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´╗┐RULE 17, EXHIBIT 7

Complex Regional Pain Syndrome/

Reflex Sympathetic Dystrophy

Medical Treatment Guidelines

Revised: December 27, 2011

Effective: February 14, 2012

Adopted: November 4, 1996 Revised: January 8, 1998 Revised: May 27, 2003 Revised: September 29, 2005

Effective: December 30, 1996 Effective: March 15, 1998 Effective: July 30, 2003 Effective: January 1, 2006

Presented by:

State of Colorado

Department of Labor and Employment DIVISION OF WORKERS' COMPENSATION

TABLE OF CONTENTS

SECTION

DESCRIPTION

PAGE

A.

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

B.

GENERAL GUIDELINES PRINCIPLES ....................................................................................2

1.

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

2.

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

3.

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

4.

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

5.

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

6.

POSITIVE PATIENT RESPONSE ..............................................................................................2

7.

RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS.............................................................2

8.

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

9.

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

10.

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

11.

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

12.

GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE ...................3

13.

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

C.

INTRODUCTION TO COMPLEX REGIONAL PAIN SYNDROME ............................................5

D.

DEFINITIONS ............................................................................................................................6

E.

INITIAL EVALUATION ..............................................................................................................8

1.

HISTORY TAKING AND PHYSICAL EXAMINATION (Hx & PE) ...............................................8

a.

Medical History.............................................................................................................8

b.

Pain History..................................................................................................................9

c.

Medical Management History.....................................................................................10

d.

Substance Use/Abuse................................................................................................11

e.

Other Factors Affecting Treatment Outcome..............................................................11

f.

Physical Examination .................................................................................................11

F.

DIAGNOSTIC CRITERIA AND PROCEDURES......................................................................13

1.

DIAGNOSIS OF CRPS.............................................................................................................13

2.

DIAGNOSTIC COMPONENTS OF CLINICAL CRPS...............................................................15

3.

DIAGNOSTIC COMPONENTS OF CONFIRMED CRPS .........................................................16

4.

SYMPATHETICALLY MEDIATED PAIN (SMP) .......................................................................17

5.

NOT CRPS OR SMP................................................................................................................17

6.

DIAGNOSTIC IMAGING...........................................................................................................17

a.

Plain Film Radiography ..............................................................................................17

b.

Triple Phase Bone Scan.............................................................................................17

7.

INJECTIONS ? DIAGNOSTIC SYMPATHETIC........................................................................18

a.

Stellate Ganglion Block ..............................................................................................19

b.

Lumbar Sympathetic Block.........................................................................................19

c.

Phentolamine Infusion Test........................................................................................19

8.

THERMOGRAPHY (INFRARED STRESS THERMOGRAPHY) ..............................................19

a.

Cold Water Stress Test (Cold Pressor Test) ..............................................................20

b.

Warm Water Stress Test ............................................................................................20

c.

Whole Body Thermal Stress.......................................................................................20

9.

AUTONOMIC TEST BATTERY ................................................................................................20

a.

Infrared Resting Skin Temperature (RST)..................................................................21

b.

Resting Sweat Output (RSO) .....................................................................................21

c.

Quantitative Sudomotor Axon Reflex Test (QSART)..................................................21

10.

OTHER DIAGNOSTIC TESTS NOT SPECIFIC FOR CRPS....................................................21

a.

Electrodiagnostic Procedures.....................................................................................21

b.

Laboratory Tests ........................................................................................................21

c.

Peripheral Blood Flow (Laser Doppler or Xenon Clearance Techniques) ..................22

11.

PERSONALITY/PSYCHOSOCIAL/PSYCHOLOGICAL EVALUATIONS FOR

PAIN MANAGEMENT ..............................................................................................................22

12.

SPECIAL TESTS......................................................................................................................33

G. THERAPEUTIC PROCEDURES ? NON-OPERATIVE ...........................................................36

1.

ACUPUNCTURE ......................................................................................................................36

2.

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

3.

COMPLEMENTARY ALTERNATIVE MEDICINE (CAM)..........................................................40

4.

DISTURBANCES OF SLEEP ...................................................................................................41

5.

INJECTIONS ? THERAPEUTIC ...............................................................................................43

a.

Sympathetic Injections ...............................................................................................43

b.

Trigger Point Injections...............................................................................................44

c.

Peripheral Nerve Blocks.............................................................................................45

d.

Other Intravenous Medications and Regional Blocks ...........................................45

e.

Continuous Brachial Plexus Infusion .............................................................45

f.

Epidural Infusions ..........................................................................................45

g.

Ketamine ........................................................................................................45

6.

INTERDISCIPLINARY REHABILITATION PROGRAMS..........................................................45

a.

Formal Interdisciplinary Rehabilitation Programs .......................................................48

b.

Informal Interdisciplinary Rehabilitation Programs .....................................................49

c.

