La. Admin. Code tit. 40 § I-2223

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-2223 - Follow-up Diagnostic Imaging and Testing Procedures

A. Cervical computed axial tomography or magnetic resonance imaging (ct/mri) are generally accepted, well-established procedures indicated to rule out cervical disc or other cervical spine disorders when clinical findings suggest these diagnoses. It should not be routinely performed for TOS. MRI is the preferred test over a CT unless a fracture is suspected, and then CT may be superior to MRI. CT/MRI is not indicated early unless there is a neurological deficit and/or the need to rule out a space- occupying lesion, such as a tumor. Repeat cervical MRI is not indicated for TOS. If cervical spine injury is confirmed, refer to the OWCA's Cervical Spine Injury Medical Treatment Guidelines. If a cervical spine disorder is not suspected, conservative therapy as indicated in Section F, Non-operative Procedures should be done for at least 8 to 12 weeks, prior to ordering an MRI for persistent symptoms.

B. Electrodiagnostic Studies

1. Electromyography/Nerve Conduction Velocities (EMG/NCV) is a generally accepted, well-established procedure. EMG/NCV is primarily indicated to rule out other nerve entrapment syndromes such as carpal tunnel or cubital tunnel syndrome when indicated by clinical examination, or to establish true neurogenic TOS. Most cases of non-specific TOS have normal electrodiagnostic studies, but EMG/NCV should be considered when symptoms have been present for approximately three months or if the patient has failed eight weeks of conservative therapy. EMG/NCV may also be performed to rule out other disorders. Somato-sensory evoked potentials (SSEPs), F waves and NCV across the thoracic outlet have no diagnostic value and should not be performed. The diagnosis is usually made by comparison to the normal extremity. For bilateral disease, each EMG lab must establish its own absolute limits of latency and amplitude from volunteer controls so that measurements exceeding these limits can be noted.

2. Criteria for True Neurogenic TOS

a. reduction of the ulnar sensory nerve action potential to digits (usually less than 60 percent of unaffected side); or

b. medial antebrachial sensory action potential which is low or absent compared to the unaffected side; or

c. reduction of the median M-wave amplitude (usually less than 50 percent of unaffected side); or

d. needle EMG examination reveals neurogenic changes in intrinsic hand muscles and the abductor pollicus brevis muscle.

3. Portable automated electrodiagnostic device: (also known as surface EMG) is not a substitute for conventional EMG/NCS testing in clinical decision-making, and therefore, is not recommended.

4. Quantitative Sensory Testing (QST). Research is not currently available on the use of QST in the evaluation of TOS. QST tests the entire spectrum of the neurological system including the brain. It is not able to reliably distinguish between organic and psychogenic pathology and therefore, is not recommended.

C. Vascular Studies. Noninvasive vascular testing, such as pulse-volume recording in different positions, is not indicated in cases of neurogenic TOS. Since the presence or absence of a pulse cutoff on physical examination is not helpful in establishing a diagnosis of TOS, the recording of finer degrees of positional pulse alteration will not add to the diagnosis. Vascular laboratory studies, including duplex scanning, Doppler studies, standard and MR arteriography and venography, are not cost-effective in cases of neurogenic TOS. These studies are only indicated in patients who have arterial or venous occlusive signs. Dynamic venography with the arm in 180 degrees of abduction may be used in cases with continued swelling and/or periodic cyanosis who have not improved with conservative therapy. Approximately 20 percent of asymptomatic individuals will have an abnormal dynamic venogram. Some individuals may have a pectoralis minor syndrome which occludes the axillary vein rather than the subclavian vein. In these cases, less invasive surgery than the TOS operative procedures may be indicated.

D. Thermography is not generally accepted or widely used for TOS. It may be used if differential diagnosis includes CRPS; in such cases refer to the OWCA's Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy Medical Treatment Guidelines.

E. Anterior scalene or pectoralis muscle blocks may be performed to provide additional information prior to expected surgical intervention. It is recommended that EMG or sonography guidance be used to assure localization.

F. Personality/psychological/psychiatric/psychosocial evaluations are generally accepted and well-established diagnostic procedures with selective use in the acute TOS population and more widespread use in the sub-acute and chronic TOS population.

1. Diagnostic testing procedures may be useful for patients with symptoms of depression, delayed recovery, chronic pain, recurrent painful conditions, disability problems, and for pre-operative evaluation as well as a possible predictive value for post-operative response. Psychological testing should provide differentiation between pre-existing depression versus injury-caused depression, as well as post-traumatic stress disorder.

2. Formal psychological or psychosocial evaluation should be performed on patients not making expected progress within 6-12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests. In addition to the customary initial exam, the evaluation of the injured worker should specifically address the following areas:

a. employment history;

b. interpersonal relationships-both social and work;

c. leisure activities;

d. current perception of the medical system;

e. results of current treatment;

f. perceived locus of control; and

g. childhood history, including abuse and family history of disability.

3. This information should provide clinicians with a better understanding of the patient, and enable a more effective rehabilitation.

