Code of Colorado Regulations
1100 - Department of Labor and Employment
1101 - Division of Workers' Compensation
7 CCR 1101-3 R17 Ex 03 - Rule 17, Exhibit 3 - THORACIC OUTLET SYNDROME MEDICAL TREATMENT GUIDELINES
Current through Register Vol. 47, No. 17, September 10, 2024
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 injured workers with upper extremity involvement pursuant to the Colorado's Workers' Compensation Act.
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 or overlook any sections.
B. GENERAL GUIDELINES 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.
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.
* Consensus means the judgment of experienced professionals based on general medical principles. Consensus recommendations are designated in the guideline as "generally well-accepted," "generally accepted," "acceptable/accepted," or "well-established."
* "Some" means the recommendation considered at least one adequate scientific study, which reported that a treatment was effective. The Division recognizes that further research is likely to have an impact on the intervention's effect.
* "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. The Division recognizes that further research may have an impact on the intervention's effect.
* "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. The Division recognizes that further research is unlikely to have an important impact on the intervention's effect.
All recommendations in the guideline are considered to represent reasonable care in appropriately selected cases, irrespective of the level of evidence or consensus statement attached to them. Those procedures considered inappropriate, unreasonable, or unnecessary are designated in the guideline as "not recommended."
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 OF THORACIC OUTLET SYNDROME
Thoracic Outlet Syndrome (TOS) may be described as 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 with forward head and shoulder postures. It should be emphasized that occupational TOS is a relatively uncommon disorder and other disorders with similar symptomatology need to be ruled out. (These syndromes can be associated with motor vehicle accident trauma, especially while wearing a shoulder strap).
There are three types of thoracic outlet syndrome. The two vascular types, comprised of subclavian vein or artery pathology, are diagnosed with imaging. Neurogenic TOS (described by some literature as true or classic TOS) consists of a chronic lower trunk brachial plexopathy diagnosed by positive electrodiagnostic testing. It is usually unilateral, predominantly affects women, and results in classic electrophysiologic and physical exam findings such as hand atrophy.
Venous TOS (VTOS) is obstruction of the subclavian vein causing arm swelling. It can be with or without thrombosis. In the workplace, VTOS is usually caused by repetitive activities with the arms above shoulder level. Most workers with this condition also present thrombosis of the subclavian vein. Venous TOS is seldom caused by work-related conditions.
Arterial TOS is usually associated with a cervical rib or anomalous first rib. This is regarded primarily as a predisposing factor. Most people with these ribs never develop symptoms. Precipitating factors in patients with cervical or anomalous ribs are trauma such as motor vehicle accidents or other events causing hyperextension neck injuries. Arterial TOS is rarely a work-related condition.
The majority of patients who present with some physical exam findings of TOS do not have vascular or neurogenic TOS. Their symptoms are caused by myofascial dysfunction. The usual physiologic cause includes abnormal posture, scapular dyskinesis, and pectoralis minor shortening. Myofascial dysfunction with TOS symptoms does not qualify as an operative condition (some literature classifies these cases under the older term of non-specific or disputed TOS). A more general, commonly used diagnostic term for myofascial dysfunction with TOS symptoms is thoracic sprain. Treatment should follow recommendations in the active therapy section. Refer to Section F.11. Therapy-Active.
D. 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 work-related TOS complaint are listed below.
A careful history documenting exacerbating activities and positions which relieve symptoms is essential. Timing of the onset of symptoms is important. TOS has been associated with trauma and motor vehicle accidents. Clavicular fractures can be related. Baseball pitchers may present with TOS symptoms. Avocational pursuits should also be specifically documented. A cervical rib is congenital, and considerations regarding work relatedness should take this into account.
Neurological symptoms are usually consistent. Other neurologic diagnoses should be considered such as other brachial plexus injuries. Neck pain is often the first symptom with complaints within the first few days of injury. Occipital headaches may also occur early. Some patients experience coldness or color changes in the hands. Neurogenic symptoms include the following:
* Sudden onset of swelling suggests a venous blood clot. This is urgent, but not emergent. Requires treatment within 24 hours. Arm viability is NOT threatened.
* This condition is urgent to emergent. Needs attention within 6-12 hours.
Patient-reported outcomes, whether of pain or function, are susceptible to a phenomenon called response shift. This refers to changes in self-evaluation which may accompany changes in health status. Patient self-reports may not coincide with objective measures of outcome, due to reconceptualization of the impact of pain on daily function and internal recalibration of pain scales. Response shift has potential to obscure treatment effects in clinical trials and clinical practice, and may lead to apparent discrepancies in patient-reported outcomes following treatment interventions. While methods of measuring and accounting for response shift are not yet fully developed, understanding that the phenomenon exists can help clinicians understand what is happening when some measures of patient progress appear inconsistent with other measures of progress.
Questionnaires may also be helpful to describe and follow symptoms and to identify coexisting conditions. Examples include Disability of the Arm, Shoulder and Hand (DASH), the Cervical Brachial Symptom Questionnaire, and depression screening such as the Beck depression scale.
In many cases, trauma is the cause of venous and arterial or neurogenic TOS. Clavicular fractures, cervical strain (including whiplash), and other causes of cervical trauma injuries have been associated with TOS. Continual overhead lifting or motion may contribute as can static postures in which the shoulders droop and the head is inclined forward. Activities which cause overdeveloped scalene muscles such as weight-lifting, baseball, rowing and swimming may contribute. The causes of TOS can be placed into 3 general categories: trauma, posture, and repetitive activities.
The Paget-Schroetter syndrome, or effort thrombosis of the subclavian vein, may occur in athletes or workers with repetitive overhead forceful motion and neck extension. It may be caused by microtraumas and by venous stasis induced by mechanical stress on the vein.
Arterial thrombosis or symptoms from subclavian aneurysms or stenosis are usually not related to work or trauma, but are associated with a cervical rib or an anomalous first rib.
Both classic neurogenic TOS (usually due to a cervical or anomalous first rib) and TOS due to arterial compromise from stenosis or aneurysm are rarely work-related conditions.
None of the following anatomical findings are pathognomonic for TOS as they occur frequently in the asymptomatic population also:
* congenital bands and ligaments around the scalene muscles
* a complete or incomplete cervical rib
* interdigitating muscle fibers between the anterior and middle scalene muscles.
Physical examination signs used to diagnose classic or non-specific neurogenic TOS. Both extremities should be examined to compare symptomatic and asymptomatic sides.
