Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 21 - Pain Medical Treatment Guidelines
Subchapter B - Complex Regional Pain Syndrome
Section I-2125 - Initial Evaluation

Universal Citation: LA Admin Code I-2125

Current through Register Vol. 50, No. 9, September 20, 2024

A. All potential pain generators should be thoroughly investigated by complete neurological and musculoskeletal exam and diagnostic procedures. Because CRPS-I is commonly associated with other injuries, it is essential that all related diagnoses are defined and treated. These disturbances are typically restricted to one extremity, usually distally, but are variable in their expression.

1. History and physical examination (Hx& PE) The history and physical exam establish the basis for subsequent diagnostic and therapeutic procedures. When clinical evaluation findings do not complement the findings of other diagnostic procedures, clinical findings should have preference. Before the diagnosis of CRPS-I or CRPS-II is established, an experienced practitioner must perform a detailed neurological and musculoskeletal exam to exclude other potentially treatable pain generators or neurological lesions.
a. Medical History. As in other fields of medicine, a thorough patient history is an important part of the evaluation of pain. In taking such a history, factors influencing a patients' current status can be made clear and taken into account when planning diagnostic evaluation and treatment. History should ascertain the following elements:
i. Causality: How did this injury occur? Was the problem initiated by a work-related injury or exposure?

ii. Presenting symptoms:
(a). severe, generally unremitting burning and/or aching pain, and/or allodynia;

(b). swelling of the involved area;

(c). changes in skin color;

(d). asymmetry in nail and/or hair growth;

(e). abnormal sweat patterns of the involved extremity;

(f). dystonia; and/or

(g). subjective temperature changes of the affected area.

b. Pain History. The patient's description of and response to pain is one of the key elements in treatment. Characterization of the patient's pain and of the patient's response to pain is one of the key elements in treatment.
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 Drawing/Visual Analog Scale (VAS)

iii. Duration

iv. Place of onset

v. Pain Characteristics. Time of pain occurrence as well as intensity, quality and radiation give clues to the diagnosis and potential treatment.

vi. Response of Pain to Activity

vii. Associated Symptoms. Does the patient have numbness or paresthesia, dysesthesia, weakness, bowel or bladder dysfunction, decreased temperature, increased sweating, cyanosis or edema? Is there local tenderness, allodynia, hyperesthesia or hyperalgesia?

c. Substance Use/Abuse:
i. alcohol use;

ii. smoking history;

iii. History of drug use and abuse.

iv. Caffeine or caffeine-containing beverages.

d. Other Factors Affecting Treatment Outcome:
i. Compensation/disability/litigation;

ii. Treatment Expectations. What does the patient expect from treatment: complete relief of pain or reduction to a more tolerable level?

e. Medical Management History. Refer to the Chronic Pain Disorder Medical Treatment Guideline's for detailed elements when performing a review of prior medical management. In addition, history may include:
i. Chronological review of medical records including previous medical evaluations and response to treatment interventions.

ii. History of diagnostic tests and results including but not limited to any response to sympathetic nerve blocks, results of general laboratory studies, EMG and nerve conduction studies, radiological examinations, including triple phase bone scan or thermography with autonomic stress testing.

iii. Medications, including prescription, over-the-counter and herbal/dietary supplements.

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. It is recommended that patients diagnosed with CRPS be referred for a psychosocial evaluation. All patients with CRPS have Chronic Pain, and are likely to suffer psychosocial consequences.

vi. Pre-existing Conditions. Treatment of these conditions is appropriate when the preexisting condition is aggravated by work related injury.

f. Physical Examination. Should include examination techniques applicable to those portions of the body in which the patient is experiencing subjective symptomatology and should include:
i. Inspection. Changes in appearance of the involved area, to include trophic changes, changes in hair and nail growth, muscular atrophy, changes in skin turgor, swelling and color changes.

ii. Temperature Evaluation. Palpable temperature changes may not be detectable in early disease stages, and the examiner will generally only be able to appreciate significant temperature variations. Thermography, or other objective testing may be necessary to display temperature asymmetries.

iii. Motor Evaluation. Involuntary movements, dystonia or muscle weakness in the involved limb(s).

iv. Sensory Evaluation. A detailed sensory examination is crucial in evaluating a patient with chronic pain complaints. Presence of allodynia. Anatomic pattern of any associated sensory abnormalities to light touch, deep touch, pain and thermal stimulation. Quantitative sensory testing may be useful.

v. Musculoskeletal Evaluation. Presence of associated myofascial problems, such as contractures, ROM or trigger points.

vi. Evaluation of Nonphysiologic Findings. Determine the presence of the following: Variabilities on formal exam including variable sensory exam, inconsistent tenderness, and or swelling secondary to extrinsic sources; Inconsistencies between formal exam and observed abilities of range of motion, motor strength, gait and cognitive/emotional state; and/or, observation of consistencies between pain behavior, affect and verbal pain rating, and affect and physical re-examination.

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

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