4. The evaluation will determine the need for further psychosocial interventions, and in those cases, a Diagnostic Statistical Manual (DSM) of Mental Disorders diagnosis should be determined and documented. An individual with a PhD, PsyD, or Psychiatric MD/DO credentials should perform initial evaluations, which are generally completed within one to two hours. A professional fluent in the primary language of the patient is strongly preferred. When such a provider is not available, services of a professional language interpreter must be provided. When issues of chronic pain are identified, the evaluation should be more extensive and follow testing procedures as outlined in the OWCA's Chronic Pain Disorder Medical Treatment Guidelines.

a. Frequency-one time visit for evaluation. If psychometric testing is indicated as a portion of the initial evaluation, time for such testing shall be allotted at least, six hours of professional time or whatever is deemed appropriate by the health care professional.

G. Special tests are generally well-accepted tests and are performed as part of a skilled assessment of the patients' capacity to return to work, his/her strength capacities, and physical work demand classifications and tolerance. The procedures in this subsection are listed in alphabetical order, not by importance.

1. Computer-enhanced evaluations may include isotonic, isometric, isokinetic and/or isoinertial measurement of movement, range-of-motion, endurance or strength. Values obtained can include degrees of motion, torque forces, pressures or resistance. Indications include determining validity of effort, effectiveness of treatment and demonstrated motivation. These evaluations should not be used alone to determine return to work restrictions. The added value of computer enhanced evaluations is unclear. Targeted work tolerance screening or gradual return to work is preferred.

a. Frequency-one time for evaluation. Can monitor improvements in strength every three to four weeks up to a total of six evaluations.

2. Functional capacity evaluation (FCE) is a comprehensive or modified evaluation of the various aspects of function as they relate to the worker's ability to return to work. Areas such as endurance, lifting (dynamic and static), postural tolerance, specific range of motion, coordination and strength, worker habits, employability as well as psychosocial, cognitive, and sensory perceptual aspects of competitive employment may be evaluated. Components of this evaluation may include: musculoskeletal screen; cardiovascular profile/aerobic capacity; coordination; lift/carrying analysis; job-specific activity tolerance; maximum voluntary effort; pain assessment/psychological screening; and non-material and material handling activities.

a. When an FCE is being used to determine return to a specific jobsite, the provider is responsible for fully understanding the job duties. A jobsite evaluation is frequently necessary. FCEs cannot be used in isolation to determine work restrictions. The authorized treating physician must interpret the FCE in light of the individual patient's presentation and medical and personal perceptions. FCEs should not be used as the sole criteria to diagnose malingering.

b. Full FCEs are sometimes necessary. In many cases, a work tolerance screening will identify the ability to perform the necessary job tasks. If partial FCEs are performed, it is recognized that all parts of the FCE that are not performed are considered normal.

i. Frequency-can be used initially to determine baseline status and for case closure when patient is unlikely to return to pre-injury position and further information is desired to determine permanent work restrictions. Prior authorization is required for FCEs performed during treatment.

3. Jobsite evaluation is a comprehensive analysis of the physical, mental and sensory components of a specific job. These components may include, but are not limited to: postural tolerance (static and dynamic); aerobic requirements; range of motion; torque/force; lifting/carrying; cognitive demands; social interactions; visual perceptual; sensation; coordination; environmental requirements; repetitiveness; and essential job functions. Job descriptions provided by the employer are helpful but should not be used as a substitute for direct observation.

a. A jobsite evaluation may include observation and instruction of how work is done, what material changes (desk, chair) should be made, and determination of readiness to return to work. Postural risk factors should be identified and awkward postures of overhead reach, hyperextension or rotation of the neck, shoulder drooped or forward-flexed and head-chin forward postures should be eliminated. Unless combined with one of the above postures, repetitiveness is not by itself a risk factor. Refer to Cumulative Trauma Disorder and Shoulder Guidelines for further suggestions.

i. Requests for a jobsite evaluation should describe the expected goals for the evaluation. Goals may include, but are not limited to the following:

(a). to determine if there are potential contributing factors to the person's condition and/or for the physician to assess causality;

(b). to make recommendations for, and to assess the potential for ergonomic changes;

(c). to provide a detailed description of the physical and cognitive job requirements;

(d). to assist the patient in their return to work by educating them on how they may be able to do their job more safely in a bio-mechanically appropriate manner;

(e). to give detailed work/activity restrictions.

(i). Frequency-one time with additional visits as needed for follow-up per jobsite.

4. Vocational Assessment. The vocational assessment should provide valuable guidance in the determination of future rehabilitation program goals. It should clarify rehabilitation goals, which optimize both patient motivation and utilization of rehabilitation resources. If prognosis for return to former occupation is determined to be poor, except in the most extenuating circumstances, vocational assessment should be implemented within 3 to 12 months post-injury. Declaration of MMI should not be delayed solely due to lack of attainment of a vocational assessment.

a. Frequency-one time with additional visits as needed for follow-up.

5. Work tolerance screening is a determination of an individual's tolerance for performing a specific job based on a job activity or task and may be used when a full functional capacity evaluation is not indicated. The screening is monitored by a therapist and may include a test or procedure to specifically identify and quantify work-relevant cardiovascular, physical fitness and postural tolerance. It may also address ergonomic issues affecting the patient's return-to-work potential.

a. Frequency-one time for initial screen. May monitor improvements in strength every three to four weeks up to a total of six visits.

La. Admin. Code tit. 40, § I-2223

Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation Administration, LR 37:1753 (June 2011), Amended LR 471657 (11/1/2021).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.