Some literature has suggested another provocative elevated arm stress test, Wright's test. The patient holds his arms over head for one minute with elbows extended, wrists in a neutral position, and forearm midway between supination and pronation. If symptoms are reproduced, the test is positive.
A positive response is onset of paresthesia in the hand or pain down the arm. This test is not specific for neurogenic TOS and may be positive in other upper extremity neurogenic conditions.
Suspicion of vascular compromise should lead to confirmation using appropriate imaging procedures.
E. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES
One diagnostic imaging procedure may provide the same or distinctive information as another procedure. Therefore, the prudent choice of a single diagnostic procedure, a complement of procedures or a sequence of procedures will optimize diagnostic accuracy, maximize cost effectiveness (by avoiding redundancy), and minimize potential adverse effects to patients.
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 form the basis for selecting an imaging procedure and interpreting its results.
Practitioners should be aware of the radiation doses associated with various procedures and provide appropriate warnings to patients. Coloradans have a background exposure to radiation, and unnecessary CT scans or X-rays increase the lifetime risk of cancer death.
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.
The diagnosis should be made by comparison to the normal extremity. For bilateral disease, each EMG lab must establish its own absolute limits of latency and amplitude from volunteer controls, so that measurements exceeding these limits can be noted. The EMG and NCV study is an extension of the physical exam. Thus, an electrical diagnosis cannot be made without clinical correlation.
Criteria for True Neurogenic TOS:
Related Studies:
There is some evidence that a latency in the MAC nerve greater than or equal to 2.4 ms and an amplitude less than 10 microvolts may confirm a clinical diagnosis of neurogenic TOS, but need not be a required part of the diagnostic evaluation. There is inadequate evidence that it is a robust diagnostic test for neurogenic TOS, since in this study the clinical examination was used to select patients for surgery even if electrodiagnostic testing is optional.
One study concluded that comparison of the amplitude of sensory nerve action potential of MAC on the injured or non-injured side was comparatively helpful for the diagnosis of TOS; however, the latency difference between the medial antebrachial cutaneous nerve and the ulnar nerve did not differ significantly between the TOS side and the asymptomatic side.
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 post-traumatic 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:
This information should provide clinicians with a better understanding of the patient, and enable a more effective rehabilitation.
The evaluation will determine the need for further psychosocial interventions, and in those cases, a Diagnostic Statistical Manual (DSM) of mental disorders diagnosis should be determined and documented. An individual with a PhD, PsyD, or Psychiatric MD/DO credentials should perform initial evaluations, which are generally completed within one to two hours. A professional fluent in the primary language of the patient is strongly preferred. When such a provider is not available, services of a professional language interpreter must be provided. When issues of chronic pain are identified, the evaluation should be more extensive and follow testing procedures as outlined in the Division's Chronic Pain Disorder Medical Treatment Guidelines.
* 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.
* Frequency: One time for evaluation, one for mid-treatment assessment, and one at final evaluation.
There is some evidence that an FCE fails to predict which injured workers with chronic low back pain will have sustained return to work. Another cohort study concluded that there was a significant relation between FCE information and return to work, but the predictive efficiency was poor. There is some evidence that time off work and gender are important predictors for return to work. Floor-to-waist lifting may also help predict return to work, however, the strength of that relationship has not been determined.
A full review of the literature reveals that there is no evidence to support the use of FCEs to prevent future injuries. There is some evidence in chronic low back pain patients that (1) FCE task performance is weakly related to time on disability and time for claim closure and (2) even claimants who fail on numerous physical performance FCE tasks may be able to return to work.
Full FCEs are rarely necessary. In many cases, a work tolerance screening or return to work performance will identify the ability to perform the necessary job tasks. There is some evidence that a short form FCE reduced to a few tests produces a similar predictive quality compared to the longer 2-day version of the FCE regarding length of disability and recurrence of a claim after return to work.
When an FCE is being used to determine return to a specific jobsite, the provider is responsible for fully understanding the physical demands and the duties of the job the worker is attempting to perform. A jobsite evaluation is usually necessary. A job description should be reviewed by the provider and FCE evaluator prior to having this evaluation performed. FCEs cannot be used in isolation to determine work restrictions. It is expected that the FCE may differ from both self-report of abilities and pure clinical exam findings in chronic pain patients. The length of a return to work evaluation should be based on the judgment of the referring physician and the provider performing the evaluation. Since return to work is a complicated multidimensional issue, multiple factors beyond functional ability and work demands should be considered and measured when attempting determination of readiness or fitness to return to work. FCEs should not be used as the sole criteria to diagnose malingering.
* Frequency: Can be used:
A jobsite evaluation may include observation and instruction of how work is done, what material changes (desk, chair) should be made, and determination of readiness to return to work. 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. Refer to Cumulative Trauma Disorder and Shoulder Guidelines for further suggestions.
Requests for a jobsite evaluation should describe the expected goals for the evaluation. Goals may include, but are not limited to the following:
* Frequency: One time with additional visits as needed for follow-up per jobsite.
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. The physician should have identified the expected permanent limitation(s) prior to the assessment. Declaration of MMI 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.
* Frequency: One time for initial screen. May monitor improvements in strength every 3 to 4 weeks up to a total of 6 visits.
F. THERAPEUTIC PROCEDURES - NON-OPERATIVE
Before initiation of any therapeutic procedure, the authorized treating provider, employer, and insurer must consider these four 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 Section F.10. Return to Work 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 patient education. Before diagnostic tests or referrals for invasive treatment take place, the patient should be able to clearly articulate the goals of the intervention, the general side effects and associated risks, and the patient's agreement with the expected treatment plan. Sleep positions should be addressed to avoid abduction, overhead posture or pressure.
Last, 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.
Home therapy is an important component of therapy and may include active and passive therapeutic procedures, as well as other modalities to assist in alleviating pain, swelling, and abnormal muscle tone.
The following procedures are listed in alphabetical order.
A sham procedure is a non-therapeutic procedure that appears similar to the patient as the purported therapeutic procedure being tested. In most controlled studies, sham and classic acupuncture have produced similar effects. However, the sham controlled studies have shown consistent advantages of both true and sham acupuncture over no acupuncture when the studies have included a third comparison group that was randomized to usual medical care. Having this third comparison group has been advantageous in the interpretation of the non-specific effects of acupuncture, since the third comparison group controls for some influences on study outcome. These influences include more frequent contact with providers, the natural history of the condition, regression to the mean, the effect of being observed in a clinical trial, and, if the follow-up observations are done consistently in all three treatment groups, for biased reporting of outcomes. Controlling for these factors enables researchers to more closely estimate the contextual and personal interactive effects of acupuncture as it is generally practiced.