Opioid/Chemical Treatment Programs .......................................................................50

7.

MEDICATIONS AND MEDICAL MANAGEMENT .....................................................................52

a.

CRPS-specific medications ........................................................................................53

b

Alpha-acting agents....................................................................................................55

c.

Anticonvulsants ..........................................................................................................56

d.

Antidepressants .........................................................................................................58

e.

Hypnotics and sedatives ............................................................................................61

f.

Marijuana ...................................................................................................................62

g.

Non-steroidal anti inflammatory drugs (NSAIDS) .......................................................64

h.

Opioids .......................................................................................................................65

i.

Skeletal muscle relaxants...........................................................................................76

j.

Topical drug delivery ..................................................................................................79

k.

Tramadol ....................................................................................................................81

8.

ORTHOTICS/PROSTHETICS/EQUIPMENT............................................................................82

9.

PATIENT EDUCATION ............................................................................................................82

10.

PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION........................... 83

11.

RESTRICTION OF ACTIVITIES...............................................................................................86

12.

RETURN-TO-WORK ................................................................................................................86

a.

Job History Interview ..................................................................................................87

b.

Coordination of Care ..................................................................................................87

c.

Communication ..........................................................................................................87

d.

Establishment of Return-to-Work Status ....................................................................87

e.

Establishment of Activity Level Restrictions ...............................................................87

f.

Rehabilitation and Return to Work .............................................................................88

g.

Vocational Assistance ................................................................................................88

13.

THERAPY ? ACTIVE................................................................................................................88

a.

Activities of Daily Living (ADL) ...................................................................................89

b.

Aquatic Therapy .........................................................................................................89

c.

Functional Activities....................................................................................................90

d.

Gait Training...............................................................................................................90

e.

Mirror Therapy Graded Motor Imagery .....................................................................................91

f.

Neuromuscular Re-education.....................................................................................91

g.

Stress Loading ...........................................................................................................91

h.

Therapeutic Exercise..................................................................................................91

i.

Work Conditioning ......................................................................................................92

j.

Work Simulation .........................................................................................................92

14.

THERAPY ? PASSIVE .............................................................................................................93

a.

Continuous Passive Motion (CPM).............................................................................93

b.

Fluidotherapy .............................................................................................................94

d.

Paraffin Bath ..............................................................................................................94

e.

Desensitization ...........................................................................................................94

f.

Superficial Heat Therapy............................................................................................94

H.

THERAPEUTIC PROCEDURES ? OPERATIVE.....................................................................96

1.

NEUROSTIMULATION ............................................................................................................96

2.

PERIPHERAL NERVE STIMULATION ..................................................................................100

3.

INTRATHECAL DRUG DELIVERY ........................................................................................100

4.

SYMPATHECTOMY ...............................................................................................................101

5.

AMPUTATION ........................................................................................................................102

I.

MAINTENANCE MANAGEMENT .........................................................................................103

1.

HOME EXERCISE PROGRAMS AND EXERCISE EQUIPMENT ..........................................103

2.

EXERCISE PROGRAMS REQUIRING SPECIAL FACILITIES ..............................................104

3.

PATIENT EDUCATION MANAGEMENT................................................................................104

4.

PSYCHOLOGICAL MANAGEMENT ......................................................................................104

5.

NON-OPIOID MEDICATION MANAGEMENT........................................................................104

6.

VITAMIN C .............................................................................................................................105

7.

OPIOID MEDICATION MANAGEMENT.................................................................................105

8.

THERAPY MANAGEMENT ....................................................................................................106

9.

INJECTION THERAPY...........................................................................................................106

a.

Sympathetic Blocks ..................................................................................................106

b.

Trigger Point Injections.............................................................................................106

10.

PURCHASE OR RENTAL OF DURABLE MEDICAL EQUIPMENT .......................................106

DEPARTMENT OF LABOR AND EMPLOYMENT

Division of Workers' Compensation

CCR 1101-3 RULE 17, EXHIBIT 7

COMPLEX REGIONAL PAIN SYNDROME/REFLEX SYMPATHETIC DYSTROPHY MEDICAL TREATMENT GUIDELINES

A. INTRODUCTION

This document has been prepared by the Colorado Department of Labor and Employment, Division of Workers' Compensation (Division) and should be interpreted within the context of guidelines for physicians/providers treating individuals qualifying under Colorado's Workers' Compensation Act as injured workers with Complex Regional Pain Syndrome (CRPS), formerly known as Reflex Sympathetic Dystrophy (RSD).

Although the primary purpose of this document is advisory and educational, these guidelines are enforceable under the Workers' Compensation Rules of Procedure, 7 CCR 1101-3. The Division recognizes that acceptable medical practice may include deviations from these guidelines, as individual cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of professional care.

To properly utilize this document, the reader should not skip nor overlook any sections.

Complex Regional Pain Syndrome

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