ENTIRE EXHIBIT 10 STRUCK AND REPLACED WITH THE FOLLOWING:
RULE 17 EXHIBIT 10
Traumatic Brain Injury
Medical Treatment Guidelines
Revised: September 29, 2005
Effective: January 1, 2006
Adopted: January 8, 1998 Effective: March 15, 1998
Revised: March 1, 2005 Effective: May 1, 2005
Presented by:
State of Colorado
Department of Labor and Employment
DIVISION OF WORKERS’ COMPENSATION
tABLE OF CONTENTS
a. INTRODUCTION 3
b. GENERAL GUIDELINE PRINCIPLES 3
1. APPLICATION OF GUIDELINES 3
2. EDUCATION 3
3. TREATMENT PARAMETER DURATION 3
4. ACTIVE INTERVENTIONS 3
5. ACTIVE THERAPEUTIC EXERCISE PROGRAM 3
6. POSITIVE PATIENT RESPONSE 3
7. RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS 3
8. SURGICAL INTERVENTIONS 3
9. RETURN TO WORK 3
10. DELAYED RECOVERY 3
11. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE 3
12. PoST MAXIMUM MEDICAL IMPROVEMENT CARE 3
c. INTRODUCTION TO TBI AND PHILOSOPHY OF CARE 3
1. DEFINITIONS AND DIAGNOSIS OF TBI 3
a. Mild TBI (MTBI) 3
b. Moderate/severe TBI 3
c. Other terminology 3
2. INTERVENTION 3
3. EDUCATION 3
4. RETURN-TO-WORK 3
5. DISABILITY 3
6. COURSE OF RECOVERY- 3
a. Mild traumatic Brain injury 3
b. Moderate/Severe TBI 3
7. GUARDIANSHIP AND CONSERVATORSHIP 3
8. SYSTEMS OF CARE 3
a. Acute Care 3
b. Comprehensive Integrated Inpatient Rehabilitation Hospital or “Acute Rehabilitation”: 3
c. Long-Term Acute Care (LTAC) Programs 3
d. Subacute Skilled Nursing Facility (SNF) Rehabilitation Programs 3
e. Post-Acute Rehabilitation 3
f. Long-Term Support Care 3
9. INTERDISCIPLINARY TREATMENT TEAM 3
a. Behavioral Psychologist 3
b. Behavioral Analyst- masters level 3
c. Case Manager 3
d. Chiropractor 3
e. Clinical Pharmacist 3
f. Clinical Psychologist 3
g. Driver Rehabilitation Specialist 3
h. Independent Life Skills Trainer 3
i. Music Therapist 3
j. Neurologist 3
k. Neuro-ophthalmologist 3
l. Neuro-otologist 3
m. Neuropsychologist 3
n. Neuroscience Nurse 3
o. Neurosurgeon (Neurological Surgeon) 3
p. Nurse 3
q. Occupational Therapist (OTR) 3
r. Occupational Medicine Physician 3
s. Optometrist 3
t. Ophthalmologist 3
u. Otolaryngologist 3
v. Physical Therapist (PT) 3
w. Physiatrist 3
x. Psychiatrist/Neuropsychiatrist 3
y. Rehabilitation Counselor 3
z. Rehabilitation Nurse 3
aa. Social Worker 3
bb. Speech-Language Pathologist 3
cc. Therapeutic Recreation Specialist (Recreational Therapist) 3
10. PREVENTION 3
a. Primary Prevention 3
b. Secondary Prevention 3
c. Tertiary Prevention 3
d. INITIAL DIAGNOSTIC PROCEDURES 3
1. HISTORY OF INJURY 3
a. Identification Data 3
b. Precipitating Event 3
c. Neurological History 3
d. Review of Medical Records 3
e. Medical/Health History 3
f. Family History 3
g. Social History 3
h. Review of Systems 3
i. Pain Diagnosis 3
j. Psychiatric history 3
2. PHYSICAL EXAMINATION 3
3. NEUROLOGICAL EXAMINATION 3
4. INITIAL NEUROPSYCHOLOGICAL ASSESSMENT 3
a. Initial Neuropsychological Assessment – Mild Traumatic Brain Injury(MTBI) 3
b. Initial Neuropsychological Assessment – Moderate/severe Traumatic Brain Injury 3
c. Post-Acute Testing 3
5. Initial IMAGING PROCEDURES 3
a. Skull X-Rays 3
b. Computed Axial Tomography (CT) 3
c. Magnetic Resonance Imaging (MRI) 3
6. VASCULAR IMAGING TESTS 3
a. CT angiography (CTA): 3
b. Arteriography 3
c. Venography 3
d. Noninvasive Vascular Assessment (NIVA) 3
e. Magnetic Resonance Angiography (Magnetic Resonance Arteriography (MRA) /Magnetic Resonance Venography (MVA)) 3
f. Brain Acoustic Monitor 3
7. LUMBAR PUNCTURE 3
e. FOLLOW-UP DIAGNOSTIC PROCEDURES 3
1. IMAGING 3
a. Structural Imaging 3
b. Dynamic Imaging 3
2. ADVANCED MRI TECHNIQUES 3