Because the sham acupuncture interventions in the clinical trials are generally done by trained acupuncturists, and not by totally untrained personnel, the sham acupuncture interventions may include some of the effects of true acupuncture, much as a partial agonist of a drug may produce some of the effects of the actual drug. For example, a sham procedure involving toothpicks rather than acupuncture needles may stimulate cutaneous afferents in spite of not penetrating the skin, much as a neurological sensory examination may test nociceptor function without skin penetration. To the extent that afferent stimulation is part of the mechanism of action of acupuncture, interpreting the sham results as purely a control group would lead to an underestimation of the analgesic effects of acupuncture. Thus, we consider in our analysis that "sham" or non-classic acupuncture may have a positive clinical effect when compared to usual care.
Clinical trials of acupuncture typically enroll participants who are interested in acupuncture, and who may respond to some of the non-specific aspects of the intervention more than would be expected of patients who have no interest in or desire for acupuncture. The non-specific effects of acupuncture may not be produced in patients who have no wish to be referred for it.
Another study provides good evidence that true acupuncture at traditional medians is marginally better than sham acupuncture with blunt needles in reducing pain, but effects on disability are unclear. In these studies 5-15 treatments were provided. Comparisons of acupuncture and sham acupuncture have been inconsistent, and the advantage of true over sham acupuncture has been small in relation to the advantage of sham over no acupuncture.
Acupuncture is recommended for subacute or chronic pain patients who are trying to increase function and/or decrease medication usage and have an expressed interest in this modality. It is also recommended for subacute or acute pain for patients who cannot tolerate nonsteroidal anti-inflammatory drugs (NSAIDs) or other medications. Acupuncture is not the same procedure as dry needling for coding purposes; however, some acupuncturists may use acupuncture treatment for myofascial trigger points. Dry needling is performed specifically on myofascial trigger points. Refer to Section F.3.c. Trigger Point Injections and Dry Needling Treatment.
Credentialed practitioners with experience in evaluation and treatment of chronic pain patients must perform acupuncture evaluations prior to acupuncture treatments. 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 may be used when pain medication is reduced or not tolerated; as an adjunct to physical rehabilitation and surgical intervention; and/or as part of multidisciplinary treatment to hasten the return of functional activity. Acupuncture must be performed by practitioners with the appropriate credentials in accordance with state and other applicable regulations. Therefore, if not otherwise within their professional scope of practice and licensure, those performing acupuncture must have the appropriate credentials, such as L.A.c, R.A.c, or Dipl. Ac.
Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain.
It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.
* Time to Produce Effect: 3 to 6 treatments.
* Frequency: 1 to 3 times per week.
* Optimum Duration: 1 to 2 months.
* Maximum Duration: 15 treatments.
Any of the above acupuncture treatments may extend longer if objective functional gains can be documented and 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 and functional gains. Such care should be re-evaluated and documented with each series of treatments.
Indications for biofeedback include cases of musculoskeletal injury, in which muscle dysfunction or other physiological indicators of excessive or prolonged stress response affects and/or delays recovery. Other applications include training to improve self-management of pain, anxiety, panic, anger or emotional distress, opioid withdrawal, insomnia/sleep disturbance, and other central and autonomic nervous system imbalances. Biofeedback is often utilized for relaxation training. Mental health professionals may also utilize it as a component of psychotherapy, where biofeedback and other behavioral techniques are integrated with psychotherapeutic interventions. Biofeedback is often used in conjunction with physical therapy or medical treatment.
Recognized types of biofeedback include the following:
The goal in biofeedback treatment is normalizing the physiology to the pre-injury status to the extent possible and involves transfer of learned skills to the workplace and daily life. Candidates for biofeedback therapy or training should be motivated to learn and practice biofeedback and self-regulation techniques. In the course of biofeedback treatment, patient stressors are discussed and self-management strategies are devised. If the patient has not been previously evaluated, a psychological evaluation should be performed prior to beginning biofeedback treatment for chronic pain. The psychological evaluation may reveal cognitive difficulties, belief system conflicts, somatic delusions, secondary gain issues, hypochondriasis, and possible biases in patient self-reports, which can affect biofeedback. Home practice of skills is often helpful for mastery and may be facilitated by the use of home training tapes.
Psychologists or psychiatrists who provide psycho-physiological therapy, which integrates biofeedback with psychotherapy, should be either Biofeedback Certification International Alliance (BCIA) certified or practicing within the scope of their training. All non-licensed health care providers of biofeedback for chronic pain patients must be BCIA certified and shall have their biofeedback treatment plan approved by the authorized treating psychologist or psychiatrist. Biofeedback treatment must be done in conjunction with the patient's psychosocial intervention. Biofeedback may also be provided by health care providers who follow a set treatment and educational protocol. Such treatment may utilize standardized material or relaxation tapes.
* Time to Produce Effect: 3 to 4 sessions.
* Frequency: 1 to 2 times per week.
* Optimum Duration: 6 to 8 sessions.
* Maximum Duration: 10 to 12 sessions. Treatment beyond 12 sessions must be documented with respect to need, expectation, and ability to facilitate positive symptomatic and functional gains.
There is some evidence that botulinum toxin type A in a dose of 75U injected into the scalene muscles does not differ appreciably from an injection of placebo in patients with TOS of several years' duration. Therefore, it is not recommended. In addition, because muscle paralysis from the injection can lead to muscle atrophy and other unexpected pathology over time, botulinum toxin is not recommended.
There is no indication for conscious sedation for patients receiving trigger point injections. The patient must be alert to help identify the site of the 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 pain.
Time to produce effect: Local anesthetic 30 minutes; 24 to 48 hours for no anesthesia.
Frequency: Weekly. Suggest no more than 4 injection sites per session per week to avoid significant post-injection soreness.
Optimum duration: 4 Weeks total for all injection sites.
* Maximum duration: 8 weeks total for all injection sites. Occasionally, patients may require 2 to 4 repetitions of trigger point injection series over a 1 to 2 year period.
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 among practices by the authorized treating physician (informal). Formal programs are able to provide a coordinated, high-intensity level of services and are recommended for most chronic pain patients who have received multiple therapies during acute management.
