Subp. 2.
Initial nonsurgical
management.
Initial nonsurgical management is appropriate for all patients
with reflex sympathetic dystrophy and must be the first phase of treatment. Any
course or program of initial nonsurgical management is limited to the
modalities specified in items A to D.
A. Therapeutic injection modalities. The only
injections allowed for reflex sympathetic dystrophy are sympathetic block,
intravenous infusion of steroids or sympatholytics, or epidural block.
(1) Unless medically contraindicated,
sympathetic blocks or the intravenous infusion of steroids or sympatholytics
must be used if reflex sympathetic dystrophy has continued for four weeks and
the employee remains disabled as a result of the reflex sympathetic dystrophy.
(a) Time for treatment response: within 30
minutes.
(b) Maximum treatment
frequency: can repeat an injection to a limb if there was a positive response
to the first injection. If subsequent injections demonstrate diminishing
control of symptoms or fail to facilitate objective functional gains, then
injections must be discontinued. No more than three injections to different
limbs are reimbursable per patient visit.
(c) Maximum treatment duration: may be
continued as long as injections control symptoms and facilitate objective
functional gains, if the period of improvement is progressively longer with
each injection.
(2)
Epidural block may only be performed in patients who had an incomplete
improvement with sympathetic block or intravenous infusion of steroids or
sympatholytics.
B. Only
the passive treatment modalities set forth in subitems (1) to (4) are
indicated. These passive treatment modalities in a clinical setting or
requiring attendance by a health care provider are not indicated beyond 12
weeks from the first modality initiated for treatment of the reflex sympathetic
dystrophy.
(1) Thermal treatment includes all
superficial and deep heating and cooling modalities. Superficial thermal
modalities include hot packs, hot soaks, hot water bottles, hydrocollators,
heating pads, ice packs, cold soaks, infrared, whirlpool, and fluidotherapy.
Deep thermal modalities include diathermy, ultrasound, and microwave.
(a) Treatment given in a clinical setting:
i. time for treatment response, two to four
treatments;
ii. maximum treatment
frequency, up to five times per week for the first one to three weeks,
decreasing in frequency thereafter; and
iii. maximum treatment duration, 12 weeks of
treatment in a clinical setting but only if given in conjunction with other
therapies specified in this subpart.
(b) Home use of thermal modalities may be
prescribed at any time during the course of treatment. Home use may only
involve hot packs, hot soaks, hot water bottles, hydrocollators, heating pads,
ice packs, and cold soaks which can be applied by the patient without
professional assistance. Home use of thermal modalities does not require any
special training or monitoring, other than that usually provided by the health
care provider during an office visit.
(2) Desensitizing procedures, such as
stroking or friction massage, stress loading, and contrast baths:
(a) time for treatment response, three to
five treatments;
(b) maximum
treatment frequency in a clinical setting, up to five times per week for the
first one to two weeks decreasing in frequency thereafter; and
(c) maximum treatment duration in a clinical
setting, 12 weeks. Home use of desensitizing procedures may be prescribed at
any time during the course of treatment.
(3) Electrical stimulation includes galvanic
stimulation, TENS, interferential, and microcurrent techniques.
(a) Treatment given in a clinical setting:
i. time for treatment response, two to four
treatments;
ii. maximum treatment
frequency, up to five times per week for the first one to three weeks,
decreasing in frequency thereafter; and
iii. maximum treatment duration, 12 weeks of
treatment in a clinical setting, but only if given in conjunction with other
therapies.
(b) Home use
of an electrical stimulation device may be prescribed at any time during a
course of treatment. Initial use of an electrical stimulation device must be in
a supervised setting in order to ensure proper electrode placement and patient
education:
i. time for patient education and
training, one to three sessions; and
ii. patient may use the electrical
stimulation device unsupervised for one month, at which time effectiveness of
the treatment must be reevaluated by the provider before continuing home use of
the device.
(4) Acupuncture treatments.
Endorphin-mediated analgesic therapy includes classic acupuncture and
acupressure:
(a) time for treatment response,
three to five sessions;
(b) maximum
treatment frequency, up to three times per week for the first one to three
weeks, decreasing in frequency thereafter; and
(c) maximum treatment duration, 12
weeks.
C.
Active treatment includes supervised and unsupervised exercise. After the first
week of treatment, initial nonsurgical management must include exercise.
Exercise is essential for a return to normal activity and must include active
patient participation in activities designed to increase flexibility, strength,
endurance, or muscle relaxation. Exercise must be specifically aimed at the
involved musculature. Exercises must be evaluated to determine if the desired
goals are being attained. Strength, flexibility, or endurance must be
objectively measured. While the provider may objectively measure the treatment
response as often as necessary for optimal care, after the initial evaluation
the health care provider may not bill for the tests sooner than two weeks after
the initial evaluation, and monthly thereafter.
(1) Supervised exercise. One goal of a
supervised exercise program must be to teach the patient how to maintain and
maximize any gains experienced from exercise. Self-management of the condition
must be promoted:
(a) maximum treatment
frequency, up to five times per week for three weeks. Should decrease in
frequency thereafter; and
(b)
maximum duration, 12 weeks.
(2) Unsupervised exercise must be provided in
the least intensive setting and may supplement or follow the period of
supervised exercise. Maximum duration is unlimited.
D. The health care provider must document the
rationale for the use of any medication. Treatment with medication may be
appropriate during any phase of treatment and must comply with all of the
applicable parameters in part
5221.6105. The prescribing health
care provider must determine that ongoing medication is effective treatment for
the patient's condition and that the most cost-effective regimen is
used.