiatric medications. Use of any medication to treat a diagnosed condition may
be ordered by the authorized treating physician or by the consulting psychiatrist. Visits for management of
psychiatric medications are medical in nature and are not a component of psychosocial treatment.
Therefore, separate visits for medication management may be necessary, depending upon the patient
and medications selected.
The screening or diagnostic workup should have clarified and distinguished between preexisting,
aggravated, and or purely causative psychological conditions. Therapeutic and diagnostic modalities
include, but are not limited to, individual counseling, and group therapy. Treatment can occur within an
individualized model, a multi-disciplinary model, or within a structured pain management program.
Refer to Chronic Pain guideline for detailed information on whom may perform the service and timeframe
parameters.
11. Restriction of Activities
Continuation of normal daily activities is the recommendation for chronic pain patients since immobility will
negatively affect rehabilitation. Prolonged immobility results in a wide range of deleterious effects, such as
a reduction in aerobic capacity and conditioning, loss of muscle strength and flexibility, increased
segmental stiffness, promotion of bone demineralization, impaired disc nutrition, and the facilitation of the
illness role.
Patients should be educated to the detrimental effects of immobility versus the efficacious use of rest
periods. Adequate rest allows the patient to comply with active treatment and benefit from the
rehabilitation program. In addition complete work cessation should be avoided, if possible, since it often
further aggravates the pain presentation and promotes disability. Modified return to work is almost always
more efficacious and rarely contraindicated in the vast majority of injured workers with chronic pain.
12. Return-to-Work
Return-to-work is one of the major components in chronic pain management. Return to work is a subject
that should be addressed by each workers' compensation provider at the first meeting with the injured
employee, and be updated at each additional visit. A return to work format should be part of a company's
health plan, knowing that return to work can decrease anxiety, reduce the possibility of depression and
reconnect the worker with society.
Because a prolonged period of time off work will decrease the likelihood of return to work, the first weeks
of treatment are crucial in preventing and/or reversing chronicity and disability mindset. In complex cases,
experienced nurse case managers may be required to assist in return to work. Other services, including
psychological evaluation and/or treatment and vocational assistance should be employed.
The following should be considered when attempting to return an injured worker with chronic pain to work.
a. Job History Interview
The authorized treating physician should perform a job history interview at the time of the initial
evaluation and before any plan of treatment is established. Documentation should include the
workers' job demands, stressors, duties of current job, and duties of job at the time of the initial
injury. In addition, cognitive and social issues should be identified and treatment of these issues
should be incorporated into the plan of care.
b. Coordination of Care
Management of the case is a significant part of return to work and may be the responsibility of the
authorized treating physician, occupational health nurse, risk manager, or others. Case
management is a method of communication between the primary provider, referral providers,
insurer, employer and employee. Because case management may be coordinated by a variety of
professionals, the case manager should be identified in the medical record.
c. Communication
Communication is essential between the patient, authorized treating physician, employer and
insurer. Employers should be contacted to verify employment status, job duties and demands,
and policies regarding injured workers. In addition, availability of temporary and permanent
restrictions, for what duration, as well as other placement options should be discussed and
documented.
d. Establishment of a Return-To-Work Status
Return to work for persons with chronic pain should be thought of as therapeutic, assuming that
work is not likely to aggravate the basic problem or increase the discomfort. In most cases of
chronic pain, the worker may not be currently working or even employed. The goal of return to
work would be to implement a plan of care to return the worker to any level of employment with
the current employer or to return them to any type of new employment.
e. Establishment of Activity Level Restrictions
A formal job description for the injured/ill employee who is employed is necessary to identify
physical demands at work and assist in the creation of modified duty. A Jobsite Evaluation may be
utilized to identify tasks such as pushing, pulling, lifting, reaching above shoulder level, grasping,
pinching, sitting, standing, posture, ambulatory distance and terrain, and if applicable,
environment for temperature, air flow, noise and the number of hours that may be worked per
day. Work restrictions assigned by the authorized treating physician may be temporary or
permanent. The case manager should continue to seek out modified work until restrictions
become less cumbersome or as the worker's condition improves or deteriorates.
f. Rehabilitation and Return to Work
As part of rehabilitation, every attempt should be made to simulate work activities so that the
authorized treating physician may promote adequate job performance. The use of ergonomic or
adaptive equipment, therapeutic breaks, and interventional modalities at work may be necessary
to maintain employment.
g. Vocational Assistance
Formal vocational assistance is a generally accepted intervention and can assist disabled
persons to return to viable employment. Assisting patients to identify vocational goals will facilitate
medical recovery and aid in the maintenance of MMI by (1) increasing motivation towards
treatment and (2) alleviating the patient's emotional distress. Chronic pain patients will benefit
most if vocational assistance is provided during the interdisciplinary rehabilitation phase of
treatment. To assess the patient's vocational capacity, a vocational assessment may be utilized to
identify rehabilitation program goals, as well as optimize both patient motivation and utilization of
rehabilitation resources.
Employers and employees of small businesses who are diagnosed with chronic pain may not be able to
perform any jobs for which openings exist. Temporary employees may fill those slots while the employee
functionally improves. Some small businesses hire other workers and if the injured employee returns to
the job, the supervisor/owner may have an extra employee. To avoid this, it is suggested that case
managers be accessed through their insurer or third party insurers. Case managers may assist with
resolution of these problems, as well as assist in finding modified job tasks, or find jobs with reduced
hours, etc., depending upon company philosophy and employee needs.
Employers and employees of mid-sized and large businesses are encouraged by the Division to identify
modified work within the company that may be available to injured workers with chronic pain who are
returning to work with temporary or permanent restrictions. To assist with temporary or permanent
placement of the injured worker, it is suggested that a program be implemented that allows the case
manager to access descriptions of all jobs within the organization.
13. Therapy — Active
Active therapy is based on the philosophy that therapeutic exercise and/or activity are beneficial for
restoring flexibility, strength, endurance, function, range of motion, and can alleviate discomfort.
Active therapy requires an internal effort by the individual to complete a specific exercise or task. This
form of therapy requires supervision from a therapist or medical provider such as verbal, visual and/or
tactile instruction(s). Active therapy is intended to promote independence and self-reliance in managing
the physical pain as well as to improve the functional status in regard to the specific diagnosis and
general conditioning and well-being. 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.
Since CRPS and SMP patients frequently have additional myofascial pain generators, other active
therapies not listed may be used in treatment. Refer to the Chronic Pain guideline for therapies and
timeframe parameters not listed. The following active therapies are listed in alphabetical order:
a. Activities of Daily Living (ADL)
Activities of daily living are instruction, active-assisted training and/or adaptation of activities or equipment
to improve a person's capacity in normal daily activities such as self-care, work re-integration training,
homemaking and driving.
(1) Time to produce effect: 4 to 5 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 weeks
b. Aquatic Therapy
Aquatic therapy is the implementation of active therapeutic procedures (individual or group) in a
swimming or therapeutic pool heated to 88-92 degrees. The water provides a buoyancy force that lessens
the amount of force gravity applies to the body, and the pool should be large enough to allow full extremity
range of motion and full erect posture. The decreased gravity effect allows the patient to have a
mechanical advantage increases the likelihood of successful therapeutic exercise. Multiple limb
involvement, weight bearing problems and vasomotor abnormalities are frequently treated with water
exercise. Indications for individuals who may not tolerate active land-based or full weight bearing
therapeutic procedures or who require augmentation of other therapy. Aquatic vests, belts and other
devices can be used to provide stability, balance, buoyancy, and resistance.
(1) Time to produce effect: 5 to 10 sessions
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 Weeks. Multiple limb involvement may require longer intervention.
c. Gait Training
Indications include the need to promote normal gait pattern with assistive devices and/or to reduce risk of
fall or loss of balance. This may include instruction in safety and proper use of assistive devices and gait
instruction on uneven surfaces and steps (with or without railings).
(1) Time to produce effect: 1 to 6 sessions
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 2 weeks. Could be needed intermittently as changes in functional status occur.
(4) Maximum duration: 1 month.
d. Neuromuscular Re-education
Neuromuscular 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.
(1) Time to produce effect: 6 treatments
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 4 to 8 weeks
(4) Maximum Duration: 8 to 12 weeks
e. Stress Loading
Stress loading is considered a reflex and sensory integration technique involving the application of a
compressive load and a carry load. It is carried out in a consistent, progressive manner and integrated as
part of a home program. Use of this technique may increase symptoms initially, but symptoms generally
subside with program consistency.
(1) Time to produce effect: 3 weeks
(2) Frequency: 2 to 3 times per week.
(3) Optimum duration: 4 to 6 weeks and concurrent with an active daily home exercise program.
(4) Maximum Duration: 6 to 10 weeks
f. Therapeutic Exercise
Therapeutic exercise, with or without mechanical assistance or resistance, may include isoinertial,
isotonic, isometric and isokinetic types of exercises. Stress loading exercises are recommended.
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 alternative/complementary exercise movement
therapy. Therapeutic exercise programs should be tissue specific to the injury and address general
functional deficits as identified in the diagnosis and clinical assessment. Patients should be instructed in
and receive a home exercise program that progresses as their functional status improves. Upon
discharge, the patient would be independent in the performance of the home exercise program and would
have been educated in the importance of continuing such a program. Educational goals would be to
maintain or further improve function and to minimize the risk for aggravation of symptoms in the future.
(1) Time to produce effect: 3 weeks
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 4 to 8 weeks and concurrent with an active daily home exercise program.
(4) Maximum Duration: 8 to 12 weeks of therapist oversight. Home exercise should continue indefinitely.
14 Therapy — Passive
Most of the following passive therapies and modalities are generally accepted methods of care for a
variety of work-related injuries. Passive therapy includes those treatment modalities that do not require
energy expenditure on the part of the patient. They are principally effective during the early phases of
treatment and are directed at controlling symptoms such as pain, inflammation and swelling and to
improve the rate of healing soft tissue injuries. They should be used adjunctively with active therapies 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.
Factors such as exacerbation of symptoms, re-injury, interrupted continuity of care, and comorbidities
may extend durations of care. Having specific goals with objectively measured functional improvement
during treatment can support extended durations of care. It is recommended that if after 6 to 8 visits no
treatment effect is observed, alternative treatment interventions, further diagnostic studies or further
consultations should be pursued.
Since CRPS and SMP patients frequently have additional myofascial pain generators, other passive
therapies not listed may be used in treatment. Refer to the Chronic Pain guideline for therapies and
timeframe parameters not listed. The following passive therapies are listed in alphabetical order:
a. Continuous Passive Motion
CPM is rarely indicated in CRPS but may occasionally be warranted if the patient shows signs of
contracture despite active therapy.
(1) Time to produce effect: 4 to 6 treatments
(2) Frequency: Varies, between 2 to 3 times per day and 1 time per week.
(3) Optimum duration: 4 treatments
(4) Maximum duration: 6 treatments. Provide home unit with improvement.
b. Fluidotherapy
Used primarily for desensitization and to facilitate increased active range of motion. Thermal heat
conduction and convection is advantageous for vasodilation, muscle relaxation and preparation for stress
and activity (exercise).
(1) Time to produce effect: 3 treatments
(2) Frequency: 3 times per week
(3) Optimum duration: 2 months.
(4) Maximum duration: 2 months as a primary therapy or intermittently as an adjunct therapy to other
procedures.
c. Orthotics/Splinting
Static splinting is discouraged. Dynamic splinting may occasionally be useful in controlling proximal
hypertonicity or for other concurrent pain generators.
(1) Time to produce effect: 1 week
(2) Frequency: varies depending upon application
(3) Optimum duration: 1 month
(4) Maximum duration: 2 months
d. Paraffin Bath
Indications include the need to enhance collagen extensibility before stretching, reduce muscle guarding,
and to prepare for functional restoration activities.
(1) Time to produce effect: 1 to 2 treatments
(2) Frequency: 1 to 3 times per week as an adjunct treatment to other procedures. May use daily if
available at home.
(3) Optimum duration: 2 weeks
(4) Maximum duration: 3 to 4 weeks. If effective, purchase home unit.
e. Desensitization
Desensitization is accomplished through sensory integration techniques. Concurrent desensitization
techniques are generally accepted as a treatment for CRPS. Home techniques using soft cloths of various
textures, massage, and vibrators may be beneficial in reducing allodynia and similar sensory
abnormalities.
(1) Time to produce effect: 6 treatments
(2) Frequency: 3 times per week and concurrent with home exercise program.
(3) Optimum duration: 3 weeks with reinforcement of home program.
(4) Maximum duration: 1 month.
f. Superficial Heat Therapy
Superficial heat is a thermal agent applied to raise the body tissue temperature. It is indicated before
exercise to elevate the pain threshold, alleviate muscle spasm, and promote increased movement. Heat
packs can be used at home as an extension of therapy in the clinic setting.
(1) Time to produce effect: Immediate
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 2 weeks as primary or intermittently as an adjunct to other therapeutic procedures
(4) Maximum duration: 2 weeks. Home use as a primary modality may continue at the providers'
discretion.
I. THERAPEUTIC PROCEDURES - OPERATIVE
When considering operative intervention in chronic pain management, the treating physician must
carefully consider the inherent risk and benefit of the procedure. All operative intervention should be
based on a positive correlation with clinical findings, the clinical course, and diagnostic tests. A
comprehensive assessment of these factors should have led to a specific diagnosis with positive
identification of the pathologic conditions(s).
Surgical procedures are seldom meant to be curative and would be employed in conjunction with other
treatment modalities for maximum functional benefit. Functional benefit should be objectively measured
and includes the following:
a. Return to work or maintaining work status
b. Fewer restrictions at work or performing activities of daily living (ADL).
c. Decrease in usage of medications
d. Measurable functional gains, such as increased range of motion or documented increase in strength.
Education of the patient should include the proposed goals of the surgery, expected gains, risks or
complications, and alternative treatment.
1. Intrathecal Drug Delivery
This mode of therapy delivers small doses of medications directly into the cerebrospinal fluid. Refer to the
Chronic Pain guideline for detailed information and recommendations for its use in CRPS patients with
chronic pain.
2. Neurostimulation
Neurostimulation is the delivery of low-voltage electrical stimulation to the spinal cord or peripheral nerves
to inhibit or block the sensation of pain. Refer to the Chronic Pain guideline for detailed information and
recommendations for its use in CRPS patients with chronic pain.
3. Sympathectomy
Description — Destruction of part of the sympathetic nervous system, which is not generally accepted or
widely used. Long-term success with this pain relief treatment is poor. This procedure requires prior
authorization.
Indications — Single extremity CRPS-I or SMP; distal pain only (should not be done if the proximal
extremity is involved). Local anesthetic Stellate Ganglion Block or Lumbar Sympathetic Block consistently
gives 90 to 100 percent relief each time a technically good block is performed (with measured rise in
temperature). The procedure may be considered for individuals who have limited duration of relief from
blocks. Permanent neurological complications are common.
J. MAINTENANCE MANAGEMENT
Successful management of chronic pain conditions results in fewer relapses requiring intense medical
care. Failure to address long-term management as part of the overall treatment program may lead to
higher costs and greater dependence on the health care system. Management of CRPS and SMP
continues after the patient has met the definition of maximum medical improvement (MMI). MMI is
declared when a patient's condition has plateaued and the authorized treating physician believes no
further medical intervention is likely to result in improved function. When the patient has reached MMI, a
physician must describe in detail the maintenance treatment.
Maintenance care in CRPS and SMP requires a close working relationship between the carrier, the
providers and the patient. Providers and patients have an obligation to design a cost effective, medically
appropriate program that is predictable and allows the carrier to set aside appropriate reserves. Carriers
and adjusters have an obligation to assure that medical providers can plan medically appropriate
programs. A designated primary physician for maintenance team management is recommended.
Maintenance Care will be based on principles of patient self-management. When developing a
maintenance plan of care, the patient, physician and insurer should attempt to meet the following goals:
a. Maximal independence will be achieved through the use of home exercise programs or exercise
programs requiring special facilities (e.g., pool, health club) and educational programs;
b. Modalities will emphasize self management and self-applied treatment;
c. Management of pain or injury exacerbations will emphasize initiation of active therapy techniques and
may occasionally require anesthetic injection blocks.
d. Dependence on treatment provided by practitioners other than the authorized treating physician will be
minimized;
e. Periodic reassessment of the patient's condition will occur as appropriate.
f. Patients will understand that failure to comply with the elements of the self-management program or
therapeutic plan of care may affect consideration of other interventions.
Specific Maintenance Interventions and Parameters
1. Home Exercise Programs and Exercise Equipment
Most patients have the ability to participate in a home exercise program after completion of a supervised
exercise rehabilitation program. Programs should incorporate an exercise prescription including the
continuation of an age-adjusted and diagnosis-specific program for aerobic conditioning, flexibility,
stabilization and strength. Some patients may benefit from the purchase or rental of equipment to
maintain a home exercise program. Determination for the need of home equipment should be based on
medical necessity to maintain MMI, compliance with an independent exercise program, and reasonable
cost. Before the purchase or long-term rental of equipment, the patient should be able to demonstrate the
proper use and effectiveness of the equipment. Effectiveness of equipment should be evaluated on its
ability to improve or maintain functional areas related to activities of daily living or work activity.