Patients with addiction problems, high-dose opioid use, or use of other drugs of abuse may require inpatient and/or outpatient chemical dependency treatment programs before or in conjunction with other interdisciplinary rehabilitation. Guidelines from the American Society of Addiction Medicine are available and may be consulted relating to the intensity of services required for different classes of patients in order to achieve successful treatment.
Informal interdisciplinary pain programs 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 where formal programs are not available. 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, an occupational rehabilitation program, or an opioid treatment program, the Division recommends the program meets the criteria of the Commission on Accreditation of Rehabilitation Facilities (CARF).
Inpatient pain rehabilitation programs are rarely needed but may be necessary for patients with any of the following conditions:
Whether formal or informal programs, they should be comprised of the following dimensions:
* 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 should be communicated to all and should include the family and/or support system.
* 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.
* 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 and self-monitored passive 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 Section F.11. Therapy - Active and F.12. Therapy - Passive. All treatment timeframes may be extended based on the patient's positive functional improvement.
* Therapeutic Exercise Programs: 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 regimen. There is good evidence that exercise alone or part of a multi-disciplinary program results in decreased disability for workers with non-acute low back pain. There is not sufficient evidence to support the recommendation of any particular exercise regimen.
* Return to Work: The authorized treating physician should continually evaluate the patient for their potential to return to work. For patients currently employed, efforts should be aimed at keeping them employed. Formal rehabilitation programs should provide assistance in creating work profiles. For more specific information regarding return to work, refer to Section F.10. Return to Work.
* 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.
* 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 problem-solving and self-management skills.
* Vocational Assistance: Vocational assistance can define future employment opportunities or assist patients in obtaining future employment. Refer to Section F.10. Return to Work for detailed information.
Interdisciplinary programs are characterized by a variety of disciplines that participate in the assessment, planning, and/or implementation of the treatment program. These programs are for patients with greater levels of perceived disability, dysfunction, de-conditioning, and psychological involvement. Programs should have sufficient personnel to work with the individual in the following areas: behavioral, functional, medical, cognitive, pain management, psychological, social, and vocational.
The interdisciplinary team maintains consistent integration and communication to ensure that all interdisciplinary team members are aware of the plan of care for the patient, are exchanging information, and implement the plan of care. The team members make interdisciplinary team decisions with the patient and then ensure that decisions are communicated to the entire care team.
The Medical Director of the pain program should ideally be board certified in pain management; or he/she should be board certified in his/her specialty area and have completed a one-year fellowship in interdisciplinary pain medicine or palliative care recognized by a national board or have two years of experience in an interdisciplinary pain rehabilitation program. Teams that assist in the accomplishment of functional, physical, psychological, social, and vocational goals must include: a medical director, pain team physician(s), and a pain team psychologist. Professionals from other disciplines on the team may include, but are not limited to: a biofeedback therapist, an occupational therapist, a physical therapist, a registered nurse (RN), a case manager, an exercise physiologist, a psychologist, a psychiatrist, and/or a nutritionist.
* Time to Produce Effect: 3 to 4 weeks.
* Frequency: Full time programs - No less than 5 hours per day, 5 days per week; part-time programs - 4 hours per day, 2-3 days per week.
* Optimum Duration: 3 to 12 weeks at least 2-3 times a week. Follow-up visits weekly or every other week during the first 1 to 2 months after the initial program is completed.
* Maximum Duration: 4 months for full-time programs and up to 6 months for part-time programs. Periodic review and monitoring thereafter for 1 year, AND additional follow-up based on the documented maintenance of functional gains.
There is some evidence that an integrated care program, consisting of workplace interventions and graded activity teaching that pain need not limit activity, is effective in returning patients with chronic low back pain to work, even with minimal reported reduction of pain.
The occupational medicine rehabilitation 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; an occupational therapist; and a physical therapist.
As appropriate, the team may also include any of the following: chiropractor, an RN, a case manager, a psychologist, a vocational specialist, or a certified biofeedback therapist.
* Time to Produce Effect: 2 weeks.
* Frequency: 2 to 5 visits per week, up to 8 hours per day.
* Optimum Duration: 2 to 4 weeks.
* Maximum Duration: 6 weeks. Participation in a program beyond 6 weeks must be documented with respect to need and the ability to facilitate positive symptomatic and functional gains.
This program is different from a formal program in that it involves lower frequency and intensity of services/treatment. Informal rehabilitation is geared toward those patients who do not need the intensity of service offered in a formal program or who cannot attend an all-day program due to employment, daycare, language, or other barriers.
Patients should be referred to professionals experienced in outpatient treatment of chronic pain. The Division recommends the authorized treating physician consult with physicians experienced in the treatment of chronic pain to develop the plan of care. Communication among care providers regarding clear objective goals and progress toward the goals is essential. Employers should be involved in return to work and work restrictions, and the family and/or social support system should be included in the treatment plan. Professionals from other disciplines likely to be involved include: a biofeedback therapist, an occupational therapist, a physical therapist, an RN, a psychologist, a case manager, an exercise physiologist, a psychiatrist, and/or a nutritionist.
* Time to Produce Effect: 3 to 4 weeks.
* Frequency: Full-time programs - No less than 5 hours per day, 5 days per week; Part-time programs - 4 hours per day for 2-3 days per week.
* Optimum Duration: 3 to 12 weeks at least 2-3 times a week. Follow-up visits weekly or every other week during the first 1 to 2 months after the initial program is completed.
* Maximum Duration: 4 months for full-time programs and up to 6 months for part-time programs. Periodic review and monitoring thereafter for 1 year, and additional follow-up based upon the documented maintenance of functional gains.
Thrombolytic agents will be required for some vascular TOS conditions.
Medication use is appropriate for pain control in TOS. 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. Nonsteroidal 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 and anti-convulsants, may be useful in selected patients with neuropathic and/or chronic pain (Refer to the Division's Chronic Pain Medical Treatment Guidelines). Opioids are rarely indicated for treatment of TOS, 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 use of a patient completed pain drawing, visual analog scale (VAS), is highly recommended to help providers track progress. Functional objective goals should be monitored regularly to determine the effectiveness of treatment. The patient should be advised regarding the interaction with prescription and over-the-counter herbal products.
The following medications are listed in alphabetical order:
* Optimum Duration: 7 to 10 days.
* Maximum Duration: Chronic use as indicated on a case-by-case basis. Use of this substance long-term (for 3 days per week or greater) may be associated with rebound pain upon cessation.
