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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsSeptember 2013

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19 DE Admin. Code 1342
A public meeting was held on July 29, 2013, by the Department of Labor to receive public comments relating to revised sections of the Fee Schedule Instructions and Guidelines ("Fee Schedule Instructions"), Forms, Provider Certification, and Utilization Review, as well as revise the Health Care Practice Guidelines to reduce the frequency of some treatment, services, or procedures and clean up language inadvertently left in the original guidelines. Pursuant to 29 Del.C. §10118(a), August 13, 2013, marks the deadline (15 days after the public meeting) to receive written public comments on the above revisions. This addendum lists the additional public comments received. The members of the Health Care Advisory Panel (HCAP) members present at the July 29, 2013, and whose electronic signatures appear below, reaffirm their recommendation that the Secretary of Labor adopt this proposal as it was published in the Register of Regulations, Volume 17, Issue 1 (July 2013), with the properly noted subsequent technical revisions to the anesthesia methodology and revenue neutral language.
The proposed Fee Schedule Instructions and Guidelines; Forms; Provider Certification, Utilization Review; and Health Care Practice Guidelines notice appeared in the Register of Regulations, Volume 17, Issue 1 (July 1, 2013). The Fee Schedule Instructions and Guidelines ("Fee Schedule Instructions"), Forms, Provider Certification, Utilization Review, and Health Care Practice Guidelines are available from the Department of Labor, Division of lndustrial Affairs, Office of Workers' Compensation or on the department's website:
Pursuant to 19 Del.C. §2322C, health care practice guidelines have been adopted and recommended by the Health Care Advisory Panel to guide utilization of health care treatments in workers' compensation including, but not limited to, care provided for the treatment of employees by or under the supervision of a licensed health care provider, prescription drug utilization, inpatient hospitalization and length of stay, diagnostic testing, physical therapy, chiropractic care and palliative care. The health care practice guidelines apply to all treatments provided after the effective date of the regulation adopted by the Department of Labor, May 23, 2008, and regardless of the date of injury.
Services rendered by any health care provider certified pursuant to 19 Del.C. §2322D(a) to provide treatment or services for injured employees shall be presumed, in the absence of contrary evidence, to be reasonable and necessary if such treatment and/or services conform to the most current version of the Delaware health care practice guidelines.
Services provided by any health care provider that is not certified pursuant to 19 Del.C. §2322D(a) shall not be presumed reasonable and necessary unless such services are pre-authorized by the employer or insurance carrier, subject to the exception set forth in 19 Del.C. §2322D(b).
2.1 EDUCATION of the patient and family, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of upper extremity pain and disability. Currently, practitioners often think of education last, after medications, manual therapy and surgery. Practitioners must develop and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers and the community as a whole. An education-based paradigm should always start with inexpensive communication providing reassuring information to the patient. More in-depth education currently exists within a treatment regime employing functional restorative and innovative programs of prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of facilitating self-management of symptoms and prevention.
2.2 TREATMENT PARAMETER DURATION Time frames for specific interventions commence once treatments have been initiated, not on the date of injury. Obviously, duration will be impacted by patient compliance, comorbitities and availability of services. Clinical judgment may substantiate the need to modify the total number of visits discussed in this document. The majority of injured workers with Shoulder Disorders often will achieve resolution of their condition within 6 to 36 visits (Guide to Physical Therapy Practice – Second Edition). It is anticipated that most injured workers will not require the maximum number of visits described in these guidelines. They are designed to be a ceiling and care extending beyond the maximum allowed visits may warrant utilization review.
2.3 ACTIVE INTERVENTIONS emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment, are generally emphasized over passive modalities, especially as treatment progresses. Generally, passive interventions are viewed as a means to facilitate progress in an active rehabilitation program with concomitant attainment of objective functional gains. All rehabilitation programs must incorporate “Active Interventions” no later than three weeks after the onset of treatment. Reimbursement for passive modalities only after the first three weeks of treatment without clear evidence of Active Interventions will require supportive documentation.
2.4 ACTIVE THERAPEUTIC EXERCISE PROGRAM Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and education. This includes functional application in vocational or community settings.
2.5 POSITIVE PATIENT RESPONSE Positive results are defined primarily as functional gains which can be objectively measured. Objective functional gains include, but are not limited to, positional tolerances, range of motion, strength, endurance, activities of daily living, cognition, and efficiency/velocity measures which can be quantified. Subjective reports of pain and function should be considered and given relative weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on objective findings.