Occasionally, compliance evaluations may be made through a 4-week membership at a facility offering
similar equipment. Home exercise programs are most effective when done 3 to 5 times a week.
2. Exercise Programs Requiring Special Facilities
Some patients may have higher compliance with an independent exercise program at a health club
versus participation in a home program. All exercise programs completed through a health club facility
should focus on the same parameters of an age-adjusted and diagnosis-specific program for aerobic
conditioning, flexibility, stabilization and strength. Selection of health club facilities should be limited to
those able to track attendance and utilization, and provide records available for physician and insurer
review. Prior to purchasing a membership, a therapist and or exercise specialist who has treated the
patient may visit the facility with the patient to assure proper use of the equipment.
(1) Frequency: 2 to 3 times per week.
(2) Optimal Duration: 1 to 3 months.
(3) Maximum Maintenance duration: 3 months. Continuation beyond 3 months should be based on
functional benefit and patient compliance. Health club membership should not extend beyond 3
months if attendance drops below 2 times per week on a regular basis.
3. Patient Education Management
Educational classes, sessions, or programs may be necessary to reinforce self-management techniques.
This may be performed as formal or informal programs, either group or individual.
(1) Maintenance duration: 2 to 6 educational sessions during one 12-month period.
4. Psychological Management
An ideal maintenance program will emphasize management options implemented in the following order:
(a) individual self-management (pain control, relaxation and stress management, etc.), (b) group
counseling, (c) individual counseling by a psychologist or psychiatrist, and (d) in-patient treatment.
Aggravation of the injury may require more intense psychological treatment to restore the patient to
baseline. In those cases, use treatments and timeframe parameters listed in the Biofeedback and
Psychological Evaluation or Intervention sections.
(1) Maintenance duration: 6 to 10 visits during one 12-month period.
5. Non-Narcotic Medication Management
In some cases, self-management of pain and injury exacerbations can be handled with medications, such
as those listed in the Medication Section. Physicians must follow patients who are on any chronic
medication or prescription regimen for efficacy and side effects. Laboratory or other testing may be
appropriate to monitor medication effects on organ function.
(1) Maintenance duration: Usually, four medication reviews within a 12-month period. Frequency
depends on the medications prescribed. Laboratory and other monitoring as appropriate.
6. Narcotic Medication Management
As compared with other pain syndromes, there may be a role for chronic augmentation of the
maintenance program with narcotic medications. In selected cases, scheduled medications may prove to
be the most cost effective means of insuring the highest function and quality of life; however,
inappropriate selection of these patients may result in a high degree of iatrogenic illness. A patient should
have met the criteria in opioids section of these guidelines before beginning maintenance narcotics.
Laboratory or other testing may be appropriate to monitor medication effects on organ function. The
following management is suggested for maintenance narcotics:
a. The medications should be clearly linked to improvement of function, not just pain control. All follow up
visits should document the patient's ability to perform routine functions satisfactorily. Examples
include the abilities to: perform work tasks, drive safely, pay bills or perform basic math
operations, remain alert for 10 hours, or participate in normal family and social activities. If the
patient is not maintaining reasonable levels of activity the patient should usually be tapered from
the narcotic and tried on a different long acting opioid.
b. A low dose narcotic medication regimen should be defined, which may minimally increase or decrease
over time. Dosages will need to be adjusted based on side effects of the medication and objective
function of the patient. A patient may frequently be maintained on additional non-narcotic
medications to control side effects, treat mood disorders, or control neuropathic pain; however,
only one long-acting narcotic and one short acting narcotic for rescue use should be prescribed in
most cases.
c. All patients on chronic narcotic medication dosages need to sign an appropriate narcotic contract with
their physician for prescribing the narcotics.
d. The patient must understand that continuation of the medication is contingent on their cooperation with
the maintenance program. Use of non-prescribed drugs may result in tapering of the medication.
The clinician may order random drug testing when deemed appropriate to monitor medication
compliance.
e. Patients on chronic narcotic medication dosages must receive them through one prescribing physician.
(1) Maintenance duration: Up to 12 visits within a 12-month period to review the narcotic plan.
Laboratory and other monitoring as appropriate.
7. Therapy Management
Some treatment may be helpful on a continued basis during maintenance care if the therapy maintains
objective function and decreases medication use. Aggravation of the injury may require intensive
treatment to get the patient back to baseline. In those cases, treatments and timeframe parameters listed
in the Active and Passive Therapy sections apply.
(1) Active Therapy, Acupuncture, and Manipulation maintenance duration: 10 visits in a 12-month period.
8. Injection Therapy
a. Sympathetic Blocks
These injections are considered appropriate if they maintain or increase function for a minimum of 4 to 8
weeks. Maintenance blocks are usually combined with and enhanced by the appropriate
neuropharmacological medication(s) and other care. It is anticipated that the frequency of the
maintenance blocks may increase in the cold winter months or with stress.
(1) Maintenance duration: Not to exceed 6 to 8 blocks in a 12-month period for a single extremity and to
be separated by no less than 4 week intervals. Increased frequency may need to be considered
for multiple extremity involvement or for acute recurrences of pain and symptoms. For treatment
of acute exacerbations, consider 2 to 6 blocks with a short time interval between blocks.
b. Trigger Point Injections
These injections may occasionally be necessary to maintain function in those with myofascial problems.
(1) Maintenance duration: Not more than 4 injections per session not to exceed 3 to 6 sessions per 12month period.
9. Purchase or Rental of Durable Medical Equipment
It is recognized that some patients may require ongoing use of self-directed modalities for the purpose of
maintaining function and or analgesic effect. Purchase or rental of modality based equipment should be
done only if the assessment by the physician and or therapist has determined the effectiveness,
compliance and improved or maintained function by its application. It is generally felt that large expense
purchases such as spas, whirlpools and special mattresses are not necessary to maintain function
beyond the areas listed above.
(1) Maintenance duration: Not to exceed 3 months for rental equipment. Purchase if effective.
RULE XVII, EXHIBIT E Cervical Spine Injury Medical Treatment Guidelines December 1, 2001
(Previously Adopted March 15, 1998) Presented By State of Colorado Department of Labor and
Employment Division of Workers' Compensation
TABLE OF CONTENTS
Cervical Spine Injury Medical Treatment Guideline
SECTION
DESCRIPTION
A.
INTRODUCTION
B.
C.
D.
GENERAL GUIDELINE PRINCIPLES
1.
APPLICATION OF GUIDELINES
2.
EDUCATION
3.
TREATMENT PARAMATER DURATION
4.
ACTIVE INTERVENTIONS
5.
ACTIVE THERAPEUTIC EXERCISE PROGRAM
6.
POSITIVE PATIENT RESPONSE
7.
RE-EVALUATION TREATMENT EVERY 3 TO 4
WEEKS
8.
SURGICAL INTER VENTIONS
9.
SIX-MONTH TIME FRAME
10.
RETURN-TO-WORK
11.
DELAYED RECOVERY
12.
GUIDELINE RECOMMENDATIONS AND
INCLUSION OF MEDICAL EVIDENCE
13.
CARE BEYOND MAXIMUM MEDICAL
IMPROVEMENT (MMI)
INITIAL DIAGNOSTIC PROCEDURES
1.
HISTORY-TAKING AND PHYSICAL
EXAMINATION (HX & PE)
a.
History of Present In
b.
Past History
c.
Physical Examinatio
d.
Spinal Cord Evaluati
e.
Soft Tissue Injury
Evaluation
2.
RADIOGRAPHIC IMAGING
3.
LABORATORY TESTING
FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES
1.
IMAGING STUDIES
a.
Magnetic Resonance
Imaging (MRI)
b.
Computerized Axial
Tomography (CT)
c.
Myelography
d.
CT Myelogram
e.
Lineal Tomography
f.
Bone Scan (Radioiso
Bone Scanning)
g.
Other Radionuclide
Scanning
2.
OTHER TESTS
a.
Personality/Psycholo
/Psychosocial/Evalua
b.
Electrodiagnostic Tes
c.
Injections—Diagnos
3.
d.
e.
SPECIAL TESTS
a.
b.
c.
d.
e.
E.
Discography
Thermography
Computer-Enhanced
Evaluations
Functional Capacity
Evaluation (FCE)
Jobsite Evaluation
Vocational Assessme
Work Tolerance
Screening
THERAPEUTIC PROCEDURES—NON-OPERATIVE
1.
ACUPUNCTURE
a.
Acupuncture
b.
Acupuncture with
Electrical Stimulation
c.
Other Acupuncture
Modalities
2.
BIOFEEDBACK
3.
INJECTIONS—THERAPEUTIC
a.
Therapeutic Spinal
Injections
b.
Facet Rhizotomy (Ra
Frequency Medial Br
Neurotomy)
c.
Occipital Nerve Bloc
a.
Trigger Point Injectio
e.
Prolotherapy
4.
MEDICATIONS
a.
Acetaminophen
b.
Minor
Tranquilizer/Muscle
Relaxants
c.
Narcotics
d.
Nonsteroidal AntiInflammatory Drugs
(NSAIDs)
e.
Oral Steroids
f.
Psychotropic/Antianxiety/Hypnotic Ag
g.
Tramadol
h.
Topical Drug Deliver
5.
OCCUPATIONAL REHABILITATION PROGRA
a.
Non-Interdisciplinary
b.
Interdisciplinary
6.
ORTHOTICS
a.
b.
c.
d.
e.
7.
8.
9.
10.
11.
12.
Cervical Collars
Poster Appliances
Cervicothoracic Orth
Halo Devices
Other Orthosis Devic
and Equipment
PATIENT EDUCATION
PERSONALITY/PSYCHOLOGICAL/PSYCHOSO
AL INTERVENTION
RESTRICTION OF ACTIVITIES
RETURN-TO-WORK
a.
Establishment of a
Return-To-Work Stat
b.
Establishment of Act
Level Restrictions
c.
Compliance with Act
Restrictions
THERAPY—ACTIVE
a.
Activities of Daily L
(ADL)
b.
Functional Activities
c.
Functional Electrical
Stimulation
d.
Cervical Lumbar
Stabilization
e.
Neuromuscular ReEducation
f.
Therapeutic Exercise
THERAPY—PASSIVE
a.
Electrical Stimulation
(Unattended)
b.
Infrared Therapy
c.
Iontophoresis
d.
Manipulation
e.
Massage—Manual o
Mechanical
f.
Mobilization (Joint)
g.
Mobilization (Soft
Tissue)
h.
Superficial Heat and
Therapy
i.
Short-Wave Diatherm
j.
Traction—Manual
k.
Traction—Mechanic
l.
Transcutaneous Elec
Nerve Stimulation
F.
(TENS)
m.
Ultrasound
13.
VOCATIONAL REHABILITATION
THERAPEUTIC PROCEDURES—OPERATIVE
1.
ACUTE FRACTURES & DISLOCATIONS
a.
Halo Immobilization
b.
Anterior or Posterior
Decompression with
Fusion
2.
DISC HERNIATION AND OTHER CERVICAL
CONDITIONS
a.
Cervical Discectomy
or without Fusion
b.
Cervical Corpectomy
c.
Cervical Laminectom
with or without
Foraminotomy or Fu
d.
Cervical Laminoplas
A. INTRODUCTION
This document has been prepared by the Colorado Department of Labor and Employment, Division of
Workers' Compensation (Division) and should be interpreted within the context of guidelines for
physicians/providers treating individuals qualifying under Colorado's Workers' Compensation Act as
injured workers with cervical spine injuries.
Although the primary purpose of this document is advisory and educational, these guidelines are
enforceable under the Workers' Compensation Rules of Procedure, 7 CCR 1101-3. The Division
recognizes that acceptable medical practice may include deviations from these guidelines, as individual
cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of
professional care.
To properly utilize this document, the reader should not skip nor overlook any sections.
B. GENERAL GUIDELINE PRINCIPLES
The principles summarized in this section are key to the intended implementation of all Division of
Workers' Compensation guidelines and critical to the reader's application of the guidelines in this
document.
1. Application of Guidelines
The Division provides procedures to implement medical treatment guidelines and to foster communication
to resolve disputes among the provider, payer and patient through the Worker's Compensation Rules of
Procedure, Rule XVII and Rule VIII. In lieu of more costly litigation, parties may wish to seek
administrative dispute resolution services through the Division.
2. Education
Education of the patient and family, as well as the employer, insurer, policy makers and the community
should be the primary emphasis in the treatment of cervical spine injuries and disability. Currently,
practitioners often think of education last, after medications, manual therapy and surgery. Practitioners
must develop and implement an effective strategy and skills to educate patients, employers, insurance
systems, policy makers and the community as a whole. An education-based paradigm should always start
with inexpensive communication providing reassuring information to the patient. More in-depth education
currently exists within a treatment regime employing functional restorative and innovative programs of
prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or
group patient education as a means of facilitating self-management of symptoms and prevention.
3. Treatment Paramater Duration
Time frames for specific interventions commence once treatments have been initiated, not on the date of
injury. Obviously, duration will be impacted by patient compliance, as well as availability of services.
Clinical judgment may substantiate the need to accelerate or decelerate the time frames discussed in this
document.
4. Active Interventions
Interventions emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment,
are generally emphasized over passive modalities, especially as treatment progresses. Generally,
passive interventions are viewed as a means to facilitate progress in an active rehabilitation program with
concomitant attainment of objective functional gains.
5. Active Therapeutic Exercise Program
Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and
education. This includes functional application in vocational or community settings.
6. Positive Patient Response
Positive results are defined primarily as functional gains that can be objectively measured. Objective
functional gains include, but are not limited to, positional tolerances, range-of-motion, strength,
endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures
that can be quantified. Subjective reports of pain and function should be considered and given relative
weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on
objective findings.
7. Re-Evaluation Treatment Every 3 to 4 Weeks
If a given treatment or modality is not producing positive results within 3 to 4 weeks, the treatment should
be either modified or discontinued. Reconsideration of diagnosis should also occur in the event of poor
response to a seemingly rational intervention.
8. Surgical Interventions
Surgery should be contemplated within the context of expected functional outcome and not purely for the
purpose of pain relief. The concept of “cure” with respect to surgical treatment by itself is generally a
misnomer. All operative interventions must be based upon positive correlation of clinical findings, clinical
course and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific
diagnosis with positive identification of pathologic conditions.
9. Six-Month Time Frame
The prognosis drops precipitously for returning an injured worker to work once he/she has been
temporarily totally disabled for more than six months. The emphasis within these guidelines is to move
patients along a continuum of care and return-to-work within a six-month time frame, whenever possible.
It is important to note that time frames may not be pertinent to injuries that do not involve work-time loss
or are not occupationally related.
10. Return-to-Work
Return-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 written physical limitations and the patient should
never be released to “sedentary” or “light duty.” The following physical limitations should be considered
and modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, bending at the
waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments,
data entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors. Even if there
is residual chronic pain, return-to-work is not necessarily contraindicated.
The practitioner should understand all of the physical demands of the patient's job position before
returning the patient to full duty and should request clarification of the patient's job duties. Clarification
should be obtained from the employer or, if necessary, including, but not limited to, an occupational health
nurse, occupational therapist, vocational rehabilitation specialist, or an industrial hygienist.
11. Delayed Recovery
Strongly consider a psychological evaluation, if not previously provided, as well as initiating
interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to
make expected progress 6 to 12 weeks after an injury. The Division recognizes that 3 to 10% of all
industrially injured patients will not recover within the timelines outlined in this document despite optimal
care. Such individuals may require treatments beyond the limits discussed within this document, but such
treatment will require clear documentation by the authorized treating practitioner focusing on objective
functional gains afforded by further treatment and impact upon prognosis.
12. Guideline Recommendations and Inclusion of Medical Evidence
Guidelines are recommendations based on available evidence and/or consensus recommendations.
When possible, guideline recommendations will note the level of evidence supporting the treatment
recommendation. When interpreting medical evidence statements in the guideline, the following apply:
Consensus means the opinion of experienced professionals based on general medical principles.
Consensus recommendations are designated in the guideline as “generally well accepted,”
“generally accepted,” “acceptable,” or “well established.”
“Some” means the recommendation considered at least one adequate scientific study, which
reported that a treatment was effective.
“Good” means the recommendation considered the availability of multiple adequate scientific
studies or at least one relevant high-quality scientific study, which reported that a treatment was
effective.
“Strong” means the recommendation considered the availability of multiple relevant and high
quality scientific studies, which arrived at similar conclusions about the effectiveness of a
treatment.
All recommendations in the guideline are considered to represent reasonable care in appropriately
selected cases, regardless of the level of evidence or consensus statement attached to it. Those
procedures considered inappropriate, unreasonable, or unnecessary are designated in the guideline as
“not recommended.”
13. Care Beyond Maximum Medical Improvement (MMI)
MMI should be declared when a patient's condition has plateaued to the point where the authorized
treating physician no longer believes further medical intervention is likely to result in improved function.
However, some patients may require treatment after MMI has been declared in order to maintain their
functional state. The recommendations in this guideline are for pre-MMI care and are not intended to limit
post-MMI treatment.
The remainder of this document should be interpreted within the parameters of these guideline principles
that may lead to more optimal medical and functional outcomes for injured workers.