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 interacting drugs. There is some evidence that oxcarbazepine (Trileptal) may be effective for neuropathic pain, but dose escalation must be done carefully, since there is good evidence that rapid dose titration produces side-effects greater than the analgesic benefits. Carbamazepine is generally not recommended.
There is an association between older anticonvulsants including gabapentin and non-traumatic fractures for patients older than 50, which should be taken into account when prescribing these medications.
There is some evidence that gabapentin may benefit some patients with post-traumatic neuropathic pain. There is good evidence that gabapentin is not superior to amitriptyline. There is some evidence that nortriptyline and gabapentin are equally effective for pain relief of post herpetic neuralgia. There is some evidence that gabapentin given with morphine may result in lower side effects from morphine and produces greater analgesia at lower doses than those usually required for either medication alone. There is strong evidence that gabapentin is more effective than placebo for neuropathic pain, even though it provides complete pain relief to a minority of patients. There is some evidence that a combination of gabapentin and nortriptyline provides more effective pain relief than monotherapy with either drug. Given the cost of gabapentin, it is recommended that patients who are medically appropriate receive a trial of tricyclics before use of gabapentin.
There is strong evidence that pregabalin has a substantive benefit for a minority, about 25%, of neuropathic pain patients, most of whom report between 30 and 50% relief of symptoms. Given the cost of pregabalin and its response for a minority of patients, it is recommended that patients who are medically appropriate receive a trial of amitriptyline or another first-line agent before use of pregabalin.
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. First line drugs for neuropathic pain are the tricyclics with the newer formulations having better side effect profiles. Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) are considered second line drugs due to their costs and the number needed to treat for a response. Selective serotonin reuptake inhibitors (SSRIs) are used generally for depression rather than neuropathic pain and should not be combined with moderate to high-dose tricyclics.
All patients being considered for anti-depressant therapy should be evaluated and continually monitored for suicidal ideation and mood swings.
(e.g., amitriptyline, nortriptyline, doxepin.
As of the time of this guideline writing, formulations of venlafaxine hydrochloride have been FDA approved for generalized anxiety disorder. There is some evidence it is modestly effective in diabetic neuropathic pain at doses of 150 to 225 mg. There is no evidence of superiority over tricyclics.
As of the time of this guideline writing, formulations of milnacipran have been FDA approved for treatment of fibromyalgia and has a success rate similar to imipramine. It is not recommended in patients as a first or second line treatment and is reserved for patients who fail other regimes due to side effects.
* Optimum Duration: 1 week.
* Maximum Duration: 2 weeks (or longer if used only at night).
Certain NSAIDs may have interactions with various other medications. Individuals may have adverse events not listed above. Intervals for metabolic screening are dependent on the patient's age and general health status and should be within parameters listed for each specific medication. Complete Blood Count (CBC) and liver and renal function should be monitored at least every six months in patients on chronic NSAIDs and initially when indicated.
Includes 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 GI 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.
* Optimum Duration: 1 week.
* Maximum duration: 1 year. Use of these substances long-term (3 days per week or greater) is associated with rebound pain upon cessation.
COX-2 inhibitors differ from the traditional NSAIDs in adverse side effect profiles. The major advantages of selective COX-2 inhibitors over traditional NSAIDs are that they have less GI toxicity and no platelet effects. 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 for whom traditional NSAIDs are not tolerated. Serious upper GI adverse events can occur even in asymptomatic patients. Patients at high risk for GI bleed include those who use alcohol, smoke, are older than 65, take corticosteroids or anti-coagulants, or have a longer duration of therapy. Celecoxib is contraindicated in sulfonamide allergic patients.
* Optimal Duration: 7 to 10 days.
* Maximum Duration: Chronic use is appropriate in individual cases. Use of these substances long-term (3 days per week or greater) is associated with rebound pain upon cessation.
Opioids 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 pain scale and assessment of function to rate effectiveness of the opioid prescribed. Any use beyond the maximum should be documented and justified based on the diagnosis and/or invasive procedures. Adverse effects include respiratory depression, impaired alertness, and the development of physical and psychological dependence.
* Optimum Duration: Up to 7 days.
* Maximum Duration: 2 weeks. Use beyond 2 weeks is acceptable in appropriate cases when functional improvement is documented. Refer to the Division's Chronic Pain Disorder Medical Treatment Guidelines, which give a detailed discussion regarding medication use in chronic pain management. Use beyond 30 days after non-traumatic injuries, or 6 weeks post-surgery after the original injury or post-operatively is not recommended. If necessary, the physician should access the Colorado Prescription Drug Monitoring Program (PDMP) and follow recommendations in the Chronic Pain Guideline. This system allows the prescribing physician to see most of the controlled substances prescribed by other physicians for an individual patient.
Informed decision making is the hallmark of a successful treatment plan. In most cases, the continuum of treatment from the least invasive to the most invasive (e.g. surgery) should be discussed. The intention is to find the treatment along this continuum that most completely addresses the condition. Patients should identify their personal functional goals of treatment at the first visit. It is recommended that specific individual goals are articulated at the beginning of treatment as this is likely to lead to increased patient satisfaction above that achieved from improvement in pain or other physical function. Progress toward the individual functional goals identified should be addressed at follow up visits and throughout treatment by other members of the health care team as well as the authorized physicians.
Documentation of this process should occur whenever diagnostic tests or referrals from the authorized treating physician are contemplated. The informed decision making process asks the patient to set their personal functional goals of treatment, describe their current health status and any concerns regarding adhering to the diagnostic or treatment plan proposed. The provider should clearly describe the following:
* The expected functional outcomes from the proposed treatment, or expected results and plan of action if diagnostic tests are involved.
* Any side effects and risks to the patient.
* Required post treatment rehabilitation time and impact on work, if any.
* Alternative therapies or diagnostic testing.
Before diagnostic tests or referrals for invasive treatment take place the patient should be able to clearly articulate the goals of the intervention, the general side effects and risks associated with it and their decision regarding compliance with the suggested plan. There is some evidence that information provided only by video is not sufficient education:
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 providing reassuring information to the patient and informed decision making. More in-depth education currently exists within a treatment regimen employing functional restoration, prevention, and cognitive behavioral techniques. Patient education and informed decision making should facilitate self-management of symptoms and prevention.
* Time to produce effect: Varies with individual patient
* Frequency: Should occur at every visit.