2.6 RE-EVALUATE TREATMENT EVERY 3-4 WEEKS If a given treatment or modality is not producing positive results within 3-4 weeks, the treatment should be either modified or discontinued. Reconsideration of diagnosis should also occur in the event of poor response to a seemingly rational intervention.
2.7 SURGICAL INTERVENTIONS Surgery should be contemplated within the context of expected functional outcome and not purely for the purpose of pain relief. The concept of "cure" with respect to surgical treatment by itself is generally a misnomer. All operative interventions must be based upon positive correlation of clinical findings, clinical course and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with positive identification of pathologic condition(s).
2.8 SIX-MONTH TIME FRAME Since the prognosis drops precipitously for returning an injured worker to work once he/she has been temporarily totally disabled for more than six months, the emphasis within these guidelines is to move patients along a continuum of care and return-to-work within a six-month time frame, whenever possible. It is important to note that time frames may not be pertinent to injuries which do not involve work-time loss or are not occupationally related.
2.9 RETURN-TO-WORK Even if there is residual chronic pain, return-to-work is not necessarily contraindicated. Return-to-work may be therapeutic, assuming the work is not likely to aggravate the basic problem or increase long-term pain. The practitioner must write detailed restrictions when returning a patient to limited duty. The following functions should be considered and modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, bending at the waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors. The patient should never be released to "sedentary or light duty" without specific physical limitations. The practitioner must understand all of the physical, demands of the patient's job position before returning the patient to full duty and should request clarification of the patient's job duties.
2.10 DELAYED RECOVERY The Department recognizes that not of all industrially injured patients will not recover within the time lines outlined in this document despite optimal care. Such individuals may require treatments beyond the limits discussed within this document, but such treatment will require clear documentation by the authorized treating practitioner focusing on objective functional gains afforded by further treatment and impact upon prognosis.
3.1 HISTORY TAKING AND PHYSICAL EXAMINATION provides information common to all injuries through a discussion of provider procedures which should be applied to each patient, regardless of the injury and diagnosis (this subsection is standard to all Division medical treatment guidelines).
3.2 SPECIFIC DIAGNOSIS, TESTING AND TREATMENT PROCEDURES provides information unique to each of the following work-related injuries/syndromes/disorders:
3.3 MEDICATION provides information common to all injuries through detailed discussions of referenced medications with indications for expected time to produce effect, frequency, and optimum and maximum durations.
3.4 NON-OPERATIVE TREATMENT PROCEDURES provides information common to all injuries through detailed discussions of referenced therapeutic procedures with indications for expected time to produce effect, frequency, and optimum and maximum durations.
4.1 HISTORY TAKING should address at least the following for each shoulder injury diagnosis:
4.2 PHYSICAL FINDINGS are specific to and addressed within each shoulder injury diagnosis noted in this section. Given the complexity of the shoulder mechanism, an evaluation for concomitant injury should be considered.
5.1 ACROMIOCLAVICULAR JOINT SPRAINS/DISLOCATIONS An acute acromioclavicular (AC) joint injury is frequently referred to as a shoulder separation. There are six classifications of an AC joint separation which are based upon the extent of ligament damage and bony displacement:
5.1.1 History and Initial Diagnostic Procedures (AC Joint Sprains/Dislocations):
5.1.2 Physical Findings (AC Joint Sprains/Dislocations) may include:
5.1.3 Laboratory Tests (AC Joint Sprains/Dislocations): are not indicated unless a systemic illness or disease is suspected.
5.1.4 Testing Procedures (AC Joint Sprains/Dislocations):
5.1.5 Non-operative Treatment Procedures (AC Joint Sprains/Dislocations): may include:
5.1.6 Operative Procedures (AC Joint Sprains/Dislocations):
5.1.7 Post-Operative Procedures (AC Joint Sprains/Dislocations): should be coordinated by the orthopedic physician working with the interdisciplinary team. Keeping with the therapeutic and rehabilitation procedures found in this Section 5.3.5. Non-operative Treatment Procedures, the patient could be immobilized for 2-3 weeks, restricted in activities, both work-related and avocational for 8-12 weeks while undergoing rehabilitation, and be expected to progress to return to full duty based upon the his/her response to rehabilitation and the demands of the job.
