Contents part 1: Introduction




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Recommend evidence-based treatments for patients with conditions that have resulted in delayed recovery. Identification of delayed recovery is dependent on the specific injury or illness, and disability duration guidelines can provide guidance. Two approaches have been suggested:


(1) At-Risk cases: Disability duration experience data, for each condition, can show expected calendar-days away from work by decile, using the 50% number for “Midrange” and the 90% number for “At-Risk”. The At-Risk number of days may be used to trigger “Delayed recovery” interventions, because it is the point at which 90% of cases with this primary diagnosis should have returned to work, and the point when the case has already become an outlier and is at risk of never returning to functionality. (ODG_Help, 2009) To identify these “At-Risk” cases, see the appropriate RTW guidelines by ICD9 diagnosis code. For example, for lumbar sprains and strains (ICD9 847.2), the At-Risk time using claims data would be 63 days. For lumbar disc disorders (ICD9 722.1), (ICD9 722.1), , it would be 144 days.

(2) 30 days beyond normal healing: The normal course of recovery can be identified from experience data in the appropriate RTW guidelines by ICD9 diagnosis code. Delayed recovery would include cases taking longer than this. (ODG_TP, 2009) For example, for lumbar sprains and strains (ICD9 847.2), the expected Midrange (median) time using claims data would be 17 days, so delayed recovery would start at 47 days, using this approach. For lumbar disc disorders (ICD9 722.1), it would be 96 days (66 plus 30).


See also Chronic pain programs (functional restoration programs).

Demerol® (meperidine)

See Meperidine (Demerol®).


Deplin® (L-methylfolate)

Not recommended. Deplin® (L-methylfolate) is a prescription medical food, for the dietary management of suboptimal folate, a naturally occurring B vitamin, in depressed patients. L-methylfolate is not an antidepressant, but may make antidepressants work better by correcting folate levels in the brainSee also Vitamin B & Medical foods.

Detoxification

Most commonly recommended when there is evidence of substance misuse or abuse, evidence that medication is not efficacious, or evidence of excessive complications related to use. See Substance abuse (substance related disorders, tolerance, dependence, addiction) for definitions. Detoxification is defined as a medical intervention that manages a patient through withdrawal syndromes. While the main indication as related to substance-related disorders is evidence of aberrant drug behaviors, other indications for detoxification have been suggested. These include the following: (1) Intolerable side effects; (2) Lack of response to current pain medication treatment (particularly when there is evidence of increasingly escalating doses of substances known for dependence); (3) Evidence of hyperalgesia; (4) Lack of functional improvement; and/or (5) Refractory comorbid psychiatric illness. It can therefore be seen that a recommendation for detoxification does not necessarily imply a diagnosis of addiction, or of substance-related disorder. There are no specific guidelines that have been developed for detoxification for patients with chronic pain. This intervention does not constitute complete substance abuse treatment. The process of detoxification includes evaluation, stabilization, and preparation of the patient for further treatment that should be specifically tailored to each patient’s diagnostic needs. Complete withdrawal of all medications is not always recommended, although evidence of abuse and/or dependence strengthens the rationale for such.(TIP 45, 2006) (Wright, 2009) (Benzon, 2005) See also Weaning of medications; Rapid detox; Substance abuse (substance related disorders, tolerance, dependence, addiction) for definitions.

For average hospital LOS if criteria are met, see Hospital length of stay (LOS).



Diabetic neuropathy

Recommend screening for diabetic neuropathy. With the increased prevalence of diabetes in the US, there has also been an increase in the presentation of diabetic neuropathy (DN) with approximately two-thirds of diabetic patients having minimal to full-blown symptoms. (Bansal, 2006) This is a condition that can confound the presentation of chronic pain from work-related injuries. The American Academy of Neurology suggests that the diagnosis of DN should be considered in patients with somatic or autonomic neuropathy and when other causes of neuropathy have been excluded. (ADA/ANA, 1988) Approximately 10% to 20% of diabetic patients have “other causes” of neuropathy. At least two out of the five following criteria are needed for diagnosis: 1) symptoms; 2) signs; 3) electrodiagnostic tests; 4) quantitative sensory; & 5) autonomic testing. Presentations and issues are outlined below:

Distal Symmetrical Polyneuropathy: The most common presentation of DN - 75%. (Bansal, 2006) This is a stocking and glove presentation to the knee, and with a latter presentation in the fingers. There are two variants: 1) Large Fiber Disease: presents with painless paresthesias, and impairment of vibration, joint position, sensation and pressure, and loss of ankle reflex. EMG shows slowing of nerve conduction; 2) Small fiber disease: results in pain and burning.

Persistent Painful Neuropathy: About 10%. (Bansal, 2006) This pain is usually worse at night, and is described as burning, pins and needles, shooting, aching, jabbing, sharp, cramping, tingling, cold and allodynia. This condition can occur prior to the onset of clinically diagnosed diabetes. Opioid tolerance and addiction has been found in this class of patients. This pain may decrease with hyperglycemia control.

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