C. INITIAL DIAGNOSTIC PROCEDURES
The Division recommends the following diagnostic procedures be considered, at least initially, the
responsibility of the workers' cornpensation carrier to ensure that an accurate diagnosis and treatment
plan can be established. Standard procedures, that should be utilized when initially diagnosing a workreiated lower extremity complaint, are listed below.
1. History-Taking and Physical Examination (Hx & PE)
History taking and physical examinations 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. History of Present Injury
1) Mechanism of injury. This includes details of symptom onset and progression;
2) Relationship to work. This includes a statement of the probability that the illness or injury is workrelated;
3) Location of pain, nature of symptoms, and alleviating/exacerbating factors, especially if raising the arm
over the head alleviates radicular-type symptoms;
4) Presence of upper and/or lower extremity numbness, weakness, or paresthesias, especially if
precipitated by coughing or sneezing;
5) Prior occupational and non-occupational injuries to the same area including specific prior treatment,
chronic or recurrent symptoms, and any functional limitations. Specific history regarding prior
motor vehicles accidents may be helpful; and
6) Ability to perform job duties and activities of daily living.
b. Past History
1) Past medical history includes neoplasm, arthritis, and diabetes;
2) Review of systems includes symptoms of rheumatologic, neurologic, endocrine, neoplastic, infectious,
and other systemic diseases;
3) Smoking history, and
4) Vocational and recreational pursuits.
c. Physical Examination
This should include accepted tests and exam techniques applicable to the area being examined,
including:
1) Visual inspection, including posture;
2) Cervical range of motion, quality of motion, and presence of muscle spasm. Motion evaluation of
specific joints may be indicated. Range of motion should not be checked in acute trauma cases
until fracture and instability have been ruled out on clinical examination, with or without
radiographic evaluation;
3) Palpation of spinous processes, facets, and muscles noting myofascial tightness, tenderness, and
trigger points;
4) Motor and sensory examination of the upper muscle groups with specific nerve root focus, as well as
sensation to light touch, pin prick, temperature, position and vibration. More than 2 cm difference
in the circumferential measurements of the two upper extremities may indicate chronic muscle
wasting; and
5) Deep tendon reflexes. Asymmetry may indicate pathology. Inverted reflexes (e.g. arm flexion or triceps
tap) may indicate nerve root or spinal cord pathology at the tested level. Pathologic reflexes
include wrist, clonus, grasp reflex, and Hoffman's sign.
d. Spinal Cord Evaluation
In cases where the mechanism of injury, history or clinical presentation suggests a possible severe injury,
additional evaluation is indicated. A full neurological examination for possible spinal cord injury may
include:
1) Sharp and light touch, deep pressure, temperature and proprioceptive sensory function;
2) Strength testing;
3) Anal sphincter tone and or perianal sensation;
4) Presence of pathological reflexes of the upper and lower extremities; or
5) Presence of an Incomplete Spinal Cord Injury Syndrome—
(a) Anterior Cord Syndrome is characterized by the loss of motor function and perception of pain
and temperature below the level of the lesion with preservation of touch, vibration, and
proprioception. This is typically seen after a significant compressive or flexion injury.
Emergent CT or MRI is necessary to look for a possible reversible compressive lesion
requiring immediate surgical intervention. The prognosis for recovery is the worst of the
incomplete syndromes.
(b) Brown-Sequard Syndrome is characterized by ipsilateral motor weakness and proprioceptive
disturbance with contralateral alteration in pain and temperature perception below the
level of the lesion. This is usually seen in cases of penetrating trauma or lateral mass
fracture. Surgery is not specifically required, although debridement of the open wound
may be.
(c) Central Cord Syndrome is characterized by sensory and motor disturbance of all limbs, often
upper extremity more than lower, and loss of bowel and bladder function with
preservation of perianal sensation. This is typically seen in elderly patients with a rigid
spine following hyperextension injuries. Surgery is not usually required.
(d) Posterior Cord Syndrome, a rare condition, is characterized by loss of sensation below the
level of the injury, but intact motor function.
e. Soft Tissue Injury Evaluation
Soft tissue injuries are traumatic injuries to the muscles, ligaments, tendons, and/or connective tissue.
The most common mechanism is sudden hyperextension and/or hyperflexion of the neck.
Acceleration/deceleration on the lateral plane may also result in one of these syndromes. A true cervical
strain is not associated with focal neurological symptoms or signs and pathophysiology of these injuries is
not well understood. Soft tissue injuries may include cervical strain, myofascial syndromes, somatic
dysfunction, and fractures. The Quebec Classification is used to categorize soft tissue and more severe
cervical injuries:
1) Grade I — Neck complaints of pain, stiffness, or tenderness only, without physical signs. Lesion not
serious enough to cause muscle spasm. Includes whiplash injury, minor cervical sprains or
strains.
2) Grade II — Neck complaints with musculoskeletal signs, such as limited range of motion. Includes
muscle spasm related to soft tissue injury, whiplash, cervical sprain, and cervicalgia with
headaches, sprained cervical facet joints and ligaments.
3) Grade III — Neck complaints, such as limited range of motion, combined with neurologic signs.
Includes whiplash, cervicobrachialgia, herniated disc, cervicalgia with headaches.
4) Grade IV — Neck complaints with fracture or dislocation.
2. Radiographic Imaging
Radiographic imaging of the cervical spine is generally accepted, well established and widely used
diagnostic procedure. Basic views are the anterioposterior (AP), lateral, right and left obliques, and
odontioid. Lateral flexion and extension views are done to evaluate instability but may have a limited role
in the acute setting. The mechanism of injury and specific indications for the radiograph should be listed
on the request form to aid the radiologist and x-ray technician. Suggested indications include:
1) History of significant trauma, especially blunt trauma, high impact motor vehicle accident, or fall from
height where fracture, dislocation, instability, or neurologic deficit is suspected - Quebec
Classification Grade III and IV. Alert, non-intoxicated patients who have isolated cervical
complaints without palpable midline cervical tenderness or neurologic findings may not require
radiographic imaging.
2) Age over 55 years.
3) Unexplained or persistent cervical pain for at least 6 weeks or that is worse with rest.
4) Localized pain, fever, constitutional symptoms, suspected tumor, or suspected systemic illness such
as a rheumatic/rheumatoid disorder or endocrinopathy.
3. Laboratory Testing
Laboratory tests are generally accepted well established and widely used procedures. They are, however,
rarely indicated at the time of initial evaluation, unless there is suspicion of systemic illness, infection,
neoplasia, or underlying rheumatologic disorder, connective tissue disorder, or based on history and/or
physical examination. Laboratory tests can provide useful diagnostic information. Tests include, but are
not limited to:
1) CBC with differential can detect infection, blood dyscrasias, and medication side effects;
2) Erythrocyte sedimentation rate, rheumatoid factor, ANA, HLA, and C-reactive protein can be used to
detect evidence of a rheumatologic, infection, or connective tissue disorder;
3) Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect
metabolic bone disease; and
4) Liver and kidney function may be performed for prolonged anti-inflammatory use or other medications
requiring monitoring.
D. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES
One diagnostic imaging procedure may provide the same or distinctive information as obtained by other
procedures. Therefore, prudent choice of procedure(s) for a single diagnostic procedure, a
complementary procedure in combination with other procedures(s), or a proper sequential order in
multiple procedures will ensure maximum diagnostic accuracy; minimize adverse effect to patients and
cost effectiveness by avoiding duplication or redundancy.
All diagnostic imaging procedures have a significant percentage of specificity and sensitivity for various
diagnoses. None is specifically characteristic of a certain diagnosis. Clinical information obtained by
history taking and physical examination should be the basis for selection and interpretation of imaging
procedure results.
Magnetic resonance imaging (MRI), myelography, or CT scanning following myelography may provide
useful information for many spinal disorders. When a diagnostic procedure, in conjunction with clinical
information, provides sufficient information to establish an accurate diagnosis, the second diagnostic
procedure will become a redundant procedure. At the same time, a subsequent diagnostic procedure can
be a complementary diagnostic procedure if the first or preceding procedures, in conjunction with clinical
information, cannot provide an accurate diagnosis. Usually, preference of a procedure over others
depends upon availability, a patient's tolerance and/or the treating practitioner's familiarity with the
procedure.
1. Imaging Studies
Imaging studies are generally accepted, well established and widely used diagnostic procedures. In
general, MRI is the preferred procedure for imaging of cervical nerve root compression or myelopathy.
Imaging usually is not appropriate until conservative therapy has been tried and failed. Six-to-eight weeks
of treatment are usually an adequate period of time before an imaging procedure is in order, but the
clinician should use judgment in this regard. When the findings of the diagnostic imaging and testing
procedures are not consistent with the clinical examination, the clinical findings should have preference.
The studies below are listed in frequency of use, not importance:
a. Magnetic Resonance Imaging (MRI)
MRI is the imaging study of choice for most abnormalities of the cervical spine. MRI is useful in suspected
nerve root compression, in myelopathy to evaluate the spinal cord and/or masses, infections such as
epidural abscesses or disc space infection, bone marrow involvement by metastatic disease, and/or
suspected disc herniation or cord contusion following severe neck injury. MRI should be performed
immediately if there is a question of infection or metastatic disease with cord compression. It is
contraindicated in patients with certain implanted devices.
In general, the high field, conventional, MRI provides better resolution. A lower field scan may be
indicated when a patient cannot fit into a high field scanner or is too claustrophobic despite sedation.
Inadequate resolution on the first scan may require a second MRI using a different technique. All
questions in this regard should be discussed with the MRI center and/or radiologist.
b. Computerized Axial Tomography (CT)
CT provides excellent visualization of bone and is used to further evaluate bony masses and suspected
fractures not clearly identified on radiographic evaluation. It may sometimes be done as a complement to
MRI scanning to better delineate bony osteophyte formation in the neural foramen. CT is usually utilized
for suspected cervical spine fracture in a patient with negative plain films, or to further delineate a cervical
fracture. CT scanning is also quite useful for congenital anomalies at the skull base and at the C1-2
levels. Plain CT scanning is poor for the C6-7 or C7-T1 levels because of shoulder artifact. Instrumentscatter reduction software provides better resolution when metallic artifact is of concern.
c. Myelography
Myelography is the injection of radiopaque material into the spinal subarachnoid space with x-rays then
taken to define anatomy. It may be used as a pre-surgical diagnostic procedure to obtain accurate
information of characteristics, location, and spatial relationships among soft tissue and bony structures.
Myelography is an invasive procedure with complications including nausea, vomiting, headache,
convulsion, arachnoiditis, CSF leakage, allergic reactions, bleeding, and infection. Therefore,
myelography should only be considered when CT and MRI are unavailable, for morbidly obese or
multiple-operated patients, and when other tests prove non-diagnostic in the surgical candidate. The use
of small needles and a less toxic, water-soluble, nonionic contrast is preferred.
d. CT Myelogram
CT myelogram provides more detailed information about relationships between neural elements and
surrounding anatomy and is appropriate in patients with multiple prior operations or tumorous conditions.
e. Lineal Tomography
Lineal tomography is infrequently used, yet may be helpful in the evaluation of bone surfaces, bony
fusion, or pseudoarthrosis.
f. Bone Scan (Radioisotope Bone Scanning)
Bone scanning is generally accepted, well established and widely used. Bone scanning is more sensitive
but less specific than MRI. 99MTechnecium diphosphonate uptake reflects osteoblastic activity and may be
useful in metastatic/primary bone tumors, stress fractures, osteomyelitis, and inflammatory lesions, but
cannot distinguish between these entities. In the cervical spine, the usual indication is for the evaluation of
neoplastic conitions, but can also be used for occult fracture or infection.
g. Other Radionuclide Scanning
Indium and gallium scans are generally accepted, well established, and widely used procedures usually to
help diagnose lesions seen on other diagnostic imaging studies. 67Gallium citrate scans are used to
localize tumor, infection, and abcesses. 111Indium-labeled leukocyte scanning is utilized for localization of
infection or inflammation and is usually not used for the cervical spine.
2. Other Tests
The following studies are listed by frequency of use, not importance:
a. Personality/Psychological/Psychosocial/Evaluation
Personality/psychological/psychosocial evaluations are generally accepted and well-established
diagnostic procedures with selective use in the acute cervical spine injury population, but have more
widespread use in sub-acute and chronic cervical spine populations.
Diagnostic testing procedures may be useful for patients with symptoms of depression, delayed recovery,
chronic pain, recurrent painful conditions, disability problems, and for pre-operative evaluation as well as
a possible predictive value for post-operative response. Psychological testing should provide
differentiation between pre-existing depression versus injury-caused depression, as well as posttraumatic stress disorder.
Formal psychological or psychosocial evaluation should be performed on patients not making expected
progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate with
objective signs and tests. In addition to the customary initial exam, the evaluation of the injured worker
should specifically address the following areas:
1) Employment history;
2) Interpersonal relationships — both social and work;
3) Leisure activities;
4) Current perception of the medical system;
5) Results of current treatment;
6) Perceived locus of control; and
7) Childhood history, including abuse and family history of disability.
Results should provide clinicians with a better understanding of the patient, thus allowing for more
effective rehabilitation. The evaluation will determine the need for further psychosocial interventions, and
in those cases, a DSM IV diagnosis should be determined and documented. An individual with a PhD,
PsyD, or Psychiatric MD/DO credentials may perform initial evaluations, which are generally completed
within one to two hours. When issues of chronic pain are identified, the evaluation should be more
extensive and follow testing procedures as outlined in Division Rule XVII, Exhibit F, Chronic Pain Disorder
Medical Treatment Guideline.
(1) Frequency: One time visit for evaluation. If psychometric testing is indicated as a portion of the initial
evaluation, time for such testing should not exceed an additional two hours of professional time.
b. Electrodiagnostic Testing
Electrodiagnostic tests include, but are not limited to, Electromyography (EMG), Nerve Conduction
Studies (NCS) and Somatosensory Evoked Potentials (SSEP). These are generally accepted, wellestablished and widely used diagnostic procedures. The SSEP study, although generally accepted, has
limited use. Electrodiagnostic studies may be useful for patients with suspected neural involvement
whose symptoms are persistent or unresponsive to initial conservative treatments. They are used to
differentiate peripheral neural deficits from radicular and spinal cord neural deficits and to rule out
concomitant myopathy.
In general, these diagnostic procedures are complementary to imaging procedures such as CT, MRI,
and/or myelography or diagnostic injection procedures. Electrodiagnostic studies may provide useful,
correlative neuropathophysiological information that would be otherwise unobtainable from standard
radiologic studies.
c. Injections — Diagnostic
1) Description — Diagnostic cervical injections are generally accepted, well-established procedures.
These injections may be useful for localizing the source of pain, and may have added therapeutic
value when combined with injection of therapeutic medication(s). Each diagnostic injection has
inherent risk and risk versus benefit should always be evaluated when considering injection
therapy. Since these procedures are invasive, less invasive or non-invasive procedures should be
considered first. Selection of patients, choice of procedure, and localization of the level for
injection should be determined by clinical information indicating strong suspicion for pathologic
condition(s) and the source of pain symptoms.
The interpretation of the test result is primarily based upon pain response; the diagnostic
significance of the test result should be evaluated in conjunction with clinical information and the
results of other diagnostic procedures. Injections with local anesthetics of differing duration are
required to confirm a diagnosis. In some cases, injections at multiple levels may be required to
accurately diagnose cervical pain. Refer to “Injections – Therapeutic” for information on specific
injections.
2) Special Requirements for Diagnostic Injections — Since fluoroscopic, arthrographic and/or CT
guidance during procedures is required to document technique and needle placement; an
experienced physician should perform the procedure. The subspecialty disciplines of the
physicians may be varied, including, but not limited to: anesthesiology, radiology, surgery, or
physiatry. The practitioner should have experience in ongoing injection training workshops
provided by organizations such as the International Spinal Injection Society (ISIS) and be
knowledgeable in radiation safety. In addition, practitioners should obtain fluoroscopy training and
radiation safety credentialing from their Departments of Radiology, as applicable.
3) Complications — General complications of diagnostic injections may include transient neurapraxia,
nerve injury, infection, headache, vasovagal effects, as well as epidural hematoma, permanent
neurologic damage, dural perforation and CSF leakage, and spinal meningeal abscess. Severe
complications are remote but can include spinal cord damage, quadriplegia, and/or death.
4) Contraindications — Absolute contraindications of diagnostic injections include: (a) bacterial infection –
systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions,
and (d) possible pregnancy. Relative contraindications of diagnostic injections may include: (a)
allergy to contrast, (b) poorly controlled Diabetes Mellitus or hypertension, (c) ASA/antiplatelet
therapy (drug may be held for 3 days prior to injection), and (d) shellfish allergy, if contrast to be
used.
5) Specific Diagnostic Injections — In general, relief should last for at least the duration of the local
anesthetic used and give significant relief of pain. Refer to “Injections – Therapeutic” for
information on specific therapeutic injections.
(a) Medial Branch Blocks are primarily diagnostic, used to confirm the diagnosis of cervical facet
pain. When used for diagnosis, two injections at different times with different duration of
local anesthetic are recommended.
(b) Intra-Articular Facet injections are principally diagnostic yet some patients may obtain
therapeutic response. If the patient demonstrates definite short-term but not long-term
response, confirmatory medial branch blocks and possible medial branch neurotomy
should be considered.