5.2 ADHESIVE CAPSULITIS/FROZEN SHOULDER DISORDERS Adhesive capsulitis of the shoulder, also known as frozen shoulder disorder, is a soft tissue lesion of the glenohumeral joint resulting in restrictions of passive and active range of motion. Occupational adhesive capsulitis arises secondarily to any chest or upper extremity trauma. Primary adhesive capsulitis is rarely occupational in origin. The disorder goes through stages, specifically:
5.2.1 History and Initial Diagnostic Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder):
5.2.2 Physical Findings (Adhesive Capsulitis/Frozen Shoulder Disorder): Restricted active and passive glenohumeral range of motion is the primary physical finding. It may be useful for the examiner to inject the glenohumeral joint with lidocaine and then repeat range of motion to rule out other shoulder pathology; lack of range of motion confirms the diagnosis. Postural changes and secondary trigger points along with atrophy of the deltoid and supraspinatus muscles may be seen.
5.2.3 Laboratory Tests (Adhesive Capsulitis/Frozen Shoulder Disorder): are not indicated unless systemic illness or disease is suspected.
5.2.4 Testing Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder):
5.2.5 Non-operative Treatment (Adhesive Capsulitis/Frozen Shoulder Disorder): address the goal to restore and maintain function and may include:
5.2.6 Operative Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder): For cases failing conservative therapy of at least 3-6 months duration and which are significantly limited in range-of-motion (abduction less than 90°), the following operative procedures may be considered:
5.2.7 Post-Operative Procedures (Adhesive Capsulitis/Frozen Shoulder Disorder): would include an individualized rehabilitation program based upon communication between the surgeon and the therapist.
5.3 BICIPITAL TENDON DISORDERS Disorders may include 1) primary bicipital tendinitis which is exceedingly rare; 2) secondary bicipital tendinitis which is generally associated with rotator cuff tendinitis or impingement syndrome (see appropriate diagnosis subsections); 3) subluxation of the biceps tendon which occurs with dysfunction of the transverse intertubercular ligament and massive rotator cuff tears; and 4) acute disruption of the tendon which can result from an acute distractive force or transection of the tendon from direct trauma.
5.3.1 History and Initial Diagnostic Procedures (Bicipital Tendon Disorders):
5.3.2 Physical Findings (Bicipital Tendon Disorders): may include:
5.3.3 Laboratory Tests (Bicipital Tendon Disorders): are not indicated unless a systemic illness or disease is suspected.
5.3.4 Testing Procedures (Bicipital Tendon Disorders):
5.3.5 Non-operative Treatment Procedures (Bicipital Tendon Disorders):
5.3.6 Operative Procedures (Bicipital Tendon Disorders):
5.3.7 Post-Operative Procedures (Bicipital Tendon Disorders): would include an individualized rehabilitation program either self-directed or in a supervised setting. Rehabilitation, lasting 6-12 weeks, is often necessary. Rehabilitation procedures discussed in Section 5.3.5, Non-operative Treatment Procedures should be referenced and used.
5.4 BRACHIAL PLEXUS INJURIES to the nerves and shoulder girdle region resulting in loss of motor and sensory function, pain and instability of the shoulder. Signs and symptoms vary with the degree of mechanism of injury. The two modes of injury are: 1) acute direct trauma, and 2) repetitive motion or overuse. Transient compression, stretch or traction (neuropraxia) causes sensory and motor signs lasting days to weeks. Damage to the axon (axonomesis) without disruption of the nerve framework may cause similar symptoms. The recovery time is delayed and depends upon axon regrowth distally from the site of injury. Laceration or disruption of the entire nerve with complete loss of framework (neuromesis) is the most severe form of nerve injury. Return of function is dependent upon regrowth of the nerve distal to the injury site.
5.4.1 Brachial Plexus: is formed by the nerve roots of C5-C8 and T1; these nerve roots exit the cervical spine and pass through the scalene musculature; after leaving the scalene musculature, at the level of the clavicle, they form trunks, divisions and chords which ultimately form the peripheral nerves of the arm.
5.4.2 Axillary Nerve: is derived from the 5th and 6th cervical roots; it passes around the shoulder and supplies motor branches to the teres minor and the three heads of the deltoid; it gives sensation to the top of the shoulder at the level of the deltoid.
5.4.3 Long Thoracic Nerve: is formed by the cervical fifth, sixth, and seventh roots; it crosses the border of the first rib and descends along the posterior surface of the thoracic wall to the serratus anterior.
5.4.4 Musculocutaneous Nerve: is derived from the fifth and sixth cervical roots; it innervates the coracobrachialis, biceps and brachioradialis muscles and also provides sensation to the lateral aspect of the forearm; trauma (including surgery) or penetrating wound to the brachial plexus, coracobrachialis, and shoulder often can cause nerve injury.