If 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 on the patient and medications selected.
Psychosocial interventions include psychotherapeutic treatments for mental health conditions, as well as behavioral medicine treatments. These interventions may similarly be beneficial for patients without psychiatric conditions, but who may need to make major life changes in order to cope with pain or adjust to disability. Examples of these treatments include cognitive behavioral therapy (CBT), relaxation training, mindfulness training, and sleep hygiene training.
The screening or diagnostic workup should clarify and distinguish between pre-existing, aggravated, and/or purely causative psychological conditions. Therapeutic and diagnostic modalities include, but are not limited to, individual counseling and group therapy. Treatment can occur within an individualized model, a multi-disciplinary model, or a structured pain management program.
A psychologist with a PhD, PsyD, EdD credentials, or a psychiatric MD/DO may perform psychosocial treatments. Other licensed mental health providers or licensed health care providers with training in CBT, or certified as CBT therapists who have experience in treating chronic pain disorders in injured workers, may also perform treatment in consultation with a PhD, PsyD, EdD, or psychiatric MD/DO.
CBT refers to a group of psychological therapies that are sometimes referred to by more specific names, such as Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy. Variations of CBT methods can be used to treat a variety of conditions, including chronic pain, depression, anxiety, phobias, and post-traumatic stress disorder (PTSD). For patients with multiple diagnoses, more than one type of CBT might be needed. The CBT used in research studies is often "manualized CBT," meaning that the treatment follows a specific protocol in a manual. In clinical settings, CBT may involve the use of standardized materials, but it is also commonly adapted by a psychologist or psychiatrist to the patient's unique circumstances. If the CBT is being performed by a non-mental health professional, a manual approach would be strongly recommended. CBT must be distinguished from neuropsychological therapies used to teach compensatory strategies to brain injured patients, which are also called "cognitive therapy."
It should be noted that most clinical trials on CBT exclude subjects who have significant psychiatric diagnoses. Consequently, the selection of patients for CBT should include the following considerations. CBT is instructive and structured, using an educational model with homework to teach inductive rational thinking. Because of this educational model, a certain level of literacy is assumed for most CBT protocols. Patients who lack the cognitive and educational abilities required by a CBT protocol are unlikely to be successful. Further, given the highly structured nature of CBT, it is more effective when a patient's circumstances are relatively stable. For example, if a patient is about to be evicted, is actively suicidal, or is coming to sessions intoxicated, these matters will generally preempt CBT treatment for pain, and require other types of psychotherapeutic response. Conversely, literate patients whose circumstances are relatively stable, but who catastrophize or cope poorly with pain or disability are often good candidates for CBT for pain. Similarly, literate patients whose circumstances are relatively stable, but who exhibit unfounded medical phobias, are often good candidates for CBT for anxiety.
There is good evidence that cognitive intervention reduces low back disability in the short term and in the long term. In one of the studies, the therapy consisted of 6, 2-hour sessions given weekly to workers who had been sick-listed for 8-12 weeks. Comparison groups included those who received routine care. There is good evidence that psychological interventions, especially CBT, are superior to no psychological intervention for chronic low back pain, and that self-regulatory interventions, such as biofeedback and relaxation training, may be equally effective. There is good evidence that six group therapy sessions lasting one and a half hours each focused on CBT skills improved function and alleviated pain in uncomplicated sub-acute and chronic low back pain patients. There is some evidence that CBT provided in seven two-hour small group sessions can reduce the severity of insomnia in chronic pain patients. A Cochrane meta-analysis grouped very heterogenous behavioral interventions and concluded that there was good evidence that CBT may reduce pain and disability but the effect size was uncertain. In total, the evidence clearly supports CBT, and it should be offered to all chronic pain patents who do not have other serious issues, as discussed above.
CBT is often combined with active therapy in an interdisciplinary program, whether formal or informal. It must be coordinated with a psychologist or psychiatrist. CBT can be done in a small group or individually, and the usual number of treatments varies between 8 and16 sessions.
Before CBT is done, the patient must have a full psychological evaluation. The CBT program must be done under the supervision of a PhD, PsyD, EdD, or psychiatric MD/DO.
Psychological Diagnostic and Statistical Manual of Mental Disorders (DSM) Axis I disorders are common in chronic pain. One study demonstrated that the majority of patients who had failed other therapy and participated in an active therapy program also suffered from major depression. However, in a program that included CBT and other psychological counseling, the success rate for return to work was similar for those with and without a DSM IV diagnosis. This study further strengthens the argument for having some psychological intervention included in all chronic pain treatment plans.
For all psychological/psychiatric interventions, an assessment and treatment plan with measurable behavioral goals, time frames, and specific interventions planned, must be provided to the treating physician prior to initiating treatment. A status report must be provided to the authorized treating physician every two weeks during initial more frequent treatment and monthly thereafter. The report should provide documentation of progress toward functional recovery and a discussion of the psychosocial issues affecting the patient's ability to participate in treatment. The report should also address pertinent issues such as pre-existing, aggravated, and/or causative issues, as well as realistic functional prognosis.
* Time to Produce Effect: 6 to 8 1-2 hour session, group or individual (1-hour individual or 2-hour group).
* Maximum Duration: 16 sessions.
NOTE: Before CBT is done, the patient must have a full psychological evaluation. The CBT program must be done under the supervision of a PhD, PsyD, EdD, or Psychiatric MD/DO.
* Time to Produce Effect: 6 to 8 weeks.
* Frequency: 1 to 2 times weekly for the first 2 weeks (excluding hospitalization, if required), decreasing to 1 time per week for the second month. Thereafter, 2 to 4 times monthly with the exception of exacerbations, which may require increased frequency of visits. Not to include visits for medication management
* Optimum Duration: 2 to 6 months.
* Maximum Duration: 6 months. Not to include visits for medication management. For select patients, longer supervised psychological/psychiatric treatment may be required, especially if there are ongoing medical procedures or complications. If counseling beyond 6 months is indicated, the management of psychosocial risks or functional progress must be documented. Treatment plan/progress must show severity.
Patients should be educated regarding the detrimental effects of immobility versus the efficacious use of limited 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.
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, jobsite analysis, and vocational assistance, may be employed.
Two counseling sessions with an occupational physician, and work site visit if necessary, may be helpful for workers who are concerned about returning to work.
At least one study suggest that health status is worse for those who do not return to work than those who do. Self-employment and injury severity predict return to work. Difficulty with pain control, activities of daily living (ADLs), and anxiety and depression were common.