a. Magnetic Resonance (MR) Spectroscopy 3
b. Functional MRI (fMRI) 3
c. Diffusion Tensor Imaging, Susceptibility—Weighted Imaging, and Magnetic Transfer imaging 3
3. NEUROPSYCHOLOGICAL ASSESSMENT 3
a. Mild Traumatic Brain Injury 3
b. Moderate/severe TBI 3
4. PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL EVALUATIONS 3
a. Qualifications 3
b. Indications 3
c. Clinical Evaluation 3
5. ELECTROENCEPHALOGRAPHY 3
a. Electroencephalography (EEG) 3
b. Quantified Electroencephalography (QEEG) (Computerized EEG) 3
6. ELECTRODIAGNOSTIC STUDIES 3
a. EMG and Nerve Conduction Studies 3
b. Electroneuronography (EnoG) 3
c. Dynamic Electromyographies 3
d. Evoked Potential Responses (EP) 3
7. LABORATORY TESTING 3
8. NERVE BLOCKS- Diagnostic 3
9. VISION EVALUATION 3
a. Visual Field Testing 3
b. Ultrasonography 3
c. Fluorescein Angiography 3
d. Visual Perceptual Testing 3
e. Low Vision Evaluation 3
f. Electrodiagnostic Studies 3
g. Optical Coherence Tomography 3
10. OTOLOGY and AUDIOMETRY 3
a. Audiometry 3
b. Tympanometry 3
c. Vestibular Function Tests 3
11. SWALLOWING EVALUATION 3
a. Clinical Assessment 3
b. Instrumental Evaluation 3
12. SPECIAL TESTS for RETURN-TO-WORK ASSESSMENT 3
a. Job site Evaluations and Alterations 3
b. Functional Capacity Evaluation (FCE) 3
f. ACUTE THERAPEUTIC PROCEDURES – NONOPERATIVE 3
1. RESUSCITATION 3
2. INTRACRANIAL PRESSURE (ICP) AND CEREBRAL PERFUSION PRESSURE (CPP) 3
3. HYPERVENTILATION 3
4. MEDICATIONS 3
5. HYPOTHERMIA 3
6. Surgery 3
7. Hyperbaric Oxygen 3
g. NONOPERATIVE THERAPEUTIC PROCEDURES – INITIAL TREATMENT CONSIDERATIONS 3
1. PATIENT/FAMILY/SUPPORT SYSTEM EDUCATION: 3
a. MTBI: 3
b. Moderate/Severe Brain Injury 3
2. BEHAVIOR 3
3. COGNITION 3
a. Mild TBI 3
b. Moderate/Severe TBI 3
c. Computer-Based Treatment 3
d. Assistive Technology 3
4. PSYCHOLOGICAL/EDUCATIONAL INTERVENTIONS - 3
a. Acute Psychological/Educational Interventions in MTBI 3
b. Problem-Specific Referrals During the First Three Months Following MTBI 3
c. Referrals Three or More Months Post-MTBI 3
d. Functional Gains 3
5. PSYCHOLOGICAL INTERVENTIONS – MODERATE/SEVERE INJURY 3
a. Acutely Symptomatic Phase 3
b. Early Recovery Phase 3
c. Stabilization Phase 3
d. Consultation in Regard to Usage of Medications 3
6. MEDICATION/Pharmacological Rehabilitation 3
a. Affective disorders medications 3
b. Behavior/ Aggression medications 3
c. Cognitive Enhancers 3
7. HEADACHE 3
a. Headache Treatment Algorithm 3
b. Botulinum Injections 3
8. THERAPEUTIC EXERCISE 3
9. DISTURBANCES OF SLEEP 3
h. NONOPERATIVE THERAPEUTIC PROCEDURES - NEUROMEDICAL CONDITIONS in MODERATE/SEVERE BRAIN INJURY 3
1. Neurological Complications 3
2. Post-Traumatic Seizures/Post-Traumatic Epilepsy (PTE) 3
3. Cardiopulmonary Complications 3
a. Cardiac System 3
b. Pulmonary System 3
4. Sleep Complications 3
5. Musculoskeletal Complications 3
a. Long-Bone Fractures 3
b. Heterotopic Ossification (HO) 3
6. Gastrointestinal Complications 3
7. Genitourinary Complications 3
8. Neuroendocrine Complications 3
9. Fluid and Electrolyte Complications 3
10. Immobilization and Disuse Complications 3
11. Vascular Complications 3
i. NONOPERATIVE THERAPEUTIC PROCEDURES – REHABILITATION 3
1. INTERDISCIPLINARY REHABILITATION PROGRAMS 3
a. Behavioral Programs 3
b. Comprehensive Integrated Inpatient Interdisciplinary Rehabilitation Programs 3
c. Home and Community-Based Rehabilitation 3
d. Nursing Care Facilities 3
e. Occupational Rehabilitation 3
f. Opioid/Chemical Treatment Programs 3
g. Outpatient Rehabilitation Services 3
h. Residential Rehabilitation 3
i. Supported Living Programs (SLP) or Long-Term Care Residential Services 3