5.4.5 Spinal Accessory Nerve: is the eleventh cranial nerve; the nerve innervates the ipsilateral sternocleidomastoid and trapezius muscles which are extremely important for scapular control and ultimately shoulder function.
5.4.6 Suprascapular Nerve: is derived from the fifth and sixth cervical root, superior trunk of the brachial plexus, and it innervates the supraspinatus and infraspinatus muscles of the rotator cuff.
5.5 BURSITIS OF THE SHOULDER Acute or chronic inflammation of the bursa (a potential fluid filled sac) that may be caused by trauma, chronic overuse, inflammatory arthritis, and acute or chronic infection that generally presents with localized pain and tenderness of the shoulder.
5.5.1 History and Initial Diagnostic Procedures (Bursitis of the Shoulder):
5.5.2 Physical Findings (Bursitis of the Shoulder): may include:
5.5.3 Laboratory Tests (Bursitis of the Shoulder): may be used to rule out systemic illness or disease when proper clinical presentation indicates the necessity for such testing. Testing could include sedimentation rate, rheumatoid profile, complete blood count (CBC) with differential, serum uric acid level, routine screening of other medical disorders may be necessary, as well as bursal aspiration with fluid analysis.
5.5.4 Testing Procedures (Bursitis of the Shoulder):
5.5.5 Non-operative Treatment Procedures (Bursitis of the Shoulder):
5.5.6 Operative Procedures (Bursitis of the Shoulder): are not commonly indicated for pure bursitis; refer to other appropriate diagnoses in Section 5.0. Specific Diagnosis, Testing and Treatment Procedures.
5.6 IMPINGEMENT SYNDROME A collection of symptoms, not a pathologic diagnosis. The symptoms result from the encroachment of the acromion, coracoacromial ligament, coracoid process, and/or the AC joint of the rotator cuff mechanism that passes beneath them as the shoulder is moved. The cuff mechanism is intimately related to the coracoacromial arch. Separated only by the thin lubricating surfaces of the bursa, compression and friction can be minimized by several factors, such as
5.6.1 History and Initial Diagnostic Procedures (Impingement Syndrome):
5.6.2 Physical Findings (Impingement Syndrome): may include:
5.6.3 Laboratory Tests (Impingement Syndrome): are not indicated unless a systemic illness or disease is suspected.
5.6.4 Testing Procedures (Impingement Syndrome):
5.6.5 Non-operative Treatment Procedures (Impingement Syndrome) may include:
5.6.6 Operative Procedures (Impingement Syndrome): should restore functional anatomy by reducing the potential for repeated impingement; procedures might include distal clavicular resection, coracoacromial ligament release, and/or acromioplasty.
5.6.7 Post-Operative Procedures (Impingement Syndrome): would include an individualized rehabilitation program based upon communication between the surgeon and the therapist.
5.7 ROTATOR CUFF TEAR Partial- or full-thickness tears of the rotator cuff tendons, most often the supraspinatus can be caused by vascular, traumatic or degenerative factors or a combination. Further tear classification includes: a small tear is less than 1cm; medium tear is 1-3cm; large tear is 3-5cm; and massive tear is greater than 5cm, usually with retraction.
5.7.1 History and Initial Diagnostic Procedures (Rotator Cuff Tear):
5.7.2 Physical Findings (Rotator Cuff Tear) may include:
5.7.3 Laboratory Tests (Rotator Cuff Tear): are not indicated unless a systemic illness or disease is suspected.
5.7.4 Testing Procedures (Rotator Cuff Tear):
5.7.5 Non-operative Treatment Procedures (Rotator Cuff Tear): Relative rest and procedures outlined in Section 5.3.5. Non-operative Treatment Procedures, such as immobilization, therapeutic exercise, alteration of occupation/work station, thermal treatment, TENS unit, therapeutic ultrasound, return-to-work, biofeedback and physical medicine and rehabilitation. If no increase in function for a partial- or full-thickness tear is observed after 6-8 weeks, a surgical consultation is indicated. Early surgical intervention produces better surgical outcome due to healthier tissues and often less limitation of movement prior to and after surgery.
5.7.6 Operative Procedures (Rotator Cuff Tear): options would include arthroscopic repair or an open debridement and repair. Goals of surgical intervention are to restore functional anatomy by reestablishing continuity of the rotator cuff, and to reduce the potential for repeated impingement by the performance of procedures such as distal clavicular resection, coracoacromial ligament release, and/or anterior acromioplasty (subacromial decompression).