(c) Atlanto-Axial and Atlanto-Occipital injections are for diagnosis and treatment but do not lend
themselves to denervation techniques owing to variable neuroanatomy. Injection of this
articulation is complicated by the proximity of the vertebral artery. The vertebral artery
may be tortuous at the level of the C0-C1 joint. Inadvertent injection of the vertebral
artery may cause respiratory arrest, seizure, stroke, or permanent neurological sequelae.
Only practitioners skilled in these injections should perform them.
d. Discography
1) Description — Discography is a generally accepted, well-established invasive diagnostic procedure to
identify a discogenic source of pain for patients who are surgical candidates. Discography should
only be performed by physicians who are experienced and have been proctored in the technique.
2) Indications — Discography may be indicated when a patient has a history of unremitting cervical pain
of greater than three months duration, with or without arm pain, which has been unresponsive to
all conservative interventions. A patient who does not desire surgical intervention is not a
candidate for an invasive nontherapeutic intervention, such as provocative discography.
Discography may prove useful for the evaluation of the pre-surgical spine, such as
pseudoarthrosis, discogenic pain at levels above or below a prior spinal fusion, annular tear, or
internal disc disruption. Discography is not useful in previously operated discs. In addition,
discography may prove useful in evaluation of the number of cervical spine levels that might
require fusion. It has also been utilized to differentiate organic from psychogenic factors. CTDiscography provides further detailed information about morphological abnormalities of the disc
and possible lateral disc herniations.
3) Preconditions for provocative discography include:
(a) A patient with unremitting neck and/or arm pain greater than 3 months duration in whom
conservative treatment has been unsuccessful and in whom the specific diagnosis of the
pain generator has not been made apparent on the basis of other noninvasive imaging
studies (e.g., MRI, CT, plain films, etc.) and in whom a psychosocial evaluation has been
considered.
(b) Patients who are considered surgical candidates (e.g., symptoms are of sufficient magnitude
and the patient has been informed of the possible surgical options that may be available
based upon the results of discography). Discography should never be the sole indication
for surgery.
(c) Informed consent regarding the risks and potential diagnostic benefits of discography has
been obtained.
4) Complications — Include, but are not limited to, discitis, nerve damage, retropharyngeal abscess,
chemical meningitis, pain exacerbation and anaphylaxis may occur with discography. Therefore,
prior to consideration of discography, the patient should undergo other diagnostic modalities in an
effort to define the etiology of the patient's complaint including psychological screening,
myelography, CT and MRI.
5) Contraindications — Contraindications for provocative discography may include: (a) active infection of
any type or continuing antibiotic treatment for infection; and/or (b) bleeding diathesis or
pharmaceutical anticoagulation with warfarin, etc.; and/or (c) significant spinal stenosis at the
level being studied as visualized by MRI, myelography or CT scan; and/or (d) presence of clinical
myelopathy; and/or (e) effacement of the cord, thecal sac or circumferential absence of epidural
fat; and (f) known allergic reactions.
6) Special Considerations:
(a) Discography should not be done by the treating surgeon and the procedure should be carried
out by an experienced individual who has received specialized training in the technique of
provocative discography.
(b) Discography should be performed in a blinded format that avoids leading the patient with
anticipated responses. The procedure should always include one or more disc levels
thought to be normal or nonpainful in order to serve as an internal control. The patient
should not know what level is being injected in order to avoid spurious results. Adjacent
discs may be identified as pain generators in more than half of cases in which discogenic
pain is identified at one level. Because surgery is likely to fail in multi-level discogenic
pain, injection of as many levels as feasible can prevent many operative failures.
(c) Sterile technique should be utilized.
(d) Judicious use of sedation during the procedure is acceptable and represents the most
common practice nationally at the current time and is recommended by most experts in
the field.
(e) CT or MRI must have established cervical spinal dimensions and ruled out spinal stenosis.
(f) Intradiscal injection of local anesthetic should be carried out after the provocative portion of
the examination and the patient's response.
(g) It is recommended that a post-discogram CT be considered as it frequently provides
additional useful information about disc morphology or other pathology.
7) Reporting of Discography — In addition to a narrative report, the discography report should contain a
standardized classification of (a) disc morphology and (b) the pain response. Both results should
be clearly separated in the report from the narrative portion. Asymptomatic annular tears are
common and the concordant pain response is an essential finding for a positive discogram.
Alternative reporting techniques using pressure monitors are being investigated and may prove
useful in identifying patients with discogenic pain.
Caution should be used when interpreting results from discography. In one study of patients
without lumbar pathology, 10 percent of pain-free patients experienced pain with discography and
83 percent of patients with somatization disorder experienced pain with lumbar discography. No
studies have yet been published which measure the frequency of false-positive discography of
the cervical spine.
(a) Reporting disc morphology as visualized by the post-injection CT scan (when available)
should follow the Modified Dallas Discogram Scale where:
Grade 0 = Normal Nucleus
Grade 1 = Annular tear confined to inner one-third of annulus fibrosis.
Grade 2 = Annular tear extending to the middle third of the annulus fibrosis.
Grade 3 = Annular tear extending to the outer one-third of the annulus fibrosis.
Grade 4 = A grade 3 tear plus dissection within the outer annulus to involve more than 30
degrees of the disc circumference.
Grade 5 = Full thickness tear with extra-annular leakage of contrast, either focal or
diffuse.
(b) Reporting of pain response should be according to the modified Aprill Scheme. In this
scheme, codes are assigned a response during the initial injection (“P” provocative
response) and the response to an injection of the local anesthetic (“R” response) where:
P0 = No Pain
P1 = Procedural pain, or pain that is nonconcordant with the patient's familiar pain
P2 = Concordant pain
R0 = No pain relief with injection of local anesthetic
R1 = Partial relief
R2 = Complete relief
N = Non-diagnostic, non-physiologic injection. The final category of “N” is suggested
when the discographer concludes that the provocative portion of the injection is nondiagnostic. For example, a patient with a morphologically normal disc who responds
when typical pain is reproduced is considered to have a non-diagnostic or nonphysiologic response. Other circumstances may occur that cause the discographer to
conclude that the provocative portion of the injection is invalid. The category “N” should
be used for these situations.
(1) Time to produce effect: Immediate
(2) Frequency: One time only
(3) Optimal duration: One time
(4) Maximum duration: Repeat discography is rarely indicated.
e. Thermography
Thermography is an accepted and established procedure, but has limited use as a diagnostic test for
cervical pain. It may be used to diagnose regional pain disorders and in these cases, refer to Division
Rule XVII, Exhibit D, Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome Medical Treatment
Guidelines.
3. Special Tests
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 physical work demand classifications
and tolerance.
a. Computer-Enhanced Evaluations
Computer-enhanced evaluations may include isotonic, isometric, isokinetic and/or isoinertial
measurement of movement, range of motion, 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.
(1) Frequency: One time for evaluation. Can monitor improvements in strength every 3 to 4 weeks up to
a total of 6 evaluations.
b. Functional Capacity Evaluation (FCE)
Functional capacity evaluation is a comprehensive or modified evaluation of the various aspects of
function as they relate to the worker's ability to return to work. Areas such as endurance, lifting (dynamic
and static), postural tolerance, specific range of motion, coordination and strength, worker habits,
employability and financial status, as well as psychosocial aspects of competitive employment may be
evaluated. Components of this evaluation may include: (a) musculoskeletal screen; (b) cardiovascular
profile/aerobic capacity; (c) coordination; (d) lift/carrying analysis; (e) job-specific activity tolerance; (f)
maximum voluntary effort; (g) pain assessment/psychological screening; and (h) non-material and
material handling activities.
(1) Frequency: Can be used initially to determine baseline status. Additional evaluations can be
performed to monitor and assess progress and aid in determining the endpoint for treatment.
c. Jobsite Evaluation
Jobsite evaluation is a comprehensive analysis of the physical, mental and sensory components of a
specific job. These components may include, but are not limited to: (a) postural tolerance (static and
dynamic); (b) aerobic requirements; (c) range of motion; (d) torque/force; (e) lifting/carrying; (f) cognitive
demands; (g) social interactions; (h) visual perceptual; (i) environmental requirements of a job; (j)
repetitiveness; and (k) essential functions of a job. Job descriptions provided by the employer are helpful
but should not be used as a substitute for direct observation.
(1) Frequency: One time with additional visits as needed for follow-up per job site.
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 should not be delayed solely due to lack of attainment of a
vocational assessment.
(1) Frequency: One time with additional visits as needed for follow-up
e. Work Tolerance Screening
Work tolerance screening 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 workrelevant cardiovascular, physical fitness and postural tolerance. It may also address ergonomic issues
affecting the patient's return-to-work potential. May be used when a full Functional Capacity Evaluation is
not indicated.
(1) Frequency: One time for evaluation. May monitor improvements in strength every 3 to 4 weeks up to
a total of 6 evaluations.
E. THERAPEUTIC PROCEDURES — NON-OPERATIVE
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 selfmanagement of symptoms.
Lastly, formal psychological or psychosocial screening should be performed on patients not making
expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate
with objective signs and tests.
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.
1. Acupuncture
Acupuncture is an accepted and widely used procedure for the relief of pain and inflammation and there is
some scientific evidence to support its use. The exact mode of action is only partially understood.
Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the
brain, promotes deep relaxation, and affects the release of neurotransmitters. Acupuncture is commonly
used as an alternative or in addition to traditional Western pharmaceuticals. While it is commonly used
when pain medication is reduced or not tolerated, it may be used as an adjunct to physical rehabilitation
and/or surgical intervention to hasten the return of functional activity. Acupuncture should be performed by
credentialed practitioners.
a. Acupuncture
Acupuncture is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points).
Needles may be inserted, manipulated and retained for a period of time. Acupuncture can be used to
reduce pain, reduce inflammation, increase blood flow, increase range of motion, decrease the side effect
of medication-induced nausea, promote relaxation in an anxious patient, and reduce muscle spasm.
Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical
pain relief, muscle spasm, and scar tissue pain.
(1) Time to produce effect: 3 to 6 treatments
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 1 to 2 months
(4) Maximum duration: 14 treatments
b. Acupuncture with Electrical Stimulation
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.
(1) Time to produce effect: 3 to 6 treatments
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 1 to 2 months
(4) Maximum duration: 14 treatments
c. Other Acupuncture Modalities
Acupuncture treatment is based on individual patient needs and therefore treatment may include a
combination of procedures to enhance treatment effect. Other procedures may include the use of heat,
soft tissue manipulation/massage, and exercise. Refer to Active Therapy (Therapeutic Exercise) and
Passive Therapy sections (Massage and Superficial Heat and Cold Therapy) for a description of these
adjunctive acupuncture modalities.
(1) Time to produce effect: 3 to 6 treatments
(2) Frequency: 1 to 3 times per week
(3) Optimum duration: 1 to 2 months
(4) Maximum 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 treatments must be documented with respect to need and ability to facilitate
positive symptomatic or functional gains. Such care should be re-evaluated and documented with each
series of treatments.
2. Biofeedback
Biofeedback 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.
(1) Time to produce effect: 3 to 4 sessions
(2) Frequency: 1 to 2 times per week
(3) Optimum duration: 5 to 6 sessions
(4) 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.
3. Injections — Therapeutic
a. Therapeutic Spinal Injections
Description — Therapeutic spinal injections are generally accepted, well-established procedures. They
may be used after initial conservative treatment, such as physical and occupational therapy, medication,
manual therapy, exercise, acupuncture etc., has been undertaken. Therapeutic injections should be used
only after pathology has been demonstrated. Injections are invasive procedures that can cause
catastrophic complications thus clinical indications and contraindications should be closely adhered to. A
concomitant therapeutic exercise program should be considered or may be appropriate for patients
receiving therapeutic spinal injections.
Special Considerations — For all cervical injections (excluding trigger point and occipital nerve blocks)
fluoroscopic, arthrographic and/or CT guidance during procedures is required to document technique and
needle placement, and should be performed by a physician experienced in the procedure. The
subspecialty disciplines of the physicians may be varied, including, but not limited to: anesthesiology,
radiology, surgery, or physiatry. The practitioner should participation in ongoing injection training
workshops such as those sponsored by International Society for Injection Studies (ISIS) and be
knowledgeable in radiation safety. In addition, practitioners should obtain fluoroscopy training and
radiation safety credentialing from their Departments of Radiology, as applicable.
Complications — General complications of spinal injections may include (a) transient neurapraxia, local
pain, nerve injury, infection, headache, vasovagal effects; (b) epidural hematoma, permanent neurologic
damage, dural perforation and CSF leakage, spinal meningeal abscess; and or (c) suppression of the
hypothalamic pituitary adrenal axis, which may be steroid dose dependent. Severe complications are
remote but can include spinal cord damage, quadriplegia, and/or death.
Contraindications — Absolute contraindications of therapeutic injections include: (a) bacterial infection systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d)
possible pregnancy. Relative contraindications of diagnostic injections may include: (a) allergy to contrast,
(b) poorly controlled Diabetes Mellitus or hypertension, (c) ASA/antiplatelet therapy (drug may be held for
3 days prior to injection), (d) shellfish allergy, if contrast to be used.
1) Cervical Epidural Steroid Injection (ESI)
(a) Description — Cervical ESIs are injections of corticosteroid into the epidural space. The
purpose of ESI is to reduce pain and inflammation, restoring range of motion and thereby
facilitating progress in more active treatment programs.
(b) Needle placernent — Radiographic guidance with epidurogram is indicated to document
placement and ensure maximal efficacy. Spinal imaging is required for all epidural steroid
injections. Contrast epidurograms allow one to verify the flow of medication into the
epidural space.
(c) Indications — Cervical ESIs are useful in patients with symptoms of cervical radicular pain
syndromes. They have less defined usefulness in non-radicular pain. There is some
evidence that epidural steroid injections are effective for patients with radicular pain or
radiculopathy (sensory or motor loss in a specific dermatome or myotome). Although
there is no evidence regarding the effectiveness of ESI for non-radicular pain, it is a
generally accepted intervention. MRI or CT scans are required before thoracic and
cervical ESIs to assure adequate epidural space.
(1) Time to Produce Effect: Local anesthetic, approximately 30 minutes; corticosteroid,
48 to 72 hours for 80% of patients and 2 weeks for 20%.
(2) Frequency: One or more divided levels can be injected in one session. Whether
injections are repeated depends upon the patient's response to the previous
injection session. Subsequent injection sessions may occur after 1 to 2 weeks if
patient response has been favorable. Injections can be repeated after a hiatus of
three months if the patient has demonstrated functional gain and pain returns or
worsens. If ESIs are repeated in the future, there should be increasing duration
of relief and continued functional gain.
(3) Optimal Duration: Usually 1 to 3 sessions of injection(s), depending upon each
patient's response and functional gain.
(4) Maximum Duration: Up to 3 to 4 sessions of injections may be done as per the
patient's response to pain and function. Patients should be reassessed after each
injection session.
2) Zygoapophyseal (Facet) Injection
(a) Description — Intra-articular or pericapsular injection of local anesthetic and corticosteroid.
There is conflicting evidence to support long-term therapeutic effect using facet injections.
(b) Indications — Facet injections may be considered in those patients whose history and
examination are suggestive of a facet pain generator. The therapeutic value of facet
injections provides short-term pain relief for patients to progress through a functionally
directed rehabilitation program. Facet injections determine level(s) of facet involvement
and the degree of pain coming from the posterior elements. If the patient demonstrates
definite short-term but not long-term response confirmatory medial branch blocks and
possible medial branch neurotomy should be considered.
(1) Time to Produce Effect: Approximately 30 minutes for local anesthetic; 48 to 72 hours
for corticosteroid.
(2) Frequency: 1 to 3 sessions for each joint.
(3) Optimal Duration: 1 to 3 sessions of injections for each joint.
(4) Maximum Duration: 3 intra-synovial or medial branch nerve injections per joint can be
done for facilitating a therapeutic exercise program.
b. Facet Rhizotomy (Radio Frequency Medial Branch Neurotomy)
1) Description — A procedure designed to denervate the facet joint by ablating the periarticular facet
nerve branches. Percutaneous radio-frequency is the method generally used. There is good
evidence to support this procedure in the cervical spine but benefits beyond one year are not yet
established.
2) Indications — Pain of well-documented facet origin, unresponsive to active and/or passive therapy,
manual therapy, and psychosocial evaluation. This procedure is commonly used to provide a
window of pain relief allowing for participation in active therapy. All patients must have a
successful response to diagnostic medial nerve branch blocks. A successful response is
considered to be a 90 percent or greater relief of pain for the length of time appropriate to the
local anesthetic used (i.e., bupivacaine greater than lidocaine). Radio-frequency rhizotomy is the
procedure of choice over alcohol, phenol, or cryoablation. Precise positioning of the probe under
fluoroscopic guidance is recommended, since the maximum effective radius of the device is 2
mm.
3) Complications — Bleeding, infection, or neural injury. The clinician must be aware of the risk of
developing a deafferentation centralized pain syndrome as a complication of this and other
neuroablative procedures.