The following should be considered when attempting to return an injured worker with chronic pain to work.
Recommendations to Employers and Employees of Small Businesses: 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 payer or third-party administrator. 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 on company philosophy and employee needs.
Recommendations to Employers and Employees of Mid-sized and Large Businesses: Employers 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.
Abnormal posture, head tilting forward and scapular dyskinesia are frequently contributors to thoracic outlet symptoms. These tip the scapula anteriorly, altering motor control of the scapulothoracic and glenohumeral articulations. The most noticeable feature is prominence of the inferior angle of the scapula. Dysfunction of the pectoralis minor and other scapular muscles places the acromion closer to the rotator cuff and humeral head, compromising the subacromial space. The altered relations of length and tension of the deltoid and cuff muscles results in poor motor control of the humerus on the glenoid fossa.
The use and integration of active and passive therapies should be directed at addressing impairments found in the clinical examination which may include abnormal posture, head tilting forward, scapula dyskinesia and joint/tissue hypomobility/hypermobility. These clinical findings are frequently contributors to the thoracic outlet symptoms and many times result in scapula anterior tipping and altered motor control of the scapula/thoracic and glenohumeral joints. In this classification of scapula dysfunction, the primary external visual feature is the anterior tilting of the scapula in the sagittal plane which produces the prominent inferior angle of the scapula. Many times the anterior tilting is associated with shortening of the pectoralis minor and poor function of the scapula muscles controlling the inferior angle. This myofascial and scapula dysfunction places the acromion in a position closer to the rotator cuff and humeral head and can thereby compromise the subacromial space. Additionally, this resultant scapula dyskinesia disrupts the length tension relationships of the shoulder complex's static and dynamic constraints and subsequently facilitates poor humeral head positioning on the glenoid. (The static constraints are the glenohumeral ligaments and the dynamic constraints are the deltoid and cuff musculature.) Therefore the treatment of this scapula dyskinesia and myofascial dysfunction is important for restoration of the normal upper quarter function.
The healthy function of the upper body is inextricably dependent on the proper function and balanced relationships with its neighboring structures: cervical, thoracic, costal, when one acknowledges the role of fascia, particularly the thoracodorsal fascia. Therefore, effective and expedient rehabilitation requires providers to have an excellent understanding of the functional anatomy of these structures and their dynamic inter-relatedness. Shoulder injuries are complex. Successful treatment of these injuries requires the providers to have expert skills. Collaboration is essential in achieving optimal outcomes.
Patients should be instructed to continue active therapies at home as an extension of the treatment process in order to maintain improvement levels. Follow-up visits to reinforce and monitor progress and proper technique are recommended. Home exercise can include exercise with or without mechanical assistance or resistance and functional activities with assistive devices.
The use of a patient completed pain drawing, VAS, and functional outcome tools is highly recommended to help providers track progress. Functional objective goals including minimum clinically important difference (MCID) of the functional tools should be monitored and documented regularly to determine the effectiveness of treatment.
On occasion, specific diagnoses and post-surgical conditions may warrant durations of treatment beyond those listed as "maximum." Factors such as exacerbation of symptoms, re-injury, interrupted continuity of care and comorbidities may also extend durations of care. Specific goals with objectively measured functional improvement during treatment must be cited to justify extended durations of care. It is recommended that, if no functional gain is observed after the number of treatments under "time to produce effect" have been completed, then alternative treatment interventions, further diagnostic studies, or further consultations should be pursued.
The following active therapies are listed in alphabetical order:
* Time to Produce Effect: 4 to 5 treatments.
* Frequency: 3 to 5 times per week.
* Optimum Duration: 4 to 6 weeks.
* Maximum Duration: 6 weeks.
* Postoperative therapy as ordered by the surgeon; or
* Intolerance for active land-based or full-weight bearing therapeutic procedures; or
* Symptoms that are exacerbated in a dry environment; and
* Willingness to follow through with the therapy on a regular basis.
The pool should be large enough to allow full extremity range of motion and fully erect posture. Aquatic vests, belts, snorkels, and other devices may be used to provide stability, balance, buoyancy, and resistance.
* Time to Produce Effect: 4 to 5 treatments.
* Frequency: 3 to 5 times per week.
* Optimum Duration: 4 to 6 weeks.
* Maximum Duration: 8 weeks.
A self-directed program is recommended after the supervised aquatics program has been established, or, alternatively a transition to a self-directed dry environment exercise program.
* Time to Produce Effect: 4 to 5 treatments.
* Frequency: 3 to 5 times per week.
* Optimum Duration: 4 to 6 weeks.
* Maximum Duration: 6 weeks.
* Time to Produce Effect: 2 to 4 weeks.
* Frequency: Up to 5 times per day by patient (patient-initiated).
* Optimum Duration: 4 to 6 sessions.
* Maximum Duration: 6 to 8 sessions.
* Time to Produce Effect: 2 to 6 treatments.
* Frequency: 3 times per week.
* Optimum Duration: 4 to 8 weeks.
* Maximum Duration: 8 weeks. Additional visits may be necessary in cases of reinjury, interrupted continuity of care, exacerbation of symptoms, and in those patients with comorbidities. Functional gains including increased range of motion must be demonstrated to justify continuing treatment.
* Time to Produce Effect: 2 to 6 treatments.
* Frequency: 2 to 3 times per week.
* Optimum Duration: 16 to 24 sessions.
* Maximum Duration: 36 sessions. Additional visits may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with comorbidities. Functional gains including increased range of motion must be demonstrated to justify continuing treatment.
The following passive therapies and modalities are generally accepted methods of care for a variety of work-related injuries. Passive therapy includes those treatment modalities that do not require energy expenditure on the part of the patient. They are principally effective during the early phases of treatment and are directed at controlling symptoms such as pain, inflammation and swelling and to improve the rate of healing soft tissue injuries. They should be used adjunctively with active therapies such as postural stabilization and exercise programs to help control swelling, pain and inflammation during the rehabilitation process. Please refer to Section B.4, General Guidelines Principles, Active Interventions. Passive therapies may be used intermittently as a therapist deems appropriate or regularly if there are specific goals with objectively measured functional improvements during treatment.