5.7.7 Post-Operative Procedures (Rotator Cuff Tear): would include an individualized rehabilitation program either home based or in conjunction with supervised therapy.
5.8 ROTATOR CUFF TENDINITIS Inflammation of one or more of the four musculotendinous structures which arise from the scapula and insert on the lesser or greater tuberosity of the humerus. These structures include one internal rotator (subscapularis), and two external rotators (infraspinatus and teres minor), and the supraspinatus which assists in abduction.
5.8.1 History and Initial Diagnostic Procedures (Rotator Cuff Tendinitis):
5.8.2 Physical Findings (Rotator Cuff Tendinitis) may include:
5.8.3 Laboratory Tests (Rotator Cuff Tendinitis): are not indicated unless a systemic illness or disease is suspected.
5.8.4 Testing Procedures (Rotator Cuff Tendinitis) may include:
5.8.5 Non-operative Treatment Procedures (Rotator Cuff Tendinitis) may include:
5.9 SHOULDER FRACTURES There are five common types of shoulder fractures; each type will be addressed separately and in the order of most frequent occurrence.
5.9.1 Clavicular Fracture:
5.9.2 Proximal Humeral Fractures:
5.9.3 Humeral Shaft Fractures:
5.9.4 Scapular Fractures:
5.9.5 Sternoclavicular Dislocation/Fracture:
5.10 SHOULDER INSTABILITY Subluxation (partial dislocation) or dislocation of the glenohumeral joint in either an anterior, interior, posterior or multidirectional position.
5.10.1 History and Initial Diagnostic Procedures (Shoulder Instability):
5.10.2 Physical Findings (Shoulder Instability) may include:
5.10.3 Laboratory Tests (Shoulder Instability): are not indicated unless a systemic illness or disease is suspected.
5.10.4 Testing Procedures (Shoulder Instability):
5.10.5 Non-operative Treatment Procedures (Shoulder Instability):
5.10.6 Operative Procedures (Shoulder Instability):
5.10.7 Post-Operative Procedures (Shoulder Instability): would include an individualized rehabilitation program. Depending upon the type of surgery, the patient will be immobilized for 3-6 weeks. As soon as it is safe to proceed without damaging the repair, progressive therapy, either home based or with consultation involving an occupational and/or physical therapist should begin with therapeutic exercise, physical medicine and rehabilitation (refer to Section 5.3.5. Non-operative Treatment Procedures). During this period of time, the patient could resume working when:
6.1 ACUPUNCTURE is an accepted and widely used procedure for the relief of pain and inflammation. There is some scientific evidence to support its use. The exact mode of action is only partially understood. Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the brain, promotes deep relaxation, and affects the release of neurotransmitters. Acupuncture is commonly used as an alternative or in addition to traditional Western pharmaceuticals. While it is commonly used when pain medication is reduced or not tolerated, it may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten the return of functional activity. Acupuncture should be performed by MD, DO[, or] DC with appropriate training[; or a licensed acupuncturist].
6.1.1 Acupuncture: is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points). Needles may be inserted, manipulated and retained for a period of time. Acupuncture can be used to reduce pain and inflammation, and to increase blood flow to an area and increase range of motion. Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain.
6.1.3 Other Acupuncture Modalities: Acupuncture treatment is based on individual patient needs and therefore treatment may include a combination of procedures to enhance treatment effect. Other procedures may include the use of heat, soft tissue manipulation/massage, and exercise.
6.2 BIOFEEDBACK is a form of behavioral medicine that helps patients learn self-awareness and self-regulation skills for the purpose of gaining greater control of their physiology, such as muscle activity, brain waves, and measures of autonomic nervous system activity. Electronic instrumentation is used to monitor the targeted physiology and then displayed or fed back to the patient visually, auditorially, or tactilely, with coaching by a biofeedback specialist. Biofeedback is provided by clinicians certified in biofeedback and/or who have documented specialized education, advanced training, or direct or supervised experience qualifying them to provide the specialized treatment needed (e.g., surface EMG, EEG, or other).