4) Post-Procedure Therapy — Active active and/or passive therapy. Implementation of a gentle
reconditioning program within the first post-procedure week is recommended, barring
complications. Instruction and participation in a long-term home-based program of ROM,
strengthening, endurance and stability exercises should be done 3 to 4 weeks post-procedure.
c. Occipital Nerve Block
1) Description — Occipital nerve blocks are used both diagnostically and therapeutically in the treatment
of occipital neuralgia. Target is the greater occipital nerve.
2) Indications — Diagnosis and treatment of occipital neuralgia/cephalgia. Peripheral block of the grater
occipital nerve may be appropriate as initial treatment. It may be indicated in patients
unresponsive to peripheral nerve block or in need of additional diagnostic information may
undergo this injection.
3) Complications — Bleeding, infection, neural injury. Post procedural ataxia is common and usually lasts
30 minutes post procedure. Because the occipital artery runs with the occipital nerve, inadvertent
intravascular injection is a risk of this procedure and may lead to systemic toxicity and/or
seizures.
(1) Time to Produce Effect: Approximately 30 minutes for local anesthetic; 48 to 72 hours for
corticosteroid.
(2) Optimal Duration: 1 to 3 sessions for each joint.
(3) Maximum Duration: Continue up to 3 injections if progressive symptomatic and functional
improvement can be documented.
a. Trigger Point Injections
1) Description — Trigger point injection consists of dry needling or injection of local anesthetic with or
without corticosteroid into highly localized, extremely sensitive bands of skeletal muscle fibers
that produce local and referred pain when activated. Medication is injected in a four-quadrant
manner in the area of maximum tenderness. Injection efficacy can be enhanced if injections are
immediately followed by myofascial therapeutic interventions, such as vapo-coolant spray and
stretch, ischemic pressure massage (myotherapy), specific soft tissue mobilization and physical
modalities. The effectiveness of trigger point injection is uncertain, in part due to the difficulty of
demonstrating advantages of active medication over injection of saline. Needling alone may be
responsible for some of the therapeutic response.
2) Indications — Trigger point injections may be used to relieve myofascial pain and facilitate active
therapy and stretching of the affected areas. They are to be used as an adjunctive treatment in
combination with other treatment modalities such as functional restoration programs. Trigger point
injections should be utilized primarily for the purpose of facilitating functional progress. Patients
should continue in an aggressive aerobic and stretching therapeutic exercise program as
tolerated throughout the time period they are undergoing intensive myofascial interventions.
Myofascial pain is often associated with other underlying structural problems and any
abnormalities need to be ruled out prior to injection.
Trigger point injections are indicated in those patients where well circumscribed trigger points
have been consistently observed, demonstrating a local twitch response characteristic radiation
of pain pattern and local autonomic reaction, such as persistent hyperemia following palpation.
Generally, these injections are not necessary unless consistently observed trigger points are not
responding to specific, noninvasive, myofascial interventions within approximately a 6-week time
frame.
3) Complications — Potential but rare complications of trigger point injections include infection,
pneumothorax, anaphylaxis, penetration of viscera, neurapraxia and neuropathy. If corticosteroids
are injected in addition to local anesthetic, there is a risk of local myopathy developing. Severe
pain on injection suggests the possibility of an intraneural injection, and the needle should be
immediately repositioned.
(1) Time to Produce Effect: Local anesthetic 30 minutes; no anesthesia 24 to 48 hours.
(2) Frequency: Weekly, suggest no more than 4 injection sites per session per week to avoid
significant post-injection soreness.
(3) Optimal Duration: 4 Weeks.
(4) Maximum Duration: 8 weeks. Occasional patients may require 2 to 4 repetitions of trigger
point injection series over a 1 to 2 year period.
e. Prolotherapy
Prolotherapy, also known as sclerotherapy, consists of a series of injections of hypertonic dextrose, with
or without glycerine and phenol, into the ligamentous structures of the neck. There is no evidence that
prolotherapy is effective in cervical pain. The injections are invasive, may be painful to the patient, are not
generally accepted or widely used. Therefore, the use of prolotherapy for cervical pain is not
recommended.
4. Medications
Medication use in the treatment of cervical injuries is appropriate for controlling acute and chronic pain
and inflammation. Use of medications will vary widely due to the spectrum of injuries from simple strains
to post-surgical healing. All drugs should be used according to patient needs. A thorough medication
history, including use of alternative and over the counter medications, should be performed at the time of
the initial visit and updated periodically.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are useful in the treatment of
inflammation. These same medications can be used for pain control.
Narcotic medications should be prescribed with strict time, quantity and duration guidelines, and with
definitive cessation parameters. Pain is subjective in nature and should be evaluated using a scale to rate
effectiveness of the narcotic prescribed. Tramadol, a centrally acting non-narcotic, can be useful to
provide pain relief. Other medications, including antidepressants, may be useful in selected patients with
chronic pain.
The following are listed in alphabetical order:
a. Acetaminophen
Acetaminophen is an effective analgesic with antipyretic but not anti-inflammatory activity. Acetaminophen
is generally well tolerated, causes little or no gastrointestinal irritation and is not associated with ulcer
formation. Acetaminophen has been associated with liver toxicity in overdose situations or in chronic
alcohol use.
(1) Optimal duration: 7 to 10 days
(2) Maximum duration: Chronic use as indicated on a case-by-case basis
b. Minor Tranquilizer/Muscle Relaxants
Minor tranquilizer/muscle relaxants are appropriate for muscle spasm, mild pain and sleep disorders.
(1) Optimal duration: 1 week
(2) Maximum duration: 4 weeks
c. Narcotics
Narcotics should be primarily reserved for the treatment of post-surgical or severe cervical pain. There
are circumstances where prolonged use of narcotics is justified based upon specific diagnosis, and in
these cases, it should be documented and justified. Adverse effects include respiratory depression, the
development of physical and psychological dependence, and impaired alertness.
(1) Optimal duration: 3 to 7 days
(2) Maximum duration: 2 weeks. Use beyond two weeks is acceptable in appropriate cases.
d. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs are useful for pain and inflammation. In mild cases, they may be the only drugs required for
analgesia. There are several classes of NSAIDs, and the response of the individual injured worker to a
specific medication is unpredictable. For this reason, a range of NSAIDs may be tried in each case with
the most effective preparation being continued. Patients should be closely monitored for adverse
reactions. Intervals for metabolic screening are dependent upon the patient's age, general health status
and should be within parameters listed for each specific medication. Liver and renal function should be
monitored at least every six months in patients on chronic NSAIDs.
1) Non-Selective Nonsteroidal Anti-Inflammatory Drugs
Includes Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and acetylsalicylic acid (aspirin).
Serious GI toxicity, such as bleeding, perforation, and ulceration can occur at any time, with or
without warning symptoms in patients treated with traditional NSAIDs. Physicians should inform
patients about the signs and/or symptoms of serious gastrointestinal toxicity and what steps to
take if they occur. Anaphylactoid reactions may occur in patients taking NSAIDs. NSAIDs may
interfere with platelet function. Fluid retention and edema have been observed in some patients
taking NSAIDs.
Due to the cross-reactivity between aspirin and NSAIDs, NSAIDs should not be used in aspirinsensitive patients, and should be used with caution in all asthma patients. NSAIDs are associated
with abnormal renal function, including renal failure, as well as abnormal liver function. Certain
NSAIDs may have interactions with various other medications. Individuals may have adverse
events not listed above.
(1) Optimal duration: 1 week
(2) Maximum duration: 1 year
2) Selective Cyclo-oxygenase-2 (COX-2) Inhibitors
Selective cyclo-oxygenase-2 (COX-2) inhibitors are more recent NSAIDs and differ in adverse
side effect profiles from the traditional NSAIDs. The major advantages of selective COX-2
inhibitors over traditional NSAIDs are that they have less gastrointestinal toxicity and no platelet
effect. COX-2 inhibitors can worsen renal function in patients with renal insufficiency, thus renal
function may need monitoring.
COX-2 inhibitors should not be first-line for low risk patients who will be using an NSAID short
term but are indicated in select patients whom traditional NSAIDs are not tolerated or in certain
high-risk patients. Patients most at risk of having a complication from traditional NSAIDs include
patients with a prior history of peptic ulcer disease, gastrointestinal bleeding, gastrointestinal
perforation, or hemophilia, as well as patients with thrombocytopenia or systemic anticoagulation.
Celecoxib is FDA approved for osteoarthritis and rheumatoid arthritis. Rofecoxib is FDA approved
for acute pain and osteoarthritis. Celecoxib is contraindicated in sulfonamide allergic patients.
(1) Optimal duration: 7 to 10 days
(2) Maximum duration: Chronic use is appropriate in individual cases.
e. Oral Steroids
Oral steroids have limited use but are accepted in cases requiring potent anti-inflammatory drug effect
and should not be routinely recommended except in cases of suspected spinal cord compression. There
is strong evidence to support the use of intravenous steroids in blunt spinal cord injury. The risks of
permanent neurological damage from acute spinal cord compression generally outweigh the risks of
pharmacologic side effects of steroids in an emergent situation.
f. Psychotropic/Anti-anxiety/Hypnotic Agents
Psychotropic/anti-anxiety/hypnotic agents may be useful for treatment of mild and chronic pain,
dysesthesias, sleep disorders, and depression. Antidepressant medications, such as tricyclics and
Selective Serotonin Reuptake Inhibitors (SSRIs), are useful for affective disorder and chronic pain
management. Tricyclic antidepressant agents, in low dose, are useful for chronic pain but have more
frequent side effects.
Anti-anxiety medications are best used for short-term treatment (i.e., less than 6 months). Accompanying
sleep disorders are best treated with sedating antidepressants prior to bedtime. Frequently, combinations
of the above agents are useful. As a general rule, physicians should access the patient's prior history of
substance abuse or depression prior to prescribing any of these agents.
(1) Optimal Duration: 1 to 6 months
(2) Maximum duration: 6 to 12 months, with monitoring
g. Tramadol
Tramadol is useful in relief of pain and has been shown to provide pain relief equivalent to that of
commonly prescribed NSAIDs. Although Tramadol may cause impaired alertness, it is generally well
tolerated, does not cause gastrointestinal ulceration, or exacerbate hypertension or congestive heart
failure. Tramadol should be used cautiously in patients who have a history of seizures or who are taking
medication that may lower the seizure threshold, such as MAO inhibiters, SSRIs, and tricyclic
antidepressants. This medication has physically addictive properties and withdrawal may follow abrupt
discontinuation and is not recommended for those with prior opoid addiction.
(1) Optimal Duration: 3 to 7 days
(2) Maximum Duration: 2 weeks. Use beyond 2 weeks is acceptable in appropriate cases.
h. Topical Drug Delivery
Topical drug delivery may be an alternative treatment for localized musculoskeletal disorders and is an
acceptable form of treatment in selected patients although there is no scientific evidence to support its
use in cervical injury. It is necessary that all topical agents be used with strict instructions for application
as well as maximum number of applications per day to obtain the desired benefit and avoid potential
toxicity. As with all medications, patient selection must be rigorous to select those patients with the
highest probability of compliance. Refer to “Iontophoresis” in the Passive Therapy section for information
regarding topical iontophoretic agents.
5. Occupational Rehabilitation Programs
a. 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.
1) Work Conditioning
These programs are usually initiated once reconditioning has been completed but may be offered
at any time throughout the recovery phase. It 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.
(1) Length of visit: 1 to 2 hours per day
(2) Frequency: 2 to 5 visits per week
(3) Optimum duration: 2 to 4 weeks
(4) Maximum duration: 6 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.
2) Work Simulation
Work simulation is a program where an individual completes specific work-related tasks for a
particular job and return to work. Use of this program is appropriate when modified duty can only
be partially accommodated in the work place, when modified duty in the work place is
unavailable, or when the patient requires more structured supervision. The need for work place
simulation should be based upon the results of a Functional Capacity Evaluation and or Jobsite
Analysis.
(1) Length of visit: 2 to 6 hours per day
(2) Frequency: 2 to 5 visits per week
(3) Optimum duration: 2 to 4 weeks
(4) Maximum duration: 6 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.
b. Interdisciplinary
Interdisciplinary programs are characterized by a variety of disciplines that participate in the assessment,
planning, and/or implementation of an injured workers program with the goal for patients to gain full or
optimal function and return to work. There should be close interaction and integration among the
disciplines to ensure that all members of the team interact to achieve team goals. These programs are for
patients with greater levels of perceived disability, dysfunction, deconditioning and psychological
involvement. For patients with chronic pain, refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder
Medical Treatment Guideline.
1) Work Hardening
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, psychological, 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 therapy, physical
therapy, case manager, and psychologist. As appropriate, the team may also include:
chiropractor, RN, or vocational specialist.
(1) Length of visit: up to 8 hours/day
(2) Frequency: 2 to 5 visits per week
(3) Optimal duration: 2 to 4 weeks
(4) Maximum duration: 6 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.
3) Spinal Cord Programs
Spinal Cord Systems of Care provide coordinated, case-managed, and integrated service for
people with spinal cord dysfunction, whether due to trauma or disease. The system includes an
inpatient component in an organization licensed as a hospital and an outpatient component. Each
component endorses the active participation and choice of the persons served throughout the
entire program. The Spinal Cord System of Care also provides or formally links with key
components of care that address the lifelong needs of the persons served.
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 and trained in rehabilitation, a case manager, occupational
therapy, physical therapy, psychologist, rehabilitation RN and MD, and therapeutic recreation
specialist. As appropriate, the team may also include: rehabilitation counselor, respiratory
therapist, social worker, or speech-language pathologist.
Timeframe durations for any spinal cord program should be determined based upon the extent of
the patient's injury and at the discretion of the rehabilitation physician in charge.
6. Orthotics
Primary principles and objectives of the application of cervical orthosis include: (a) control of the position
through the use of control forces; (b) application of corrective forces to abnormal curvatures; (c) aid in
spinal stability when soft tissues or osteoligamenteous structures cannot sufficiently perform their role as
spinal stabilizers; and (d) restrict spinal segment movement after acute trauma or surgical procedure. In
cases of traumatic cervical injury, the most important objective is the protection of the spinal cord and
nerve root.
a. Cervical Collars
1) Soft Collars are well tolerated by most patients but may not significantly restrict motion in any plane
and are associated with delayed recovery. There is no evidence that their use promotes recovery
from cervical sprain. In acute strain/sprain type injuries, use of cervical collars may prolong
disability, limit early mobilization, promote psychological dependence, and limit self-activity. There
is some evidence that patients encouraged to continue usual activity have less neck stiffness and
headache than patients placed in cervical collars following motor vehicle crashes.
2) Rigid Collars, such as a Philadelphia Orthosis, are useful post-operative or in emergency situations.
These collars restrict flexion and extension motion, and to a lesser degree, lateral bending and
rotation. Duration of wear post-surgery is dependent upon the surgeon and degree of cervical
healing but is generally not used beyond 8 weeks.
b. Poster Appliances
Poster appliances, such as the Miami brace, restrict flexion and extension motion to about the same
degree as a Philadelphia collar and to a greater degree, lateral bending and rotation. Not recommended
in sprain or strain injuries.
c. Cervicothoracic Orthosis
Cervicothoracic orthosis, such as Yale and SOMI type braces, restrict flexion and extension motion to a
fuller degree than the Philadelphia collar and to a better degree lateral bending and rotation. Not
recommended in sprain or strain type injuries.
d. Halo Devices
Halo devices are used in the treatment of cervical fracture, dislocation, and instability at the discretion of
the treating surgeon. Refer to Halo Devices in the Operative Treatment section.
e. Other Orthosis Devices and Equipment
Special orthosis or equipment may have a role in the rehabilitation of a cervical injury such as those
injuries to a cervical nerve root resulting in upper extremity weakness or a spinal cord injury with some
degree of paraparesis or tetraparesis. Use of such devices would be in a structured rehabilitation setting
as part of a comprehensive rehabilitation program.
7. Patient Education
No treatment plan is complete without addressing issues of individual and/or group patient 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 be encouraged to take an active role in the
establishment of function outcome goals. They should be educated on their specific injury, assessment
findings, and plan of treatment. Instruction on proper body mechanics and posture, positions to avoid,
self-care for exacerbation of symptoms, and home exercise should also be addressed.
(1) Time to produce effect: Varies with individual patient
(2) Frequency: Should occur at each visit
8. Personality/Psychological/Psychosocial Intervention
Psychosocial treatment is generally accepted, widely used and well established intervention. This group
of therapeutic and diagnostic modalities includes, but is not limited to, individual counseling, group
therapy, stress management, psychosocial crises intervention, hypnosis and meditation. Any screening or
diagnostic workup should clarify and distinguish between preexisting versus aggravated versus purely
causative psychological conditions. Psychosocial intervention is recommended as an important
component in the total management program that should be implemented as soon as the problem is
identified. This can be used alone or in conjunction with other treatment modalities. Providers treating
patients with chronic pain should refer to Division Rule XVII, Exhibit F, Chronic Pain Disorder Medical
Treatment Guideline.
(1) Time to produce effect: 2 to 4 weeks
(2) Frequency: 1 to 3 times weekly for the first 4 weeks (excluding hospitalization, if required), decreasing
to 1 to 2 times per week for the second month. Thereafter, 2 to 4 times monthly.