On occasion, specific diagnoses and post-surgical conditions may warrant durations of treatment beyond those listed as "maximum." Factors such as exacerbation of symptoms, re-injury, interrupted continuity of care and comorbidities may also extend durations of care. Specific goals with objectively measured functional improvement during treatment must be cited to justify extended durations of care. It is recommended that, if no functional gain is observed after the number of treatments under "time to produce effect" has been completed, alternative treatment interventions, further diagnostic studies, or further consultations should be pursued.
The following passive therapies and modalities are listed in alphabetical order.
* Time to Produce Effect: 2 to 4 treatments.
* Frequency: Varies, depending upon indication, between 2 to 3 times/day to 1 time/week.
* Optimum Duration: 1 month.
* Maximum Duration: Use beyond 6 weeks requires a home unit.
* Time to Produce Effect: 1 to 4 treatments.
* Frequency: 3 times per week with at least 48 hours between treatments.
* Optimum Duration: 8 to 10 treatments.
* Maximum Duration: 10 treatments.
High velocity, low amplitude (HVLA) technique, chiropractic manipulation, osteopathic manipulation, muscle energy techniques, counter strain, and non-force techniques are all types of manipulative treatment. This may be applied by osteopathic physicians (D.O.), chiropractors (D.C.), properly trained physical therapists (P.T.), properly trained occupational therapists (O.T.), or properly trained medical physicians. Under these different types of manipulation exist many subsets of different techniques that can be described as a) direct- a forceful engagement of a restrictive/pathologic barrier, b) indirect- a gentle/non-forceful disengagement of a restrictive/pathologic barrier, c) the patient actively assisting in the treatment and d) the patient relaxing, allowing the practitioner to move the body tissues. When the proper diagnosis is made and coupled with the appropriate technique, manipulation has no contraindications and can be applied to all tissues of the body. Pre-treatment assessment should be performed as part of each manipulative treatment visit to ensure that the correct diagnosis and correct treatment is employed. Mobilization may be directed at the first rib and the scapula.
* Time to produce effect for all types of manipulative treatment: 1 to 6 treatments.
* Frequency: Up to 3 times per week for the first 3 weeks as indicated by the severity of involvement and the desired effect.
* Optimum Duration: 10 treatments.
* Maximum Duration: 12 treatments. Additional visits may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with comorbidities. Functional gains including increased range of motion must be demonstrated to justify continuing treatment.
* Time to Produce Effect: Immediate.
* Frequency: 1 to 2 times per week.
* Optimum Duration: 6 weeks.
* Maximum Duration: 2 months.
* Time to Produce Effect: 6 to 9 treatments.
* Frequency: 3 times per week.
* Optimum Duration: 6 weeks.
* Maximum Duration: 2 months.
* Time to Produce Effect: 2 to 3 weeks.
* Frequency: 2 to 3 times per week.
* Optimum Duration: 4 to 6 weeks.
* Maximum Duration: 6 weeks.
* Time to Produce Effect: Immediate.
* Frequency: 2 to 5 times per week.
* Optimum Duration: 3 weeks as primary, or up to 2 months if used intermittently as an adjunct to other therapeutic procedures.
* Maximum Duration: 2 months.
* Time to Produce Effect: Immediate.
* Frequency: Variable.
* Optimum Duration: 3 sessions.
* Maximum Duration: 3 sessions. If beneficial, provide with home unit or purchase if effective.
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 anti-inflammatory and anesthetics.
* Time to Produce Effect: 6 to 15 treatments.
* Frequency: 3 times per week.
* Optimum Duration: 4 to 8 weeks.
* Maximum Duration: 2 months.
It may also be beneficial for full vocational rehabilitation to be started before MMI if it is evident that the injured worker will be unable to return to his/her previous occupation. A positive goal and direction may aid the patient in decreasing stress and depression, and promote optimum rehabilitation.
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 operative conditions (e.g., peripheral neuropathy, myofascial pain, scleratogenous or sympathetically mediated pain syndromes, psychological), prior to consideration of elective surgical intervention. Operative procedures are only appropriate for Neurogenic or Vascular TOS as defined below. Patients with thoracic outlet symptoms due to myofascial issues are not surgical candidates.
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 neuro-musculoskeletal 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.
Post-operative therapy will frequently require a repeat of the therapy provided pre-operatively. Refer to Section F. Therapeutic Procedures, Non-operative, and consider the first post-operative visit as visit number one, for the time frame parameters provided.
Return-to-work restrictions should be specific according to the recommendation in Section F.10, Therapeutic Procedures - Non-operative.
The patient and treating physician must identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work activities. The patient should agree to comply with the pre- and post-operative treatment plan, including home exercise. The provider should be especially careful to make sure the patient understands the amount of post-operative treatment required and the length of partial- and full-disability expected post-operatively. The patient should have committed to the recommended post-operative treatment plan and fully completed the recommended active, manual and pre-operative treatment plans.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Compression of the neurovascular bundle by the pectoralis muscle. This syndrome, described by a few authors, is usually caused by neck or shoulder trauma and generally resolves with physical therapy.
(Note: this condition is almost never work related.)
A long-term follow-up study of patients having surgery for neurogenic TOS reported that disability at 4 years postoperatively was strongly related to the presence of major depression, as evaluated by the Beck Depression Inventory taken preoperatively. The adjusted odds ratio for depression and disability was 15.7. Even though the response rate for the four-year survey was only 58% of the eligible population, the association between preoperative depression and long-term disability was robust and not likely to be vulnerable to nonresponse bias. Refer to Section E.7 Personality/Psychological/Psychosocial Evaluations.
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 and is most appropriate for the patient.
Vascular TOS procedures include resection of the abnormal rib and repair of the involved vessel. Anticoagulation is required for thrombotic cases.
Individualized rehabilitation programs based upon communication between the surgeon and the therapist.
* Activities of Daily Living.
* Functional Activities.
* Nerve gliding.
* Neuromuscular re-education.
* Therapeutic exercise.
* Proper work techniques: Refer to Section E.8.c. Jobsite Evaluation, and Section F.10. Return-to-Work of these guidelines.
* Limited passive therapies may be appropriate in some cases.
For history of this section, see Editor's Notes in the first section, 7 CCR 1101-3
7 CCR 1101-3 has been divided into smaller sections for ease of use. Versions prior to 01/01/2011 and rule history are located in the first section, 7 CCR 1101-3. Prior versions can be accessed from the All Versions list on the rule's current version page. To view versions effective on or after 01/01/2011, select the desired part of the rule, for example 7 CCR 1101-3 Rules 1-17, or 7 CCR 1101-3 Rule 18: Exhibit 1.