6.3 INJECTIONS – THERAPEUTIC are generally accepted, well-established procedures that may play a significant role in the treatment of patients with upper extremity pain or pathology. Therapeutic injections involve the delivery of anesthetic and/or anti-inflammatory medications to the painful structure. Therapeutic injections have many potential benefits. Ideally, a therapeutic injection will: (a) reduce inflammation in a specific target area; (b) relieve secondary muscle spasm; and (c) diminish pain and support therapy directed to functional recovery. Diagnostic and therapeutic injections should be used early and selectively to establish a diagnosis and support rehabilitation. If injections are overused or used outside the context of a monitored rehabilitation program, they may be of significantly less value.
6.3.1 Steroid Injections: may provide both diagnostic and therapeutic value in treating a variety of shoulder disorders. These include biceps tendonitis, bursitis, rotator cuff tendonitis and impingement syndrome.
6.3.2 Trigger Point Injections: are generally accepted, although used infrequently in uncomplicated cases. They may, however, be used to relieve myofascial pain and facilitate active therapy and stretching of the affected areas, and as an adjunctive treatment in combination with other treatment modalities, such as functional restoration programs, including stretching therapeutic exercise. Trigger point injections should be utilized primarily for the purpose of facilitating functional progress. The Division does not recommend their routine use in the treatment of upper extremity injuries.
6.4 JOB SITE ALTERATION Early evaluation and training of body mechanics and other ergonomic factors are essential for every injured worker and should be done by a qualified individual. In some cases, this requires a job site evaluation. Some evidence supports alteration of the work site in the early treatment of non-traumatic Shoulder Disorders. There is no single factor or combination of factors that is proven to prevent or ameliorate Shoulder Disorders, but a combination of ergonomic are generally considered to be important. Physical factors that may be considered include use of force, repetition, awkward positions, upper extremity vibration, cold environment, and contact pressure on the nerve.
6.5.1 NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs) are probably the most useful medications in acute and chronic shoulder injury. In mild cases, they may be the only drug required for analgesia. There are several classes of NSAIDs and the response of the individual patient to a specific medication is unpredictable. For this reason, a range of anti-inflammatory medications may be tried in each case with the most effective preparation being continued.
6.5.2 ANALGESICS (acetaminophen and aspirin are the common choice for non-narcotic analgesia.
6.5.3 PSYCHOTROPIC MEDICATION may be used in patients with a high level of anxiety or depression. A variety of psychotropic drugs may be used. In acute or subacute shoulder injury, these medications are generally unnecessary except for the use of tricyclic antidepressants as substitutes for hypnotics and/or analgesics. In most cases, major tranquilizers, anxiolytics and antidepressants are reserved for chronic pain disorders. Patients, whose chief complaint is shoulder injury, but require use of major tranquilizers or anxiolytics for greater than two weeks. In particular, benzodiazepams are almost always contraindicated in patients with shoulder injury unless a severe anxiety state exist requiring psychiatric supervision or in cases of extremely severe, objectively visualized acute muscle spasm. In this type of acute scenario, the maximum duration for benzodiazepam administration should be limited to less than five days.
6.5.4 HYPNOTICS may be given to shoulder injury sufferers because of a chief complaint of "inability to sleep." Such medication must be used with caution because of their dependence-producing capabilities. The Division recommends consideration of sedating tricyclic antidepressants as an alternative when necessary. Physical methods of restoring a normal sleep pattern can usually be employed as an alternative to medication.
6.5.5 NARCOTICS should be primarily reserved for the treatment of acute shoulder injury or the treatment of patients with objectively documented acute exacerbations. The action of these drugs is central, affecting the patient's perception of pain rather than the pain process itself.
6.5.6 MINOR TRANQUILIZERS/MUSCLE RELAXANTS should be primarily reserved for the treatment of acute shoulder with muscle spasm or the treatment of patients with objectively documented acute exacerbations. Muscle relaxants may have a significant effect on the early phases of acute shoulder disorders. Their action is central and with no effect on the neuromuscular junction of the muscles themselves. Purported peripheral effects are difficult to separate from the anxiolytic central action.
6.7 PATIENT EDUCATION No treatment plan is complete without addressing issues of individual patient and/or group education as a means of prolonging the beneficial effects of treatment, as well as facilitating self-management of symptoms and injury prevention. The patient should take an active role in the establishment of functional outcome goals, and should be educated on his or her specific injury, assessment findings, and plan of treatment. Education and instruction in proper body mechanics and posture, positions to avoid task/tool adaptation, self-care for exacerbation of symptoms, and home exercise/task adaptation should also be addressed.