(3) Optimum duration: 6 weeks to 3 months
(4) Maximum duration: 3 to 12 months. Counseling is not intended to delay but to enhance functional
recovery. For select patients, longer supervised treatment may be required, and if further
counseling beyond 3 months is indicated, extensive documentation addressing which pertinent
issues are preexisting versus aggravated versus causative, as well as projecting a realistic
functional prognosis, should be provided by the authorized treating practitioner every 4 to 6
weeks during treatment.
9. Restriction of Activities
There is some evidence to support the continuation of normal daily activities as the recommended
treatment for acute and chronic cervical injuries without neurologic symptoms. Complete work cessation
should be avoided, if possible, since it often further aggravates the pain presentation. Modified return-towork is almost always more efficacious and rarely contraindicated in the vast majority of injured workers
with cervical spine injuries.
10. Return-to-Work
Early return-to-work should be a prime goal in treating occupational injuries given the poor return-to-work
prognosis for an injured worker who has been out of work for more than six months. It is imperative that
the patient be educated regarding the benefits of return-to-work, restrictions, and follow-up if problems
arise. When attempting to return a patient to work after a specific injury, clear objective restrictions of
activity level should be made. An accurate job description may be necessary to assist the physician in
making return-to-work recommendations.
Return-to-work is defined as any work or duty that the patient is able to perform safely, and it may not be
the patient's regular work. Due to the large spectrum of injuries of varying severity and varying physical
demands in the work place, it is not possible to make specific return-to-work guidelines for each injury.
Therefore, the Division recommends the following:
a. Establishment of a Return-To-Work Status
Ascertaining a return-to-work status is part of medical care, should be included in the treatment and
rehabilitation plan, and addressed at every visit. A description of daily activity limitations is part of any
treatment plan and should be the basis for restriction of work activities. In most non-surgical cases, the
patient should be able to return to work in some capacity or in an alternate position consistent with
medical treatment within several days unless there are extenuating circumstances. Injuries requiring more
than two weeks off work should be thoroughly documented.
b. Establishment of Activity Level Restrictions
Communication is essential between the patient, employer and provider to determine appropriate
restrictions and return-to-work dates. It is the responsibility of the physician to provide clear concise
restrictions, and it the employer's responsibility to determine if temporary duties can be provided within
the restrictions. For cervical spine extremity injuries, the following should be addressed when describing
the patient's activity level:
1) Total body position including upper trunk, especially rotation and flexion. To include duration and
frequency.
2) Upper extremity requirements including reaching above the shoulder, repetitive motions, and lifting or
carrying requirements. Duration and frequency should be included.
3) Sitting duration and frequency with regard to posture, work height(s), and movements of the head and
neck.
4) Visual field requirements in respect to limitations in head and neck movements.
5) Use of adaptive devices or equipment for proper office ergonomics or to enhance capacities can be
included.
c. Compliance with Activity Restrictions
In some cases, compliance with restriction of activity levels may require a complete jobsite evaluation, a
functional capacity evaluation (FCE), or other special testing. Refer to the “Special Tests” section of this
guideline.
11. Therapy — Active
The following active therapies have some evidence to support their use and are widely used and
accepted methods of care for a variety of work-related injuries. They are based on the philosophy that
therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function,
range of motion, and can alleviate discomfort. Active therapy requires an internal effort by the individual to
complete a specific exercise or task. This form of therapy requires supervision from a therapist or medical
provider such as verbal, visual and/or tactile instruction(s). At times, the provider may help stabilize the
patient or guide the movement pattern but the energy required to complete the task is predominately
executed by the patient.
Patients should be instructed to continue active therapies at home as an extension of the treatment
process in order to maintain improvement levels. Home exercise can include exercise with or without
mechanical assistance or resistance and functional activities with assistive devices.
The following active therapies are listed in alphabetical order:
a. Activities of Daily Living (ADL)
Activities of daily living are instruction, active-assisted training and/or adaptation of activities or equipment
to improve a person's capacity in normal daily activities such as self-care, work re-integration training,
homemaking and driving.
(1) Time to produce effect: 4 to 5 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 weeks
b. Functional Activities
Functional activities are the use of therapeutic activity to enhance mobility, body mechanics,
employability, coordination, and sensory motor integration.
(1) Time to produce effect: 4 to 5 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 weeks
c. Functional Electrical Stimulation
Functional electrical stimulation is the application of electrical current to elicit involuntary or assisted
contractions of atrophied and/or impaired muscles. Indications include muscle atrophy, weakness, and
sluggish muscle contraction secondary to pain, injury, neuromuscular dysfunction, peripheral nerve lesion,
or radicular symptoms.
(1) Time to produce effect: 2 to 6 treatments
(2) Frequency: 3 times per week
(3) Optimum duration: 8 weeks.
(4) Maximum duration: 8 weeks. If beneficial, provide with home unit.
d. Cervical Lumbar Stabilization
Cervicial Lumbar stabilization is a therapeutic program whose goal is to strengthen the spine in its neural
and anatomic position. The stabilization is dynamic which allows whole body movements while
maintaining a stabilized spine. It is the ability to move and function normally through postures and
activities without creating undue vertebral stress.
(1) Time to produce effect: 4 to 8 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 4 to 8 weeks
(4) Maximum duration: 8 weeks
e. Neuromuscular Re-Education
Neuromuscular 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.
(1) Time to produce effect: 2 to 6 treatments
(2) Frequency: 3 times per week
(3) Optimum duration: 4 to 8 weeks
(4) Maximum duration: 8 weeks
f. Therapeutic Exercise
Therapeutic exercise, with or without mechanical assistance or resistance, may include isoinertial,
isotonic, isometric and isokinetic types of exercises. Indications include the need for cardiovascular
fitness, reduced edema, improved muscle strength, improved connective tissue strength and integrity,
increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle
recruitment, increased range-of-motion and are used to promote normal movement patterns. Can also
include complementary/alternative exercise movement therapy.
(1) Time to produce effect: 2 to 6 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 4 to 8 weeks
(4) Maximum duration: 8 weeks
12. Therapy — Passive
Most of the following passive therapies and modalities are generally accepted methods of care for a
variety of work-related injuries. Passive therapy includes those treatment modalities that do not require
energy expenditure on the part of the patient. They are principally effective during the early phases of
treatment and are directed at controlling symptoms such as pain, inflammation and swelling and to
improve the rate of healing soft tissue injuries. They should be use adjunctively 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.
While protocols for specific diagnoses and post-surgical conditions may warrant durations of treatment
beyond those listed as “maximum,” factors such as exacerbation of symptoms, re-injury, interrupted
continuity of care, and comorbidities may extend durations of care. Having specific goals with objectively
measured functional improvement during treatment can support extended durations of care. It is
recommended that if after 6 to 8 visits no treatment effect is observed, alternative treatment interventions,
further diagnostic studies or further consultations should be pursued.
The following passive therapies are listed in alphabetical order:
a. Electrical Stimulation (Unattended)
Electrical stimulation, once applied, requires minimal on-site supervision by the physical or nonphysical
provider. Indications include pain, inflammation, muscle spasm, atrophy, decreased circulation, and the
need for osteogenic stimulation.
(1) Time to produce effect: 2 to 4 treatments
(2) Frequency: Varies, depending upon indication, between 2 to 3 times/day to 1 time/week. Provide
home unit if frequent use.
(3) Optimum duration: 1 to 3 months
(4) Maximum duration: 3 months
b. Infrared Therapy
Infrared therapy is a radiant form of heat application. Indications include the need to elevate the pain
threshold before exercise and to alleviate muscle spasm to promote increased movement.
(1) Time to produce effect: 2 to 4 treatments
(2) Frequency: 3 to 5 times per week
(3) Optimum duration: 3 weeks as primary, or intermittently as an adjunct to other therapeutic procedures
up to 2 months
(4) Maximum duration: 2 months
c. Iontophoresis
Iontophoresis 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).
(1) Time to produce effect: 1 to 4 treatments
(2) Frequency: 3 times per week with at least 48 hours between treatments
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 weeks
d. Manipulation
Manipulation is a generally accepted, well-established and widely used therapeutic intervention.
Manipulation can include high velocity, low amplitude (HVLA) technique, chiropractic manipulation,
osteopathic manipulation, muscle energy techniques and non-force techniques. It is performed by taking
a joint to its end range of motion and moving the articulation into the zone of accessory joint movement,
well within the limits of anatomical integrity.
There is good scientific evidence to suggest that manipulation can be effective for relieving pain,
decreasing muscle spasm, and to increase range of motion for patients with cervical pain. There is some
evidence to show that manipulation of the cervical spine can be beneficial for relief of tension-type,
cervicogenic, and migraine headaches. Contraindications include joint instability, fractures, severe
osteoporosis, infection, metastatic cancer, active inflammatory arthridites, and signs of progressive
neurologic deficits, vertebrobasilar insufficiency, or carotid artery disease.
(1) Time to produce effect: 1 to 6 treatments.
(2) Frequency: 1 to 5 times per week for the first 2 weeks as indicated by the severity of involvement and
the desired effect, then 2 to 3 treatments per week for the next 4 weeks, then 1 to 2 treatments
per week for the next 6 weeks.
(3) Optimum duration: 8 to 12 weeks
(4) Maximum duration: 3 months. 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. Care beyond 3 months is indicated for certain chronic
syndromes in which manipulation is helpful in improving function, decreasing pain and improving
quality of life. Such care should be re-evaluated and documented on a monthly basis. Treatment
may include visits 2 times a month through the 7th month post-injury, then on a monthly basis
thereafter through the 10th month post-injury. Care beyond the 10th month should be reviewed and
allowed on a case-by-case basis according to the unique needs of the patient with chronic and/or
permanent injury.
e. Massage — 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
practitioners hands. Indications include edema (peripheral or hard and non-pliable edema), muscle
spasm, adhesions, the need to improve peripheral circulation and range-of-motion, or to increase muscle
relaxation and flexibility prior to exercise.
(1) Time to produce effect: Immediate
(2) Frequency: 1 to 2 times per week
(3) Optimum duration: 6 weeks
(4) Maximum duration: 2 months
f. Mobilization (Joint)
Mobilization is passive movement involving oscillatory motions to the vertebral segment(s). The passive
mobility is performed in a graded manner (I, II, III, IV, or V), which depicts the speed of the maneuver. It
may include skilled manual joint tissue stretching. Indications include the need to improve joint play,
segmental alignment, improve intracapsular arthrokinematics, or reduce pain associated with tissue
impingement. Contraindications include joint instability, fractures, severe osteoporosis, infection,
metastatic cancer, active inflammatory arthridities, aortic aneurysm, and signs of progressive neurologic
deficits.
(1) Time to produce effect: 6 to 9 treatments
(2) Frequency: 3 times per week
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 weeks
g. Mobilization (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.
(1) Time to produce effect: 2 to 3 weeks
(2) Frequency: 2 to 3 times per week
(3) Optimum duration: 4 to 6 weeks
(4) Maximum duration: 6 weeks
h. Superficial Heat and Cold Therapy
Superficial heat and cold 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.
(1) Time to produce effect: Immediate
(2) Frequency: 2 to 5 times per week
(3) Optimum duration: 3 weeks as primary or intermittently as an adjunct to other therapeutic procedures
up to 2 months
(4) Maximum duration: 2 months
i. Short-Wave Diathermy
Short-wave diathermy involves the use of equipment that exposes soft tissue to a magnetic or electrical
field. Indications include enhanced collagen extensibility before stretching, reduced muscle guarding,
reduced inflammatory response and enhanced reabsorption of hemorrhage/hematoma or edema.
(1) Time to produce effect: 2 to 4 treatments
(2) Frequency: 2 to 3 times per week up to 3 weeks
(3) Optimum duration: 3 to 5 weeks
(4) Maximum duration: 5 weeks
j. Traction — Manual
Manual traction is an integral part of manual manipulation or joint mobilization. Indications include
decreased joint space, muscle spasm around joints, and the need for increased synovial nutrition and
response. Manual traction is contraindicated in patients with tumor, infection, fracture, or fracture
dislocation.
(1) Time to produce effect: 1 to 3 sessions
(2) Frequency: 2 to 3 times per week
(3) Optimum duration: 30 days
(4) Maximum duration: 1 month
k. Traction — Mechanical
Mechanical traction is indicated for decreased joint space, muscle spasm around joints, and the need for
increased synovial nutrition and response. Traction modalities are contraindicated in patients with tumor,
infections, fracture or fracture dislocation. Nonoscillating inversion traction methods are contraindicated in
patients with glaucoma or hypertension.
(1) Time to produce effect: 1 to 3 sessions up to 30 minutes. If response is negative after 3 treatments,
discontinue this modality.
(2) Frequency: 2 to 3 times per week
(3) Optimum duration: 4 weeks
(4) Maximum duration: 1 month
l. Transcutaneous Electrical Nerve Stimulation (TENS)
TENS should include least one instructional session for proper application and use. Indications include
muscle spasm, atrophy, and decreased circulation and pain control. Minimal TENS unit parameters
should include pulse rate, pulse width and amplitude modulation.
(1) Time to produce effect: Immediate
(2) Frequency: Variable
(3) Optimum duration: 3 sessions.
(4) Maximum duration: 3 sessions. If beneficial, provide with home unit or purchase if effective.
m. Ultrasound
Ultrasound 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 the
need to extend muscle tissue or accelerate the soft tissue healing. Ultrasound with electrical stimulation is
concurrent delivery of electrical energy that involves dispersive electrode placement. Indications include
muscle spasm, scar tissue, pain modulation and muscle facilitation. Phonophoresis is the transfer of
medication through the use of sonic generators to the target tissue to control inflammation and pain.
These topical medications include, but are not limited to, steroidal anti-inflammatory and anesthetics.
(1) Time to produce effect: 6 to 15 treatments
(2) Frequency: 3 times per week
(3) Optimum duration: 4 to 8 weeks
(4) Maximum duration: 2 months
13. Vocational Rehabilitation
Vocational rehabilitation is a generally accepted intervention, but Colorado limits its use as a result of
Senate Bill 87-79. Initiation of vocational rehabilitation requires adequate evaluation of patients for
quantification 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.
F. THERAPEUTIC PROCEDURES — OPERATIVE
All operative interventions should be based on a positive correlation with clinical findings, the natural
history of the disease, the clinical course, and diagnostic tests. A comprehensive assimilation of these
factors should have led to a specific diagnosis with positive identification of the pathologic condition(s). It
is imperative for the clinician to rule out non-physiologic modifiers of pain presentation, or non-operative
conditions mimicking radiculopathy or instability (peripheral compressive neuropathy, chronic soft tissue
injuries, and psychological conditions), prior to consideration of elective surgical intervention. Patients
who are not candidates for or refuse surgical treatment should be treated with non-operative therapy as
indicated.
In situations requiring the possible need for re-surgery, a second opinion may be necessary.
Psychological evaluation is strongly encouraged to determine if the patient will likely benefit from the
treatment. Structured rehabilitation and psychological evaluation should be strongly considered in patients
not making expected functional progress in the immediate post-operative period.
Return to work activity restrictions should be specific according to the recommendations in the section
“Return to Work.” Most cervical non-fusion surgical patients can return to a limited level of duty between 3
to 6 weeks. Full activity is generally achieved between 6 weeks to 6 months, depending on the procedure
and healing of the individual.
1. Acute Fractures & Dislocations
Decisions regarding the need for surgery in acute traumatic injury will depend on the specific injury type
and possibility of long-term neurologic damage.
a. Halo Immobilization:
1) Description — Intervention that restricts flexion-extension motion. Halo vest will provide significant but
not complete rotational control and is the most effective device for treating unstable injuries to the
cervical spine.
2) Complications — May include pin infection, pin loosening, and palsy of the sixth cranial nerve.
3) Surgical Indications — Cervical fractures requiring the need for nearly complete restriction of rotational
control, and to prevent graft dislodgment, spine malalignment or pseudoarthrosis. Decision for
use of halo is at the discretion of the surgeon based upon the patients' specific injury. Not
indicated for unstable skull fractures or if skin overlying pin sites is traumatized.
4) Operative Treatment — Placement of the pins and apparatus.
5) Post-Operative Therapy — Traction may be required for realignment and or fracture reduction (amount
to be determined by surgeon), active and/or passive therapy, pin care.
b. Anterior or Posterior Decompression with Fusion
1) Description — To provide relief of pressure on the cervical spinal column and alignment and
stabilization of the spine. May involve the use of bone grafts, sometimes combined with metal
devices, to produce a rigid connection between two or more adjacent vertebrae.
2) Complications — Instrumentation failure such as screw loosening, plate failure, or dislodgement (more
common in posterior instrumentation), bone graft donor site pain, in-hospital mortality, deep
wound infection, superficial infection, graft extrusion, CSF leak, laryngeal nerve damage (anterior
approach), and iatrogenic kyphosis.
3) Surgical Indications —When a significant or progressive neurological deficit exists in the presence of
spinal canal compromise. Whether early decompression and reduction of neural structures
enhances neurological recovery continues to be debated. Currently, a reasonable approach
would be to treat non-progressive neurological deficits on a semiurgent basis, when the patient's
systemic condition is medically stable.
4) Operative Treatment — Both anterior and posterior surgical decompression of the cervical spine are
widely accepted. The approach is guided by location of the compressive pathology as well as the
presence of other concomitant injuries. Posterior stabilization and fusion alone may be indicated
for patients who have been realigned with traction and do not have significant canal compromise.
