Chronic Pain Disorder Medical Treatment Guideline

RULE 17, EXHIBIT 9

Chronic Pain Disorder

Medical Treatment Guideline

Revised: 10/6/2017 Effective: 11/30/2017

Adopted: January 8, 1998 Revised: May 27, 2003 Revised: September 29, 2005 Revised: April 26, 2007 Revised: December 27, 2011

Effective: March 15, 1998 Effective: July 30, 2003 Effective: January 1, 2006 Effective: July 1, 2007 Effective: February 14, 2012

Presented by:

DIVISION OF WORKERS' COMPENSATION

TABLE OF CONTENTS

SECTION

DESCRIPTION

PAGE

A.

INTRODUCTION.............................................................................................................................. 1

B.

GENERAL GUIDELINE PRINCIPLES ............................................................................................ 2

1.

APPLICATION OF THE GUIDELINES ............................................................................... 2

2.

EDUCATION ....................................................................................................................... 2

3.

INFORMED DECISION MAKING ....................................................................................... 2

4.

TREATMENT PARAMETER DURATION........................................................................... 2

5.

ACTIVE INTERVENTIONS ................................................................................................. 2

6.

ACTIVE THERAPEUTIC EXERCISE PROGRAM.............................................................. 2

7.

POSITIVE PATIENT RESPONSE ...................................................................................... 3

8.

RE-EVALUATION OF TREATMENT NO LESS THAN EVERY 3 TO 4 WEEKS ............... 3

9.

SURGICAL INTERVENTIONS ........................................................................................... 3

10. SIX-MONTH TIME FRAME................................................................................................. 3

11. RETURN-TO-WORK........................................................................................................... 3

12. DELAYED RECOVERY ...................................................................................................... 3

13. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE .......... 4

14. TREATMENT OF PRE-EXISTING CONDITIONS .............................................................. 4

C.

OVERVIEW OF CHRONIC PAIN MANAGEMENT ......................................................................... 5

D.

INTRODUCTION TO CHRONIC PAIN ............................................................................................ 8

E.

DEFINITIONS ................................................................................................................................ 11

1.

AFTER SENSATION......................................................................................................... 11

2.

ALLODYNIA ...................................................................................................................... 11

3.

ANALGESIA ...................................................................................................................... 11

4.

BIOPSYCHOSOCIAL........................................................................................................ 11

5.

CENTRAL PAIN ................................................................................................................ 11

6.

CENTRAL SENSITIZATION ............................................................................................. 11

7.

DYSESTHESIA ................................................................................................................. 11

8.

HYPERALGESIA .............................................................................................................. 11

9.

HYPERESTHESIA (POSITIVE SENSORY PHENOMENA)............................................. 11

10. HYPERPATHIA................................................................................................................. 11

11. HYPOALGESIA................................................................................................................. 11

12. HYPOESTHESIA/HYPESTHESIA (NEGATIVE SENSORY PHENOMENA) ................... 12

13. MALINGERING ................................................................................................................. 12

14. MYOFASCIAL PAIN.......................................................................................................... 12

15. MYOFASCIAL TRIGGER POINT ..................................................................................... 12

16. NEURALGIA ..................................................................................................................... 12

17. NEURITIS ......................................................................................................................... 12

18. NEUROGENIC PAIN ........................................................................................................ 12

19. NEUROPATHIC PAIN....................................................................................................... 12

20. NEUROPATHY ................................................................................................................. 12

21. NOCICEPTOR .................................................................................................................. 12

22. PAIN BEHAVIOR .............................................................................................................. 12

23. PAIN THRESHOLD........................................................................................................... 12

24. PARESTHESIA ................................................................................................................. 12

25. PERIPHERAL NEUROPATHIC PAIN............................................................................... 12

26. SOMATIC DYSFUNCTION............................................................................................... 13

27. SUMMATION .................................................................................................................... 13

28. SYMPATHETICALLY MAINTAINED PAIN (SMP)............................................................ 13

Chronic Pain Disorder

29. TENDER POINTS ............................................................................................................. 13

F.

INITIAL EVALUATION & DIAGNOSTIC PROCEDURES ............................................................ 14

1.

HISTORY TAKING AND PHYSICAL EXAMINATION (HX & PE) .................................... 14

a.

Medical History..................................................................................................... 14

b.

Pain History.......................................................................................................... 15

c.

Medical Management History: ............................................................................. 16

d.

Substance Use/Abuse: ........................................................................................ 17

e.

Other Factors Affecting Treatment Outcome:...................................................... 17

f.

Physical Examination: .......................................................................................... 17

2.

PERSONALITY/ PSYCHOLOGICAL/PSYCHOSOCIAL EVALUATIONS FOR PAIN

MANAGEMENT ................................................................................................................ 18

a.