6.8 RETURN-TO-WORK is therapeutic, assuming the work is not likely to aggravate the basic problem or increase long-term pain. The practitioner must provide specific physical limitations per the Physician’s Form. The following physical limitations should be considered and modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, bending at the waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors. Even if there is residual chronic pain, return-to-work is not necessarily contraindicated.
6.9 SLEEP DISTURBANCES are a common secondary symptom of CTD. Although primary insomnia may accompany pain as an independent co-morbid condition, it more commonly occurs, secondary to the pain condition itself. Exacerbations of pain often are accompanied by exacerbations of insomnia; the reverse can also occur. Sleep laboratory studies have shown disturbances of sleep architecture in pain patients. Loss of deep slow-wave sleep and increase in light sleep occur and sleep efficiency, the proportion of time in bed spent asleep, is decreased. These changes are associated with patient reports of non-restorative sleep.
6.10 THERAPY–PASSIVE includes those treatment modalities that do not require energy expenditure on the part of the patient. They are principally effective during the early phases of treatment and are directed at controlling symptoms such as pain, inflammation and swelling and to improve the rate of healing soft tissue injuries. They should be used in adjunct with active therapies to help control swelling, pain and inflammation during the rehabilitation process. They may be used intermittently as a therapist deems appropriate or regularly if there are specific goals with objectively measured functional improvements during treatment.
6.10.1 Electrical Stimulation (Unattended and Attended): once applied, requires minimal on-site supervision by the physician or non-physician provider. Indications include pain, inflammation, muscle spasm, atrophy, and decreased circulation.
6.10.2 Extracorporeal shock wave treatment: Consists of the application of pulses of high pressure sound to soft tissues, similar to lithotriptors. It has been investigated for its effectiveness in the treatment of Calcific Tendonitis. It has not been shown to have an advantage over other conservative treatments and remains investigational. It is not recommended.
6.10.3 Iontophoresis: is the transfer of medication, including, but not limited to, steroidal anti-inflammatories and anesthetics, through the use of electrical stimulation. Indications include pain (Lidocaine), inflammation (hydrocortisone, salicylate), edema (mecholyl, hyaluronidase, salicylate), ischemia (magnesium, mecholyl, iodine), muscle spasm (magnesium, calcium), calcific deposits (acetate), scars and keloids (chlorine, iodine, acetate).
6.10.4 Laser irradiation: Consists of the external application of an array of visible and infrared wavelengths to soft tissues. Frequency and duration are dependent on severity and chronicity of problem.
6.10.5 Manual Therapy Techniques: are passive interventions in which the providers use his or her hands to administer skilled movements designed to modulate pain; increase joint range of motion; reduce/eliminate soft tissue swelling, inflammation, or restriction; induce relaxation; and improve contractile and non-contractile tissue extensibility. These techniques are applied only after a thorough examination is performed to identify those for whom manual therapy would be contraindicated or for whom manual therapy must be applied with caution. MANIPULATION: is generally accepted, well-established and widely used therapeutic intervention for low back pain. Manipulative Treatment (not therapy) is defined as the therapeutic application of manually guided forces by an operator to improve physiologic function and/or support homeostasis that has been altered by the injury or occupational disease, and has associated clinical significance. MOBILIZATION (Joint) /Manipulation MOBILIZATION (Soft Tissue)
Nerve Gliding: consist of a series of flexion and extension movements of the hand, wrist, elbow, shoulder, and neck that produce tension and longitudinal movement along the length of the median and other nerves of the upper extremity. These exercises are based on the principle that the tissues of the peripheral nervous system are designed for movement, and that tension and glide (excursion) of nerves may have an effect on neurophysiology through alterations in vascular and axoplasmic flow. Biomechanical principles have been more thoroughly studied than clinical outcomes. Nerve gliding performed on a patient by the clinician should be reinforced by patient performance of similar techniques as part of a home exercise program at least twice per day.
6.10.6 Massage: Manual or Mechanical - Massage is manipulation of soft tissue with broad ranging relaxation and circulatory benefits. This may include stimulation of acupuncture points and acupuncture channels (acupressure), application of suction cups and techniques that include pressing, lifting, rubbing, pinching of soft tissues by or with the practitioner’s hands. Indications include edema, muscle spasm, adhesions, the need to improve peripheral circulation and range of motion, or to increase muscle relaxation and flexibility prior to exercise.