The anterior approach is acceptable if there is disc and/or vertebral body anteriorly compromising
the canal, or be performed posterioly if the compressive pathology arises posteriorly. The
posterior approach is indicated in radiculopathy in the absence of myelopathy and with evidence
of pseudoarthosis on radiographs.
The number of levels involved in the fracture pattern determines the choice between use of wire
techniques versus spinal plates. In injuries treated with an anterior decompression procedure,
anterior bone grafting alone does not provide immediate internal fixation and an anterior cervical
plate is significantly beneficial. Patients who undergo surgery for significant fracture dislocations
of the spine (three column injury) with canal compromise are best managed with anterior cervical
decompression, fusion, and plating but in some cases posterior stabilization and fusion are also
considered. Allografts may be used for single bone graft fusion; however autografts are generally
preferable for multi-level fusions unless a strut graft is required.
5) Post-Operative Treatment — Active and/or passive therapy, cervical bracing. Referral to a formal
rehabilitation program may be appropriate once participation in a home-based fitness program
has been completed. Home programs should include instruction in ADL's, stretching, and sitting,
and a daily walking program.
2. Disc Herniation and other Cervical Conditions
Operative treatment is indicated only when the natural history of a treatable problem is better than the
natural history of benign neglect. All patients being considered for surgical intervention should undergo a
comprehensive neuromuscular examination to identify pain generators that may respond to nonsurgical
techniques or may be refractory to surgical intervention. Timely decision making for operative intervention
is critical to avoid deconditioning, and increased disability of the cervical spine.
General Recommendations — There is some evidence to suggest that recovery from cervical
radiculopathy in patients without clinical signs of spinal cord compression at one year is similar with onelevel fusion, physical therapy, or rigid cervical collar use. For patients with whiplash injury (Quebec
Classification Grade Levels I or II), there is no evidence of any beneficial effect of operative treatment. If
cervical fusion is being considered, it is recommended that the injured worker refrain from smoking for at
least six weeks prior to surgery and during the time of healing.
General Indications for Surgery — Operative intervention should be considered and a consultation
obtained when improvement of symptoms has plateaued and the residual symptoms of pain and
functional disability are unacceptable at the end of six weeks of treatment, or at the end of longer duration
of nonoperative intervention for debilitated patients with complex problems. Choice of hardware
instrumentation is based on anatomy, the patient's pathology, and surgeons experience and preference.
General indications include:
1. For patients with myelopathy, immediate surgical evaluation and treatment is indicated.
2. For patients with cervical radiculopathy, specific indications include:
a. Persistence or recurrent arm pain with functional limitations, unresponsive to conservative
treatment after six weeks; or
b. Progressive functional neurological deficit; or
c. Static neurological deficit associated with significant radicular pain; and
d. Confirmatory imaging studies consistent with clinical findings.
3. For patients with persistent non-radicular cervical pain in the absence of a radiculopathy, it is
recommended that a decisive commitment to surgical or nonsurgical interventions be made within
4 to 5 months following injury. The effectiveness of three-level cervical fusion for non-radicular
pain has not been established. In patients with non-radicular cervical pain for whom fusion is
being considered, required pre-operative indications include all of the following:
a. All pain generators are identified and treated; and
b. All physical medicine and manual therapy interventions are completed; and
c. X-ray, MRI, or CT/discography demonstrating disc pathology or spinal instability; and
d. Spine pathology limited to two levels; and
e. Psychosocial evaluation for confounding issues addressed.
f. For any potential surgery, it is recommended that the injured worker refrain from smoking for at
least six weeks prior to surgery and during the period of healing.
a. Cervical Discectomy with or without Fusion
1) Description — Procedure to relieve pressure on one or more nerve roots or spinal cord.
2) Complications — May include strut graft dislodgment (multi-level decompression), infection,
hemorrhage, CSF leak, hematoma, catastrophic spinal cord injury causing varying degrees of
paralysis, pseudoarthosis, in-hospital mortality, non-union of fusion, donor site pain (autograft
only). Anterior approach: permanent or transient dysphonia, permanent or transitory dysphagia,
denervation, esophageal perforation, and airway obstruction.
3) Surgical Indications — Radiculopathy from ruptured disc or spondylosis, spinal instability, or patients
with non-radicular neck pain meeting fusion criteria. There is no evidence that discectomy with
fusion versus discectomy without fusion has superior long-term results. Discectomy alone is
generally considered in patients with pure radicular symptoms from their herniated disc and who
have sufficiently large foramen that disc space collapse is unlikely to further compromise the
nerve root. Failure rates increase with disease at more than two levels.
4) Operative Treatment — Allografts may be used for single bone graft fusion; however autografts are
generally preferable for multi-level fusions unless a large strut graft is required. Cervical plating
may be used to prevent graft dislodgment especially for multi-level disease.
5) Post-Operative Therapy — Long-term neck bracing (6 to 12 weeks) with fusion. Active and/or passive
therapy. Initial home rehabilitation programs should include instruction in ADL's, posture, and
contain a daily walking program. Referral to a formal rehabilitation program may be appropriate
for most patents at 8 to 16 weeks post-operatively and should be strongly considered in patients
not making expected functional progress in the immediate postoperative period.
b. Cervical Corpectomy
1) Description — Removal of a portion or the entire vertebral body from the front of the spine. May also
include removal of the adjacent discs. Usually involves fusion.
2) Complications — May include strut graft dislodgment (multi-level decompression), infection,
hemorrhage, CSF leak, hematoma, catastrophic spinal cord injury causing varying degrees of
paralysis, pseudoarthosis, in-hospital mortality, non-union of fusion, donor site pain (autograft
only). Anterior approach: permanent or transient dysphonia, permanent or transitory dysphagia,
denervation, esophageal perforation, and airway obstruction.
3) Surgical Indications — Single or two-level spinal stenosis, spondylothesis, or severe kyphosis with
cord compression.
4) Operative Treatment — Neural decompression, fusion with instrumentation, or halo vest placement to
maintain cervical position. Hemicorpectomy may be done when only a portion of the vertebral
body needs to be resected. Allografts may be used for single bone graft fusion; however
autografts are generally preferable for multilevel fusions unless a large strut graft is required.
5) Post-Operative Therapy — Dependent upon number of vertebral bodies involved, healing time longer
than discectomy. Active and/or passive therapy, halo vest care. Initial home rehabilitation
programs should include instruction in ADL's, posture, and contain a daily walking program.
Referral to a formal rehabilitation program may be appropriate for most patents at 8 to 16 weeks
post-operatively and should be strongly considered in patients not making expected functional
progress in the immediate post-operative period.
c. Cervical Laminectomy with or without Foraminotomy or Fusion
1) Description — Surgical removal of the posterior portion of a vertebrae in order to gain access to the
spinal cord or nerve roots.
2) Complications — May include perineural fibrosis, kyphosis in fractures without fusion or with failed
fusion, nerve injury, post surgical instability (with foraminotomies), CSF leak, infection, inhospital
mortality, non-union of fusion, donor site pain (autograft only).
3) Surgical Indications — Neural decompression.
4) Operative Treatment — Laminotomy, partial discectomy, and nerve root decompression.
5) Post-Operative Therapy — Neck bracing, active and/or passive therapy. Initial home rehabilitation
programs should include instruction in ADL's, posture, and contain a daily walking program.
Referral to a formal rehabilitation program may be appropriate for most patents at 8 to 16 weeks
post-operatively and should be strongly considered in patients not making expected functional
progress in the immediate post-operative period.
d. Cervical Laminoplasty
1) Description — Technique that increases anterior or posterior dimensions of the spinal canal while
leaving posterior elements partially intact.
2) Complications — Loss of cervical motion, especially extension.
3) Surgical Indications — Multi-level disease: cervical spinal stenosis or spondylitic myelopathy. Not
indicated in cervical kyphosis.
4) Operative Treatment — Posterior approach, with or without instrumentation.
5) Post-Operative Therapy — Active and/or passive therapy. May include 4 to 12 weeks of bracing. Initial
home rehabilitation programs should include instruction in ADL's, posture, and contain a daily
walking program. Referral to a structured rehabilitation program may be appropriate for most
patents at 8 to 16 weeks post-operatively and should be strongly considered in patients not
making expected functional progress in the immediate post-operative period.
RULE XVII, EXHIBIT F Chronic Pain Disorder Medical Treatment Guidelines July 30, 2003
(Previously Adopted March 15, 1998)
Presented By:
State of Colorado Department of Labor and Employment DIVISION OF WORKERS'
COMPENSATION
TABLE OF CONTENTS
A. INTRODUCTION
B. GENERAL GUIDELINE PRINCIPLES
1. APPLICATION OF GUIDELINES
2. EDUCATION
3. TREATMENT PARAMETER DURATION
4. ACTIVE INTERVENTIONS
5. ACTIVE THERAPEUTIC EXERCISE PROGRAM
6. POSITIVE PATIENT RESPONSE
7. RE-EVALUATION TREATMENT EVERY 3 TO 4 WEEKS
8. SURGICAL INTERVENTIONS
9. SIX-MONTH TIME FRAME
10. RETURN-TO-WORK
11. DELAYED RECOVERY
12. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE
13. TREATMENT OF PREEXISTING CONDITIONS
C. INTRODUCTION TO CHRONIC PAIN
D. DEFINITIONS
E. INITIAL EVALUATION & DIAGNOSTIC PROCEDURES
1. HISTORY AND PHYSICAL EXAMINATION (HX & PE)
2. PERSONALITY/PSYCHOSOCIAL/PSYCHOLOGICAL EVALUATION
3. DIAGNOSTIC STUDIES
4. LABORATORY TESTING
5. INJECTIONS – DIAGNOSTIC
6. SPECIAL TESTS
a. Computer-Enhanced Evaluations
b. Functional Capacity Evaluation (FCE)
c. Job Site Evaluation
d. Vocational Assessment
e. Work Tolerance Screening
F. THERAPEUTIC PROCEDURES — NON-OPERATIVE
1. ACUPUNCTURE
a. Acupuncture
b. Acupuncture with Electrical Stimulation
c. Other Acupuncture Modalities
2. BIOFEEDBACK
3. COMPLEMENTARY ALTERNATIVE MEDICINE (CAM)
4. SLEEP DISTURBANCES
5. INJECTIONS — THERAPEUTIC
a. Epidural Steroid Spinal Injections
b. Zygoapophyseal (Facet) Injection
c. Selective Nerve Root Blocks
d. Trigger point Injections
e. Botulinum Toxin (Botox) Injection
f. Sacroiliac Joint Injection
g. Sympathetic Injections
h. Peripheral Nerve Blocks
6. INTERDISCIPLINARY REHABILITATION PROGRAMS
a. Formal Rehabilitation Programs
b. Informal Rehabilitation Program
7. MEDICATIONS
a. Alpha-Acting Agents
b. Anticonvulsants
c. Antidepressants
d. Hypnotics and Sedatives
e. Skeletal Muscle Relaxants
f. Opioids
g. Non-Steroidal Anti-Inflammatory Drugs
h. Topical Drug Delivery
i. Herbal/Dietary Supplements
j. Other Agents
8. ORTHOTICS/PROSTHETICS/EQUIPMENT
9. PATIENT EDUCATION
10. PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION
11. RESTRICTION OF ACTIVITIES
12. RETURN-TO-WORK
13. THERAPY — ACTIVE
a. Activities of Daily Living (ADL)
b. Aquatic Therapy
c. Functional Activities
d. Functional Electrical Stimulation
e. Lumbar Stabilization
f. Neuromuscular Re-Education
g. Therapeutic Exercise
h. Work Conditioning
i. Work Simulation
14. THERAPY — PASSIVE
a. Electrical Stimulation (Unattended)
b. Infrared Therapy
c. Iontophoresis
d. Manipulation
e. Massage — Manual or Mechanical
f. Mobilization (Joint)
g. Mobilization (Soft Tissue)
h. Superficial Heat and Cold Therapy
i. Traction — Manual
j. Traction — Mechanical
k. Transcutaneous Electrical Nerve Stimulation (TENS)
l. Ultrasound
G. THERAPEUTIC PROCEDURES — OPERATIVE
1. NEUROSTIMULATION
2. INTRATHECAL DRUG DELIVERY
3. NEUROABLATION WITH RHIZOTOMY AS THE EXCEPTION
4. FACET RHIZOTOMY
H. MAINTENANCE MANAGEMENT
1. HOME EXERCISE PROGRAMS AND EXERCISE EQUIPMENT
2. EXERCISE PROGRAMS REQUIRING SPECIAL FACILITIES
3. PATIENT EDUCATION MANAGEMENT
4. PSYCHOLOGICAL MANAGEMENT
5. NON-NARCOTIC MEDICATION MANAGEMENT
6. NARCOTIC MEDICATION MANAGEMENT
7. THERAPY MANAGEMENT
8. INJECTION THERAPY
9. PURCHASE OR RENTAL OF DURABLE MEDICAL EQUIPMENT
A. INTRODUCTION
This document has been prepared by the Colorado Department of Labor and Employment, Division of
Workers' Compensation (Division) and should be interpreted within the context of guidelines for
physicians/providers treating individuals qualifying under Colorado's Workers' Compensation Act as
injured workers with chronic pain.
Although the primary purpose of this document is advisory and educational, these guidelines are
enforceable under the Workers' Compensation Rules of Procedure, 7 CCR 1101-3. The Division
recognizes that acceptable medical practice may include deviations from these guidelines, as individual
cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of
professional care.
To properly utilize this document, the reader should not skip nor overlook any sections.
B. GENERAL GUIDELINE PRINCIPLES
The principles summarized in this section are key to the intended implementation of all Division of
Workers' Compensation guidelines and critical to the reader's application of the guidelines in this
document.
1. Application of Guidelines
The Division provides procedures to implement medical treatment guidelines and to foster communication
to resolve disputes among the provider, payer and patient through the Worker's Compensation Rules of
Procedure, Rule XVII and Rule VIII. In lieu of more costly litigation, parties may wish to seek
administrative dispute resolution services through the Division.
2. Education
Education of the patient and family, as well as the employer, insurer, policy makers and the community
should be the primary emphasis in the treatment of chronic pain and disability. Currently, practitioners
often think of education last, after medications, manual therapy and surgery. Practitioners must develop
and implement an effective strategy and skills to educate patients, employers, insurance systems, policy
makers and the community as a whole. An education-based paradigm should always start with
inexpensive communication providing reassuring information to the patient. More in-depth education
currently exists within a treatment regime employing functional restorative and innovative programs of
prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or
group patient education as a means of facilitating self-management of symptoms and prevention.
3. Treatment Parameter Duration
Timeframes for specific interventions commence once treatments have been initiated, not on the date of
injury. Obviously, duration will be impacted by patient compliance, as well as availability of services.
Clinical judgment may substantiate the need to accelerate or decelerate the timeframes discussed in this
document.
4. Active Interventions
Interventions emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment,
are generally emphasized over passive modalities, especially as treatment progresses. Generally,
passive interventions are viewed as a means to facilitate progress in an active rehabilitation program with
concomitant attainment of objective functional gains.
5. Active Therapeutic Exercise Program
Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and
education. This includes functional application in vocational or community settings.
6. Positive Patient Response
Positive results are defined primarily as functional gains that can be objectively measured. Objective
functional gains include, but are not limited to, positional tolerances, range-of-motion, strength,
endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures
that can be quantified. Subjective reports of pain and function should be considered and given relative
weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on
objective findings.
7. Re-Evaluation Treatment Every 3 to 4 Weeks
If a given treatment or modality is not producing positive results within 3 to 4 weeks, the treatment should
be either modified or discontinued. Reconsideration of diagnosis should also occur in the event of poor
response to a seemingly rational intervention.
8. Surgical Interventions
Surgery should be contemplated within the context of expected functional outcome and not purely for the
purpose of pain relief. The concept of “cure” with respect to surgical treatment by itself is generally a
misnomer. All operative interventions must be based upon positive correlation of clinical findings, clinical
course and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific
diagnosis with positive identification of pathologic conditions.
9. Six-Month Time Frame
The prognosis drops precipitously for returning an injured worker to work once he/she has been
temporarily totally disabled for more than six months. The emphasis within these guidelines is to move
patients along a continuum of care and return-to-work within a six-month timeframe, whenever possible. It
is important to note that timeframes may not be pertinent to injuries that do not involve work-time loss or
are not occupationally related.
10. Return-to-Work
Return-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 written physical limitations and the patient should
never be released to “sedentary” or “light duty.” The following physical limitations should be considered
and modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, overhead work,
bending at the waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold
environments, data entry and other repetitive motion tasks, sustained grip, tool usage and vibration
factors. Even if there is residual chronic pain, return-to-work is not necessarily contraindicated.
The practitioner should understand all of the physical demands of the patient's job position before
returning the patient to full duty and should request clarification of the patient's job duties. Clarification
should be obtained from the employer or, if necessary, including, but not limited to, an occupational health
nurse, occupational therapist, vocational rehabilitation specialist, or an industrial hygienist.
