Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 21 - Pain Medical Treatment Guidelines
Subchapter A - Chronic Pain Disorder Medical Treatment Guidelines
Section I-2109 - Initial Evaluation and Diagnostic Procedures

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

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

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

iv. current employment status;

v. marital status;

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

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

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

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

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

xi. past and present psychological problems;

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

xiii. history of disability in the family;

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

viii. family history pertaining to similar disorders.

i. alcohol use;

ii. smoking history and use of nicotine replacements;

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

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

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

i. compensation/disability/litigation;

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

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

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

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

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

iv. evaluation of non-physiologic findings:

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

ii. interpersonal relationships-both social and work;

iii. patient activities;

iv. current perception of the medical system;

v. current perception/attitudes toward employer/job;

vi. results of current treatment;

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

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

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

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

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

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

v. Brief Specialized Psychiatric Screening Measures

i. Qualifications

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

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

i. thyroid stimulating hormone (TSH) for hypothyroidism;

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

iii. serum protein electrophoresis;

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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