2. ACTIVITES OF DAILY LIVING (ADLS) 3
a. Basic ADLs 3
b. Instrumental ADLs (IADL) 3
3. MOBILITY 3
a. Therapy 3
b. Adaptive Devices 3
4. Ataxia 3
5. NEUROMUSCULAR re-education 3
a. Motor Control 3
b. Motor Learning 3
6. Work Conditioning 3
7. Work Simulation 3
8. MUSCLE TONE AND JOINT RESTRICTION MANAGEMENT Including spasticity 3
a. Orthotics and Casting 3
b. Postural Control 3
c. Functional and Therapeutic Activities 3
d. Therapeutic Nerve and Motor Point Blocks 3
e. Botulinum Toxin (Botox) Injections 3
f. Pharmaceutical agents 3
g. Intrathecal Baclofen Drug Delivery 3
j. NONOPERATIVE THERAPEUTIC PROCEDURES – VISON, SPEECH, SWALLOWING, BALANCE & HEARING 3
1. VISUAL TREATMENT 3
a. Visual Acuity and Visual Field Function 3
b. Disorders Involving Ocular Motor Control and Ocular Alignment 3
c. Visual Perception 3
d. Visual Inattention 3
e. Total Time Frames for all Vision Therapy (Orthoptic Therapy) 3
2. NEURO-OTOLOGIC TREATMENTS 3
a. Treatment of Fixed Lesions 3
b. Treatment of recurrent, non-progressive otologic disorders 3
c. Treatment of progressive otologic disorders 3
d. In-Office treatment procedures 3
e. Tympanostomy 3
f. Vestibular Rehabilitation: 3
3. SWALLOWING IMPAIRMENTS (DYSPHAGIA) 3
a. Compensatory Treatment 3
b. Therapy Techniques 3
4. COMMUNICATION 3
a. Motor Speech Disorders 3
b. Voice Disorders 3
c. Language Disorders 3
d. Cognitive-Communicative Disorders 3
k. NONOPERATIVE THERAPEUTIC PROCEDURES – RETURN-TO-WORK, DRIVING & OTHER 3
1. DRIVING 3
2. RETURN-TO-WORK 3
a. Return-to-Work - MTBI 3
b. Return to Work Moderate/severe TBI 3
c. The following should be considered when attempting to return an injured worker with Moderate/Severe TBI to work 3
3. VOCATIONAL REHABILITATION 3
4. COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM) 3
5. OTHER TREATMENTS 3
a. Hyperbaric Oxygen 3
b. Deep Thalamic Stimulation 3
c. Transcranial Magnetic Stimulation 3
l. OPERATIVE THERAPEUTIC PROCEDURES 3
1. EXTRACRANIAL SOFT TISSUE 3
2. MAXILLOFACIAL 3
3. SKULL 3
4. BRAIN 3
5. CEREBRAL SPINAL FLUID (CSF) 3
a. CSF Leak or Fistula 3
b. Ventricular Shunting 3
c. Ventriculostomy 3
6. OPHTHALMOLOGIC 3
7. OTOLOGIC 3
a. Direct Trauma Or Barotrauma 3
b. Tympanostomy 3
c. Middle Ear Exploration 3
d. Vestibular Nerve Section 3
8. DECOMPRESSION OF FACIAL NERVE 3
9. OTHER CRANIAL NERVE REPAIR OR DECOMPRESSION 3
10. VASCULAR INJURY 3
11. PERIPHERAL NERVE INJURY 3
12. ORTHOPEDIC 3
13. SPASTICITY 3
m. MAINTENANCE MANAGEMENT 3
1. GENERAL PRINCIPLES 3
2. COGNITIVE/BEHAVIORAL/PSYCHOLOGICAL MANAGEMENT 3
3. EXERCISE PROGRAMS REQUIRING SPECIAL FACILITIES 3
4. HOME EXERCISE PROGRAMS AND EXERCISE EQUIPMENT 3
5. LONG-TERM RESIDENTIAL CARE 3
6. MAINTENANCE HOME CARE 3
7. MEDICATION MANAGEMENT 3
8. NEUROMEDICAL MANAGEMENT 3
9. PATIENT EDUCATION MANAGEMENT 3
10. PHYSICAL, OCCUPATIONAL and Speech Language THERAPY 3
11. PURCHASE, RENTAL AND MAINTENANCE OF DURABLE MEDICAL EQUIPMENT 3
DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
CCR 1101-3
RULE 17 EXHIBIT 10
TRAUMATIC BRAIN INJURY 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 Workers’ Compensation Act as injured workers with traumatic brain injury (TBI).
Although the primary purposes of this document for practitioners are 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 or overlook any sections.
b. GENERAL GUIDELINE PRINCIPLES
The principles summarized in this section are key to the intended implementation of these guidelines and are critical to the reader's application of the guidelines in this document.