11. Delayed Recovery
Strongly consider a psychological evaluation, if not previously provided, as well as initiating
interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to
make expected progress 6 to 12 weeks after an injury. The Division recognizes that 3 to 10% of all
industrially injured patients will not recover within the timelines outlined in this document despite optimal
care. Such individuals may require treatments beyond the limits discussed within this document, but such
treatment will require clear documentation by the authorized treating practitioner focusing on objective
functional gains afforded by further treatment and impact upon prognosis.
12. Guideline Recommendations and Inclusion of Medical Evidence
Guidelines are recommendations based on available evidence and/or consensus recommendations.
When possible, guideline recommendations will note the level of evidence supporting the treatment
recommendation. When interpreting medical evidence statements in the guideline, the following apply:
Consensus means the opinion of experienced professionals based on general medical principles.
Consensus recommendations are designated in the guideline as “generally well accepted,”
“generally accepted,” “acceptable,” or “well established.”
“Some” means the recommendation considered at least one adequate scientific study, which
reported that a treatment was effective.
“Good” means the recommendation considered the availability of multiple adequate scientific
studies or at least one relevant high-quality scientific study, which reported that a treatment was
effective.
“Strong” means the recommendation considered the availability of multiple relevant and high
quality scientific studies, which arrived at similar conclusions about the effectiveness of a
treatment.
All recommendations in the guideline are considered to represent reasonable care in appropriately
selected cases, regardless of the level of evidence attached to it. Those procedures considered
inappropriate, unreasonable, or unnecessary are designated in the guideline as “not recommended.”
13. Treatment of Preexisting Conditions
Conditions that preexisted the work injury/disease will need to be managed under two circumstances: (a)
A preexisting condition exacerbated by a work injury/disease should be treated until the patient has
returned to their prior level of functioning or MMI; and (b) A preexisting condition not directly caused by a
work injury/disease but which may prevent recovery from that injury should be treated until its negative
impact has been controlled. The focus of treatment should remain on the work injury/disease.
C. INTRODUCTION TO CHRONIC PAIN
The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and
emotional experience with actual or potential tissue damage.” Pain is a complex experience embracing
physical, mental, social and behavioral processes that often compromises the quality of life of many
individuals. Pain is an unpleasant subjective perception usually in the context of tissue damage.
Pain is subjective and cannot be measured or indicated objectively. Pain evokes negative emotional
reactions such as fear, anxiety, anger, and depression. People usually regard pain as an indicator of
physical harm, despite the fact that pain can exist without tissue damage and tissue damage can exist
without pain. Many people report pain in the absence of tissue damage or any likely pathophysiologic
cause. There is no way to distinguish their experience from that due to actual tissue damage. If they
regard their experience as pain and they report it the same way as pain caused by tissue damage, it
should be accepted as pain.
Pain can generally be classified as:
a. Nociceptive, which includes pain from visceral origins or damage to other tissues. Myofascial
pain is a nociceptive type of pain characterized by myofascial trigger points limited to a
specific muscle or muscles.
b. Neuropathic, including that originating from brain, peripheral nerves or both; and
c. Psychogenic, that originates in mood, characterological, social, or psychophysiological
processes.
Recent advances in the neurosciences reveal additional mechanisms involved in chronic pain. In the past,
pain was seen as a sensation arising from the stimulation of pain receptors by damaged tissue, initiating a
sequence of nerve signals ending in the brain and there recognized as pain. A consequence of this model
was that ongoing pain following resolution of tissue damage was seen as less physiological and more
psychological than acute pain with identifiable tissue injury. Current research indicates that chronic pain
involves additional mechanisms that cause: 1) neural remodeling at the level of the spinal cord and higher
levels of the central nervous system; 2) changes in membrane responsiveness and connectivity leading to
activation of larger pain pathways; and 3) recruitment of distinct neurotransmitters.
Changes in gene function and expression may occur, with lasting functional consequences. These
physiologic functional changes cause chronic pain to be experienced in body regions beyond the original
injury and to be exacerbated by little or no stimulation. The chronic pain experience clearly represents
both psychologic and complex physiologic mechanisms, many of which are just beginning to be
understood.
Chronic Pain is defined as “pain that persists for at least 30 days beyond the usual course of an acute
disease or a reasonable time for an injury to heal or that is associated with a chronic pathological process
that causes continuous pain (e.g., reflex sympathetic dystrophy).” The very definition of chronic pain
describes a delay or outright failure to relieve pain associated with some specific illness or accident.
Delayed recovery should prompt a clinical review of the case and a psychological evaluation by the health
care provider. Referral to a recognized pain specialist for further evaluation is recommended.
Consideration may be given to new diagnostic testing or a change in treatment plan.
Use of the term “chronic pain syndrome” has been used and defined in a variety of ways that generally
indicate a belief on the part of the health care provider that the patient's pain is inappropriate or out of
proportion to existing problems or illness. Use of the term “chronic pain syndrome” should be discontinued
because the term ceases to have meaning due to the many different physical and psychosocial issues
associated with it. Instead, practitioners should use the nationally accepted terminology indicated in the
definition section and/or the psychiatric diagnosis of “Pain Disorder” and the subtypes according to
established standards of the American Psychiatric Association.
The IASP offers taxonomy of pain, which underscores the wide variety of pathological conditions
associated with chronic pain. This classification system may not address the psychological and
psychosocial issues that occur in the perception of pain, suffering and disability and may require referral
to psychiatric or psychological clinicians. These issues should be documented with preference to the
diagnostic categories of the Diagnostic and Statistical Manual of Mental Disorders, published by the
American Psychiatric Association, including the subcategories of pain disorder and any other applicable
diagnostic categories (i.e., depressive, anxiety, and adjustment disorders).
Chronic pain is a phenomenon not specifically relegated to anatomical or physiologic parameters. The
prevailing biomedical model (which focuses on identified disease pathology as the sole cause of pain)
cannot capture all of the important variables in pain behavior. While diagnostic labels may pinpoint
contributory physical and/or psychological factors and lead to specific treatment interventions that are
helpful, a large number of patients defy precise taxonomic classification. Furthermore, such diagnostic
labeling often overlooks important social contributions to the chronic pain experience. Failure to address
these operational parameters of the chronic pain experience may lead to incomplete or faulty treatment
plans. The term “pain disorder” is perhaps the most useful term in the medical literature today, in that it
captures the multifactorial nature of the chronic pain experience.
It is recognized that some health care practitioners, by virtue of their experience, additional training and/or
accreditation by pain specialty organizations, have much greater expertise in the area of chronic pain
evaluation and treatment than others. Referrals for the treatment of chronic pain should be to such
recognized specialists. Chronic pain treatment plans should be monitored and coordinated by pain
medicine physicians with such specialty training, in conjunction with other health care specialists.
Most acute and some chronic pain problems are adequately addressed in other Division treatment
guidelines, and are generally beyond the scope of these guidelines. However, because chronic pain is
more often than not multifactorial, involving more than one pathophysiologic or mental disorder, some
overlap with other guidelines is inevitable. These guidelines are meant to apply to any patient who fits the
operational definition of chronic pain discussed at the beginning of this section.
D. DEFINITIONS
a. After Sensation – Refers to the abnormal persistence of a sensory perception, provoked by a stimulus
even though the stimulus has ceased.
b. Allodynia – Pain due to a non-noxious stimulus that does not normally provoke pain.
Mechanical Allodynia – Refers to the abnormal perception of pain from usually non-painful
mechanical stimulation.
Static Mechanical Allodynia – Refers to pain obtained by applying a single stimulus such as light
pressure to a defined area.
Dynamic Mechanical Allodynia – Obtained by moving the stimulus such as a brush or cotton tip
across the abnormal hypersensitive area.
Thermal Allodynia – Refers to the abnormal sensation of pain from usually non-painful thermal
stimulation such as cold or warmth.
c. Analgesia – Absence of pain in response to stimulation that would normally be painful.
d. Biopsychosocial – A term that reflects the multiple facets of any clinical situation; namely, the
biological, psychological, and social situation of the patient.
e. Central Pain – Pain initiated or caused by a primary lesion or dysfunction in the central nervous
system.
f. Central Sensitization – The experience of pain evoked by the excitation of non-nociceptive neurons or
of nerve fibers that normally relay non-painful sensations to the spinal cord. This results when
non-nociceptive afferent neurons act on a sensitized CNS.
g. Dysesthesia – An abnormal sensation described by the patient as unpleasant. As with paresthesia,
dysesthesia may be spontaneous or evoked by maneuvers on physical examination.
h. Hyperalgesia – Refers to an exaggerated pain response from a usually painful stimulation.
i. Hyperesthesia (Positive Sensory Phenomena) – Includes allodynia, hyperalgesia, and hyperpathia.
Elicited by light touch, pin prick, cold, warm, vibration, joint position sensation or two point
discrimination, which is perceived as increased or more.
j. Hyperpathia – Refers to an abnormally painful and exaggerated reaction to stimulus, especially to a
repetitive stimulus.
k. Hypoalgesia – Diminished pain perception in response to a normally painful stimulus.
l. Hypoesthesia (Negative Sensory Phenomena) – Refers to a stimulus such as light touch, pin prick,
cold, point position sensation, two-point discrimination or sensory neglect which is perceived as
decreased.
m. Malingering – Intentional feigning of illness or disability in order to escape work or gain compensation.
n. Myofascial Pain – A regional pain characterized by tender points in taut bands of muscle that produce
pain in a characteristic reference zone.
o. Myofascial Trigger Point – A physical sign in a muscle which includes a) exquisite tenderness in a taut
muscle band; and b) referred pain elicited by mechanical stimulation of the trigger point. The
following findings may be associated with myofascial trigger points: 1) Local twitch or contraction
of the taut band when the trigger point is mechanically stimulated; 2) Reproduction of the patient's
spontaneous pain pattern when the trigger point is mechanically stimulated; 3) Weakness without
muscle atrophy; 4) Restricted range of motion of the affected muscle; and 5) Autonomic
dysfunction associated with the trigger point such as changes in skin or limb temperature.
p. Neuralgia – Pain in the distribution of a nerve or nerves.
q. Neuritis – Inflammation of a nerve or nerves.
r. Neurogenic Pain – Pain initiated or caused by a primary lesion, dysfunction, or transitory perturbation in
the peripheral or central nervous system.
s. Neuropathic Pain – Pain due to an injured or dysfunctional central or peripheral nervous system.
t. Neuropathy – A disturbance of function or pathological change in a nerve: in one nerve,
mononeuropathy; in several nerves, mononeuropathy multiplex; if diffuse and bilateral,
polyneuropathy.
u. Nociceptor – A receptor preferentially sensitive to a noxious stimulus or to a stimulus which would
become noxious if prolonged.
v. Pain Behavior – The non-verbal actions (such as grimacing, groaning, limping, using visible pain
relieving or support devices and requisition of pain medications, among others) that are outward
manifestations of pain, and through which a person may communicate that pain is being
experienced.
w. Pain Threshold – The smallest stimulus perceived by a subject as painful.
x. Paresthesia – An abnormal sensation that is not described as pain. It can be either a spontaneous
sensation (such as pins and needles) or a sensation evoked from non-painful or painful
stimulation, such as light touch, thermal, or pinprick stimulus on physical examination.
y. Peripheral Neurogenic Pain – Pain initiated or caused by a primary lesion or dysfunction or transitory
perturbation in the peripheral nervous system.
z. Peripheral Neuropathic Pain – Pain initiated or caused by a primary lesion or dysfunction in the
peripheral nervous system.
aa. Summation – Refers to abnormally painful sensation to a repeated stimulus although the actual
stimulus remains constant. The patient describes the pain as growing and growing as the same
intensity stimulus continues.
bb. Sympathetically Maintained Pain – A pain that is maintained by sympathetic efferent innervations or
by circulating catecholamines.
cc. Tender Points – Tenderness on palpation at a tendon insertion, muscle belly or over bone. Palpation
should be done with the thumb or forefinger, applying pressure approximately equal to a force of
4 kilograms (blanching of the entire nail bed).
E. INITIAL EVALUATION & DIAGNOSTIC PROCEDURES
The Division 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 workrelated chronic pain complaint are listed below.
1. History and Physical Examination (Hx & PE)
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 patient's current status can be made clear and taken
into account when planning diagnostic evaluation and treatment. One efficient manner in which to obtain
historical information 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. The following item are considered essential
history:
1) General Information – General items requested are name, sex, age, birth date, etc.
2) Level of Education – The level of patients' education may influence response to treatment.
3) 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.
4) Current Employment Status
5) Marital Status
6) 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.
7) 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.
8) Belief System – The patient may refuse various treatments or may have an altered perception
of his pain due to his particular beliefs.
9) Activities of Daily Living – Pain has a multidimensional effect on the patient that is reflected in
changes in usual daily vocational, social, recreational, and sexual activities.
10) Past And Present Psychological Problems
11) History of Abuse – Physical, emotional, sexual.
12) History of Disability in the Family
13) Sleep Disturbances
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.
1) Site of Pain – localization and distribution of the pain help determine the type of pain the
patient has (i.e., central versus peripheral).
2) Pain Drawing/Visual Analog Scale (VAS)
3) Duration
4) Place of onset
5) Pain Characteristics – time of pain occurrence as well as intensity, quality and radiation give
clues to the diagnosis and potential treatment.
6) Response of Pain to Activity
7) Associated Symptoms – Does the patient have numbness or paresthesia, dysesthesia,
weakness, bowel or bladder dysfunction, decreased temperature, increased sweating,
cyanosis or edema? Is there local tenderness, allodynia, hyperesthesia or hyperalgesia?
c. Medical Management History
1) Prior Treatment – What has been tried and which treatments have helped?
2) Prior Surgery – If the patient has had prior surgery specifically for the pain, he/she is less likely
to have a positive outcome.
3) Medications – History of and current use of medications, including over the counter and
herbal/dietary supplements to determine drug usage (or abuse) interactions and efficacy
of treatment.
4) Review of Systems Check List – Determine if there is any interplay between the pain
complaint and other medical conditions.
5) 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. It is recommended that patients diagnosed with Chronic Pain
be referred for a psychosocial evaluation.
6) Diagnostic Tests – All previous radiological and laboratory investigations should be reviewed.
7) Preexisting Conditions – Treatment of these conditions is appropriate when the preexisting
condition affects recovery from chronic pain.
d. Substance Use/Abuse
1) Alcohol use
2) Smoking History
3) History of drug use and abuse.
4) Caffeine or caffeine-containing beverages.
e. Other Factors Affecting Treatment Outcome
1) Compensation/Disability/Litigation
2) Treatment Expectations – What does the patient expect from treatment: complete relief of pain
or reduction to a more tolerable level?
f. Physical Examination
1) Neurologic Evaluation – Cranial nerves, muscle tone and strength, atrophy, upper motor
neuron signs, motor evaluation reflexes, and provocative neurological maneuvers.
2) 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. The examination should determine
if the following sensory signs are present:
a) Hyperalgesia
b) Hyperpathia
c) Paresthesia
d) Dysesthesia
e) Mechanical Allodynia – static versus dynamic
f) Thermal Allodynia
g) Hypoesthesia
h) Hyperesthesia
i) Summation
3) 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 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.
4) Evaluation of Nonphysiologic Findings
a) Waddell's nonorganic findings including: a) superficial or nonorganic tenderness; b)
pseudo maneuvers; c) discrepant straight leg raise; d) nonanatomic sensory
and/or motor examination; and e) overreaction: collapsing, tremor, pain behavior,
muscle tension.
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.
d) Observation of consistencies between pain behavior, affect and verbal pain rating,
and affect and physical re-examination.
2. Personality/Psychosocial/Psychological Evaluation
Psychosocial Evaluations are generally accepted, well-established diagnostic procedures not only with
selected use in acute pain problems, but also with more widespread use in subacute and chronic pain
populations. Diagnostic evaluations should distinguish between conditions that are preexisting,
aggravated by the current injury or work related.
Psychosocial evaluations should determine if further psychosocial 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 their social environment, thus allowing for more effective rehabilitation.
Psychosocial assessment requires consideration of variations in pain experience and expression because
of factors such as gender, age, race, ethnicity, national origin, religion, sexual orientation, disability,
language or socioeconomic status.
Psychometric Testing is a valuable component of a consultation to assist the physician in making a more
effective treatment plan. There is strong evidence that psychometric testing provides unique and useful
information, and that the validity of such tests is comparable to the validity of medical tests.
All patients who are diagnosed as having chronic pain should be referred for a Psychosocial Evaluation
as well as concomitant interdisciplinary rehabilitation treatment whenever appropriate.
a. Qualifications
1) A psychologist with a PhD, PsyD, 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 in
injured workers.
2) Psychometric tests may be administered by psychologists with a PhD, PsyD, or EdD, or by
physicians with appropriate training.
b. Clinical Evaluation – All chronic pain patients should have a clinical evaluation that addresses the
following areas:
1) 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
2) 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
3) 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
4) Psychological test results, if performed
5) Danger to self or others.
6) Current psychiatric diagnosis consistent with the standards of the American Psychiatric
Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).
7) Preexisting psychiatric conditions. Treatment of these conditions is appropriate when the
preexisting condition affects recovery from chronic pain.
8) Causality (to address medically probable cause and effect, distinguishing pre-existing
psychological symptoms, traits and vulnerabilities from current symptoms).
9) Treatment recommendations with respect to specific goals, frequency, timeframes, and
expected outcomes.
c. 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 effec