6.10.7 Orthotics/Immobilization with Splinting: is a generally accepted, well-established and widely used therapeutic procedure. Splints may be effective when worn at night or during portions of the day, depending on activities. Splints should be loose and soft enough to maintain comfort while supporting the involved joint in a relatively neutral position. Splint comfort is critical and may affect compliance. Although off-the-shelf splints are usually sufficient, custom thermoplastic splints may provide better fit for certain patients.
6.10.8 Superficial Heat and Cold Therapy: are thermal agents applied in various manners that lowers or raises the body tissue temperature for the reduction of pain, inflammation, and/or effusion resulting from injury or induced by exercise. Includes application of heat just above the surface of the skin at acupuncture points. Indications include acute pain, edema and hemorrhage, need to increase pain threshold, reduce muscle spasm and promote stretching/flexibility. Cold and heat packs can be used at home as an extension of therapy in the clinic setting.
Maximum duration: 18 12 visits, with maximum visits 1 per day. If symptoms persist, consideration should be given to further diagnostic studies or other treatment options.
6.10.9 Ultrasound: uses sonic generators to deliver acoustic energy for therapeutic thermal and/or nonthermal soft tissue effects. Indications include scar tissue, adhesions, collagen fiber and muscle spasm, and to improve muscle tissue extensibility and soft tissue healing. Ultrasound with electrical stimulation is concurrent delivery of electrical energy that involves dispersive electrode placement. Indications include muscle spasm, scar tissue, pain modulation and muscle facilitation. Phonophoresis is the transfer of medication to the target tissue to control inflammation and pain through the use of sonic generators. These topical medications include, but are not limited to, steroidal anti-inflammatory and anesthetics.
6.11 THERAPY–ACTIVE therapies are based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion, and alleviating discomfort. Active therapy requires an internal effort by the individual to complete a specific exercise or task, and thus assists in developing skills promoting independence to allow self-care after discharge. This form of therapy requires supervision from a therapist or medical provider such as verbal, visual, and/or tactile instructions. At times a provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is predominately executed by the patient.
6.11.1 Activities of Daily Living: Supervised instruction, active-assisted training, and/or adaptation of activities or equipment to improve a person’s capacity in normal daily living activities such as self-care, work re-integration training, homemaking, and driving.
6.11.2 Aquatic Therapy: is a well-accepted treatment which consists of the therapeutic use of aquatic immersion for therapeutic exercise to promote strengthening, core stabilization, endurance, range of motion, flexibility, body mechanics, and pain management. Aquatic therapy includes the implementation of active therapeutic procedures in a swimming or therapeutic pool. The water provides a buoyancy force that lessens the amount of force gravity applies to the body. The decreased gravity effect allows the patient to have a mechanical advantage and more likely have a successful trial of therapeutic exercise. The therapy may be indicated for individuals who:
6.11.3 Functional Activities: are the use of therapeutic activity to enhance mobility, body mechanics, employability, coordination, and sensory motor integration.
6.11.4 Neuromuscular Re-education: is the skilled application of exercise with manual, mechanical, or electrical facilitation to enhance strength, movement patterns, neuromuscular response, proprioception, kinesthetic sense, coordination education of movement, balance, and posture. Indications include the need to promote neuromuscular responses through carefully timed proprioceptive stimuli, to elicit and improve motor activity in patterns similar to normal neurologically developed sequences, and improve neuromotor response with independent control.
6.11.5 Proper Work Techniques: Please refer to the “Job Site Evaluation” and “Job Site Alteration” sections of these guidelines.
6.11.6 Therapeutic Exercise: with or without mechanical assistance or resistance may include isoinertial, isotonic, isometric and isokinetic types of exercises. Indications include the need for cardiovascular fitness, reduced edema, improved muscle strength, improved connective tissue strength and integrity, increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle recruitment, increased range of motion, and are used to promote normal movement patterns. Can also include complimentary/alternative exercise movement therapy.
6.12 RESTRICTION OF ACTIVITIES Continuation of normal daily activities is the recommendation for most Shoulder Disorders with or without neurologic symptoms. Complete work cessation should be avoided, if possible, since it often further aggravates the pain presentation. Modified return-to-work is almost always more efficacious and rarely contraindicated in the vast majority of injured workers with Shoulder Disorders.
6.13 VOCATIONAL REHABILITATION is a generally accepted intervention. Initiation of vocational rehabilitation requires adequate evaluation of patients for quantification of highest functional level, motivation, and achievement of maximum medical improvement. Vocational rehabilitation may be as simple as returning to the original job or as complicated as being retrained for a new occupation.
Last Updated: December 31 1969 19:00:00.
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