Guidelines for Treatment of Chronic Pain Disorders

OKLAHOMA

Guidelines for Treatment of Chronic Pain Disorders

Developed and Adopted by the

Physician Advisory Committee

Adopted by the Administrator of the

Oklahoma Workers' Compensation Court

Effective September 1, 2007

TABLE OF CONTENTS

A. INTRODUCTION...........................................................................................................................................1 1. BACKGROUND...............................................................................................................................1 2. DEVELOPMENT OF THE GUIDELINES......................................................................................1 3. APPLICATION OF THE GUIDELINES .........................................................................................1

B. GENERAL GUIDELINE PRINCIPLES.........................................................................................................2 1. EDUCATION ...................................................................................................................................2 2. TREATMENT PARAMETER DURATION....................................................................................2 3. ACTIVE INTERVENTIONS ...........................................................................................................2 4. ACTIVE THERAPEUTIC EXERCISE PROGRAM .......................................................................2 5. POSITIVE PATIENT RESPONSE ..................................................................................................2 6. RE-EVALUATION OF TREATMENT EVERY 3 TO 4 WEEKS ..................................................2 7. SURGICAL INTERVENTIONS ......................................................................................................2 8. SIX-MONTH TIME FRAME...........................................................................................................2 9. RETURN-TO-WORK.......................................................................................................................3 10. DELAYED RECOVERY .................................................................................................................3 11. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE ..............3 12. TREATMENT OF PRE-EXISTING CONDITIONS .......................................................................3

C. INTRODUCTION TO CHRONIC PAIN .......................................................................................................4

D. DEFINITIONS ................................................................................................................................................5 1. ABUSE .............................................................................................................................................5 2. ACUTE PAIN ...................................................................................................................................5 3. ADDICTION ....................................................................................................................................5 4. AFTERSENSATION........................................................................................................................5 5. ALLODYNIA ...................................................................................................................................5 6. ANALGESIA....................................................................................................................................6 7. BIOPSYCHOSOCIAL......................................................................................................................6 8. CENTRAL PAIN ..............................................................................................................................6 9. CENTRAL SENSITIZATION..........................................................................................................6 10. CHRONIC PAIN ..............................................................................................................................6 11. DYSESTHESIA................................................................................................................................6 12. HYPERALGESIA.............................................................................................................................6 13. HYPERESTHESIA (POSITIVE SENSORY PHENOMENA) ........................................................6 14. HYPERPATHIA...............................................................................................................................6 15. HYPOALGESIA...............................................................................................................................6 16. HYPOESTHESIA (NEGATIVE SENSORY PHENOMENA) ........................................................6 17. MALINGERING...............................................................................................................................6 18. MYOFASCIAL PAIN.......................................................................................................................6 19. MYOFASCIAL TRIGGER POINT..................................................................................................6 20. NEURALGIA ...................................................................................................................................7 21. NEURITIS ........................................................................................................................................7 22. NEUROGENIC PAIN ......................................................................................................................7 23. NEUROPATHIC PAIN ....................................................................................................................7 24. NEUROPATHY................................................................................................................................7 25. NOCICEPTOR .................................................................................................................................7 26. PAIN BEHAVIOR............................................................................................................................7 27. PAIN THRESHOLD.........................................................................................................................7 28. PARESTHESIA ................................................................................................................................7 29. PERIPHERAL NEUROGENIC PAIN .............................................................................................7 30. PERIPHERAL NEUROPATHIC PAIN ...........................................................................................7 31. PHYSICAL DEPENDENCE ............................................................................................................7

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32. SUMMATION ..................................................................................................................................7 33. SYMPATHETICALLY MAINTAINED PAIN (SMP) ....................................................................7 34. TENDER POINTS............................................................................................................................7 35. TOLERANCE ...................................................................................................................................7

E. INITIAL EVALUATION & DIAGNOSTIC PROCEDURES........................................................................7 1. HISTORY AND PHYSICAL EXAMINATION (HX & PE) ............................................................8 a. Medical History ..................................................................................................................8 b. Pain History ........................................................................................................................8 c. Medical Management History.............................................................................................9 d. Substance Use/Abuse ..........................................................................................................9 e. Other Factors Affecting Treatment Outcome......................................................................9 f. Physical Examination..........................................................................................................9 2. PERSONALITY/PSYCHOSOCIAL/PSYCHOLOGICAL EVALUATIONS................................10 a. Qualifications....................................................................................................................11 b. Clinical Evaluation............................................................................................................11 c. Tests of Psychological Functioning ..................................................................................12 3. DIAGNOSTIC STUDIES ...............................................................................................................17 4. LABORATORY TESTING ............................................................................................................17 5. INJECTIONSBDIAGNOSTIC........................................................................................................17 a. Medial Branch Blocks.......................................................................................................18 b. Intra-Articular Facet Injections .........................................................................................18 c. Atlanto-Axial and Atlanto-Occipital Injections ................................................................18 d. Sympathetic Injections ......................................................................................................18 e. Peripheral Nerve Blocks ...................................................................................................19 6. SPECIAL TESTS............................................................................................................................19 a. Computer-Enhanced Evaluations ......................................................................................19 b. Functional Capacity Evaluation (FCE) .............................................................................19 c. Job Site Evaluation ...........................................................................................................19 d. Vocational Assessment .....................................................................................................19 e. Work Tolerance Screening................................................................................................20