Qualifications........................................................................................................ 19

b.

Clinical Evaluation................................................................................................ 20

c.

Tests of Psychological Functioning...................................................................... 22

3.

DIAGNOSTIC STUDIES ................................................................................................... 24

4.

LABORATORY TESTING ................................................................................................. 25

5.

INJECTIONS?DIAGNOSTIC ............................................................................................ 26

a.

Spinal Diagnostic Injections ................................................................................. 26

6.

SPECIAL TESTS .............................................................................................................. 29

a.

Computer-Enhanced Evaluations ........................................................................ 29

b.

Functional Capacity Evaluation (FCE) ................................................................. 30

c.

Jobsite Evaluation and Alterations ....................................................................... 31

d.

Vocational Assessment........................................................................................ 32

e.

Work Tolerance Screening (Fitness for Duty)...................................................... 32

G. THERAPEUTIC PROCEDURES ? NON-OPERATIVE................................................................. 34

1.

ACUPUNCTURE............................................................................................................... 34

a.

Overview .............................................................................................................. 34

b.

Acupuncture ......................................................................................................... 36

c.

Acupuncture with Electrical Stimulation ............................................................... 37

d.

Other Acupuncture Modalities.............................................................................. 37

e.

Total Time Frames for Acupuncture and Acupuncture with Electrical Stimulation

............................................................................................................................. 38

2.

BIOFEEDBACK................................................................................................................. 39

a.

Overview .............................................................................................................. 39

b.

EMG/Electromyogram (EMG) .............................................................................. 39

c.

Skin Temperature................................................................................................. 39

d.

Respiration Feedback (RFB) ............................................................................... 39

e.

Respiratory Sinus Arrhythmia (RSA) ................................................................... 39

f.

Heart Rate Variability (HRV) ................................................................................ 39

g.

Electrodermal Response (EDR)........................................................................... 39

h.

Electroencephalograph (EEG, QEEG) ................................................................ 39

3.

COMPLEMENTARY MEDICINE....................................................................................... 41

a.

Overview .............................................................................................................. 41

b.

Alternative Medical Systems ................................................................................ 41

c.

Mind-body Interventions....................................................................................... 41

d.

Biological-based Practices ................................................................................... 41

e.

Body-based Therapy............................................................................................ 41

f.

Energy-based Practices ....................................................................................... 41

4.

DIRECT CORTICAL STIMULATION ................................................................................ 42

5.

DISTURBANCES OF SLEEP ........................................................................................... 42

a.

Overview .............................................................................................................. 42

6.

EDUCATION/INFORMED/SHARED DECISION MAKING............................................... 45

7.

INJECTIONS?SPINAL THERAPEUTIC ........................................................................... 46

a.

Steroid Associated Issues.................................................................................... 46

Chronic Pain Disorder

b.

Epidural Steroid Injection (ESI) ............................................................................ 47

c.

Intradiscal Steroid Injections ................................................................................ 48

d.

Sacroiliac Joint Injection ...................................................................................... 48

e.

Transforaminal Injection with Etanercept............................................................. 48

f.

Zygapophyseal (Facet) Injection .......................................................................... 48

8.

INJECTIONS ? OTHER (INCLUDING RADIO FREQUENCY)......................................... 50

a.

Botulinum Toxin Injections ................................................................................... 50

b.

Epiduroscopy and Epidural Lysis of Adhesions ................................................... 52

c.

Prolotherapy......................................................................................................... 53

d.

Radio Frequency Ablation ? Dorsal Nerve Root Ganglion .................................. 54

e.

Radio Frequency Ablation ? Genicular Nerves.................................................... 54

f.

Radio Frequency (RF) Denervation - Medial Branch Neurotomy/Facet Rhizotomy

............................................................................................................................. 55

g.

Radio Frequency Denervation - Sacro-iliac (SI) Joint Cooled ............................. 57

h.

Transdiscal Biacuplasty ....................................................................................... 60

i.

Trigger Point Injections ........................................................................................ 60

9.

INTERDISCIPLINARY REHABILITATION PROGRAMS ................................................. 61

a.

Overview .............................................................................................................. 61

b.

Formal Interdisciplinary Rehabilitation Programs ................................................ 64

c.

Informal Interdisciplinary Rehabilitation Program ................................................ 67

10. MEDICATIONS AND MEDICAL MANAGEMENT ............................................................ 69

a.

Alpha-Acting Agents ............................................................................................ 71

b.

Anticonvulsants .................................................................................................... 72

c.

Antidepressants ................................................................................................... 79

d.

Cannabinoid Products.......................................................................................... 83

e.

Hypnotics and Sedatives ..................................................................................... 86

f.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)................................................. 87

g.

Opioids ................................................................................................................. 89

h.