1. APPLICATION OF GUIDELINES The Division provides procedures to implement medical treatment guidelines and to foster communication to resolve disputes among the provider, payer and patient through the Workers' Compensation Rules of Procedure. In lieu of more costly litigation, parties may wish to seek administrative dispute resolution services through the Division or the office of administrative courts.
2. EDUCATION of the individual and/or family/support system, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of TBI and disability. Practitioners often think of education last, after medications, manual therapy and surgery. Practitioners should develop and implement an effective strategy and skills to educate individuals with TBI, 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 individual with TBI. More in-depth education currently exists within a treatment regimen employing functional restorative and rehabilitation. No treatment plan is complete without addressing issues of individual and/or family/support system education as a means of facilitating self-management of symptoms and prevention.
3. 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 individual’s compliance, as well as availability of services. Clinical judgment may substantiate the need to accelerate or decelerate the time frames discussed in this document.
4. ACTIVE INTERVENTIONS emphasizing personal responsibility, such as therapeutic exercise and/or functional treatment, are used predominantly over passive modalities, especially as treatment progresses. Generally, passive and palliative interventions are viewed as a means to facilitate progress in an active rehabilitation program with concomitant attainment of objective functional gains.
5. ACTIVE THERAPEUTIC EXERCISE PROGRAM goals should incorporate strength, endurance, flexibility, coordination, and education. This includes functional application in vocational or community settings.
6. POSITIVE PATIENT RESPONSE results are defined primarily as functional gains which may be objectively measured. Objective functional gains include, but are not limited to, positional tolerances, range-of-motion, strength, and endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures which may 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 should be based upon objective findings.
7. RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS If a given treatment or modality is not producing positive results within three to four 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.
8. SURGICAL INTERVENTIONS 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 should 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).
9. RETURN TO WORK following TBI involves a skillful match between the individual’s abilities (physical, cognitive, emotional, and behavioral) and the work requirements.
The practitioner must write detailed restrictions when returning an individual with TBI to limited duty. The individual with TBI should never be released to "sedentary or light duty" without specific physical or cognitive limitations. The practitioner must understand all of the physical, visually, cognitive, emotional and behavioral demands of the individual's job position before returning him/her to full duty and should request clarification of job duties. Clarification should be obtained from the employer or others if necessary, including but not limited to: an occupational health nurse, occupational therapist, physical therapist, speech therapist, vocational rehabilitation specialist, case manager, industrial hygienist, or other appropriately trained professional.