F. THERAPEUTIC PROCEDURES B NON-OPERATIVE .............................................................................20 1. ACUPUNCTURE ...........................................................................................................................20 a. Acupuncture......................................................................................................................21 b. Acupuncture with Electrical Stimulation ..........................................................................21 c. Other Acupuncture Modalities ..........................................................................................21 2. BIOFEEDBACK.............................................................................................................................21 a. Electromyogram (EMG) ...................................................................................................22 b. Skin Temperature..............................................................................................................22 c. Respiration Feedback (RFB).............................................................................................22 d. Respiratory Sinus Arrhythmia (RSA)................................................................................22 e. Heart Rate Variability (HRV) ...........................................................................................22 f. Electrodermal Response (EDR) ........................................................................................22 g. Electroencephalograph (EEG, QEEG)..............................................................................22 3. COMPLEMENTARY ALTERNATIVE MEDICINE (CAM) .......................................................23 a. Alternative Medical Systems.............................................................................................23 b. Mind-Body Interventions ..................................................................................................23 c. Biological-based Practices ................................................................................................23 d. Body-Based Therapy ........................................................................................................23 e. Energy-Based Practices.....................................................................................................23 4. DISTURBANCES OF SLEEP ........................................................................................................24 5. INJECTIONSCTHERAPEUTIC....................................................................................................24 a. Epidural Steroid Spinal Injections ....................................................................................26 b. Zygoapophyseal (Facet) Injection.....................................................................................27 c. Selective Nerve Root Blocks (SNRB) ..............................................................................27

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d. Trigger Point Injections ....................................................................................................28 e. Botulinum Toxin (Botox) Injection ..................................................................................28 f. Sacroiliac Joint Injection ..................................................................................................29 g. Peripheral Nerve Blocks ...................................................................................................29 6. INTERDISCIPLINARY REHABILITATION PROGRAMS ........................................................30 a. Formal Rehabilitation Programs .......................................................................................32 b. Informal Rehabilitation Program ......................................................................................33 7. MEDICATIONS .............................................................................................................................33 a. Alpha-Acting Agents ........................................................................................................34 b. Anticonvulsants.................................................................................................................35 c. Antidepressants.................................................................................................................36 d. Hypnotics and Sedatives ...................................................................................................37 e. Skeletal Muscle Relaxants ................................................................................................38 f. Opioids..............................................................................................................................39 g. Nonsteroidal Anti-Inflammatory Drugs ............................................................................43 h. Topical Drug Delivery ......................................................................................................43 i. Herbal/Dietary Supplements .............................................................................................44 j. Other Agents .....................................................................................................................44 8. ORTHOTICS/PROSTHETICS/EQUIPMENT...............................................................................45 9. PATIENT EDUCATION................................................................................................................46 10. PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION ..............................47 11. RESTRICTION OF ACTIVITIES..................................................................................................48 12. RETURN-TO-WORK.....................................................................................................................48 a. Job History Interview........................................................................................................48 b. Coordination of Care ........................................................................................................49 c. Communication.................................................................................................................49 d. Establishment of a Return-To-Work Status ......................................................................49 e. Establishment of Activity Level Restrictions....................................................................49 f. Rehabilitation and Return-to-work....................................................................................49 g. Vocational Assistance.......................................................................................................49 13. THERAPYCACTIVE.....................................................................................................................50 a. Activities of Daily Living (ADL)......................................................................................50 b. Aquatic Therapy ...............................................................................................................50 c. Functional Activities .........................................................................................................50 d. Functional Electrical Stimulation......................................................................................51 e. Lumbar Stabilization.........................................................................................................51 f. Neuromuscular Re-education............................................................................................51 g. Therapeutic Exercise.........................................................................................................51 h. Work Conditioning ...........................................................................................................52 i. Work Simulation...............................................................................................................52 14. THERAPYCPASSIVE ...................................................................................................................53 a. Electrical Stimulation (Unattended)..................................................................................53 b. Infrared Therapy ...............................................................................................................53 c. Iontophoresis.....................................................................................................................53 d. Manipulation.....................................................................................................................54 e. MassageCManual or Mechanical .....................................................................................55 f. Mobilization (Joint) ..........................................................................................................55 g. Mobilization (Soft Tissue) ................................................................................................55 h. Superficial Heat and Cold Therapy...................................................................................56 i. TractionCManual..............................................................................................................56 j. TractionCMechanical .......................................................................................................56 k. Transcutaneous Electrical Nerve Stimulation (TENS) .....................................................56 l. Ultrasound.........................................................................................................................57

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