Post-Operative Pain Management..................................................................... 111

i.

Skeletal Muscle Relaxants ................................................................................. 111

j.

Smoking Cessation Medications and Treatment ............................................... 114

k.

Topical Drug Delivery......................................................................................... 115

l.

Other Agents ...................................................................................................... 120

11. NON-INVASIVE BRAIN STIMULATION ......................................................................... 121

12. OPIOID ADDICTION TREATMENT................................................................................ 121

13. OPIOID/CHEMICAL TREATMENT PROGRAM REQUIREMENTS ............................... 125

14. ORTHOTICS/PROSTHETICS/EQUIPMENT.................................................................. 127

15. PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION ..................... 128

a.

Introduction ........................................................................................................ 128

b.

Hypnosis ............................................................................................................ 130

16. RESTRICTION OF ACTIVITIES ..................................................................................... 133

17. RETURN-TO-WORK....................................................................................................... 134

a.

Job History Interview.......................................................................................... 134

b.

Coordination of Care .......................................................................................... 134

c.

Communication .................................................................................................. 134

d.

Establishment of Return-To-Work Status .......................................................... 134

e.

Establishment of Activity Level Restrictions ...................................................... 135

f.

Rehabilitation and Return-To-Work ................................................................... 135

g.

Vocational Assistance ........................................................................................ 135

18. THERAPY--ACTIVE....................................................................................................... 136

a.

Activities of Daily Living (ADL) ........................................................................... 137

b.

Aquatic Therapy ................................................................................................. 137

c.

Functional Activities ........................................................................................... 139

d.

Functional Electrical Stimulation ........................................................................ 139

e.

Neuromuscular Re-education ............................................................................ 139

f.

Spinal Stabilization............................................................................................. 140

Chronic Pain Disorder

g.

Therapeutic Exercise ......................................................................................... 140

h.

Work Conditioning.............................................................................................. 145

i.

Work Simulation ................................................................................................. 145

19. THERAPY--PASSIVE .................................................................................................... 146

a.

Electrical Stimulation (Unattended).................................................................... 146

b.

Iontophoresis...................................................................................................... 147

c.

Low Level Laser ................................................................................................. 147

d.

Manual Treatment including Manipulation ......................................................... 147

e.

Manipulation Under General Anesthesia (MUA)................................................ 150

f.

Manipulation Under Joint Anesthesia (MUJA) ................................................... 151

g.

Massage--Manual or Mechanical...................................................................... 151

h.

Mobilization (Soft Tissue)................................................................................... 152

i.

Percutaneous Electrical Nerve Stimulation (PENS) .......................................... 152

j.

Superficial Heat and Cold Therapy (Including Infrared Therapy) ...................... 153

k.

Traction--Manual............................................................................................... 153

l.

Traction--Mechanical ........................................................................................ 153

m. Transcutaneous Electrical Nerve Stimulation (TENS) ....................................... 154

n.

Trigger Point Dry Needling (TDN)...................................................................... 154

o.

Ultrasound (Including Phonophoresis)............................................................... 155

p.

Vertebral Axial Decompression (VAX-D)/DRX, 9000 ........................................ 156

H.

THERAPEUTIC PROCEDURES ? OPERATIVE ........................................................................ 157

1.

NEUROSTIMULATION ................................................................................................... 157

2.

DORSAL ROOT GANGLION STIMULATOR ................................................................. 163

3.

PERIPHERAL NERVE STIMULATION........................................................................... 163

4.

INTRATHECAL DRUG DELIVERY................................................................................. 163

5.

NEUROABLATION WITH RHIZOTOMY AS THE EXCEPTION .................................... 165

6.

DORSAL NERVE ROOT RESECTION .......................................................................... 166

I.

MAINTENANCE MANAGEMENT ............................................................................................... 167

1.

HOME EXERCISE PROGRAMS AND EXERCISE EQUIPMENT ................................. 167

2.

EXERCISE PROGRAMS REQUIRING SPECIAL FACILITIES...................................... 168

3.

PATIENT EDUCATION MANAGEMENT........................................................................ 168

4.

PSYCHOLOGICAL MANAGEMENT .............................................................................. 168

5.

NON OPIOID MEDICATION MANAGEMENT ................................................................ 169

6.

OPIOID MEDICATION MANAGEMENT ......................................................................... 169

7.

THERAPY MANAGEMENT ............................................................................................ 170

8.

INJECTION THERAPY ................................................................................................... 170

9.

PURCHASE OR RENTAL OF DURABLE MEDICAL EQUIPMENT (DME) ................... 172

APPENDIX: DESCRIPTION OF TESTS OF PSYCHOLOGICAL FUNCTIONING ..................... 173

Chronic Pain Disorder

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