DWD 81.08(1)(L)(L) Consultations with other health care providers may be initiated at any time by a treating health care provider consistent with standard medical practice. DWD 81.08(2)(2) General treatment guidelines for thoracic back pain. DWD 81.08(2)(a)(a) All medical care for thoracic back pain, appropriately assigned to a category of sub. (1) (b) 1. to 3. is determined by the diagnosis and clinical category that the patient has been assigned. General guidelines for treatment modalities are set forth in subs. (3) to (10). Specific treatment guidelines for each clinical category are set forth in subs. (11), (12), and (13) as follows: DWD 81.08(2)(b)(b) A health care provider shall, at each visit, reassess the appropriateness of the clinical category assigned and reassign the patient if warranted by new clinical information including symptoms, signs, results of diagnostic testing and opinions, and information obtained from consultations with other health care providers. When the clinical category is changed the treatment plan shall be appropriately modified to reflect the new clinical category. A change of clinical category may not in itself allow a health care provider to continue a therapy or treatment modality past the maximum duration specified in this section or to repeat a therapy or treatment previously provided for the same injury. DWD 81.08(2)(c)(c) In general, a course of treatment is divided into the following 3 phases: DWD 81.08(2)(c)1.1. First, all patients with thoracic back problems, except patients with myelopathy under sub. (1) (b) 3., shall be given initial nonoperative care that may include active and passive treatment modalities, injections, durable medical equipment, and medications. These modalities and guidelines are described in subs. (3), (4), (5), (8), and (10). The period of initial nonsurgical treatment begins with the first clinical passive, active, injection, durable medical equipment, or medication modality initiated. Initial nonsurgical treatment shall result in progressive improvement as specified in sub. (9). DWD 81.08(2)(c)2.2. Second, for patients with persistent symptoms, initial nonsurgical management is followed by a period of surgical evaluation. This evaluation shall be completed in a timely manner. Surgery, if necessary, shall be performed as expeditiously as possible consistent with sound medical practice and subs. (6), (11), (12), (13), and s. DWD 81.12 (1). A treating health care provider may do the evaluation or may refer the patient to another health care provider. DWD 81.08(2)(c)2.b.b. Any patient who has had surgery may require postoperative therapy with active and passive treatment modalities. This therapy may be in addition to any received during the period of initial nonsurgical care. DWD 81.08(2)(c)2.d.d. A decision against surgery at any particular time does not preclude a decision for surgery made at a later date in light of new clinical information. DWD 81.08(2)(c)3.3. Third, for those patients who are not candidates for or refuse surgical therapy, or who do not have complete resolution of their symptoms with surgery, a period of chronic management may be necessary. Chronic management modalities are described in s. DWD 81.13 and may also include durable medical equipment as described in sub. (8). DWD 81.08(2)(d)(d) A treating health care provider may refer the patient for a consultation at any time during the course of treatment consistent with accepted medical practice. DWD 81.08(3)(a)(a) General. Except as set forth in par. (b) or s. DWD 81.04 (5), a health care provider may not direct the use of passive treatment modalities in a clinical setting as set forth in pars. (c) to (i) beyond 12 calendar weeks after any of the passive modalities in pars. (c) to (i) are initiated. There are no limitations on the use of passive treatment modalities by the patient at home. DWD 81.08(3)(b)(b) Additional passive treatment modalities. A health care provider may direct an additional 12 visits for the use of passive treatment modalities over an additional 12 months if all of the following apply: DWD 81.08(3)(b)1.1. The patient is released to work or is permanently totally disabled and the additional passive treatment shall result in progressive improvement in, or maintenance of, functional status achieved during the initial 12 weeks of passive care. DWD 81.08(3)(b)3.3. A health care provider documents in the medical record a plan to encourage the patient’s independence and decreased reliance on health care providers. DWD 81.08(3)(b)4.4. Management of the patient’s condition includes active treatment modalities during this period. DWD 81.08(3)(b)5.5. The additional 12 visits for passive treatment does not delay the required surgical or chronic pain evaluation required by this chapter. DWD 81.08(3)(b)6.6. Passive care is not necessary while the patient has chronic pain syndrome. DWD 81.08(3)(c)(c) Adjustment or manipulation of joints. For purposes of this paragraph, “adjustment or manipulation of joints” includes chiropractic and osteopathic adjustments or manipulations. All of the following guidelines apply to adjustment or manipulation of joints: DWD 81.08(3)(c)2.2. Maximum treatment frequency is up to 5 times per week for the first one to 2 weeks decreasing in frequency until the end of the maximum treatment duration period in subd. 3. DWD 81.08(3)(d)(d) Thermal treatment. For purposes of this paragraph, “thermal treatment” includes all superficial and deep heating modalities and cooling modalities. Superficial thermal modalities include hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, cold soaks, infrared, whirlpool, and fluidotherapy. Deep thermal modalities include diathermy, ultrasound, and microwave. All of the following guidelines apply to thermal treatment: DWD 81.08(3)(d)1.b.b. Maximum treatment frequency is up to 5 times per week for the first one to 3 weeks decreasing in frequency until the end of the maximum treatment duration period in subd. 1. c. DWD 81.08(3)(d)1.c.c. Maximum treatment duration is 12 weeks of treatment in a clinical setting but only if given in conjunction with other therapies. DWD 81.08(3)(d)2.2. Home use of thermal modalities may be prescribed at any time during the course of treatment. Home use may only involve hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, and cold soaks that can be applied by the patient without health care provider assistance. Home use of thermal modalities may not require any special training or monitoring, other than that usually provided by a health care provider during an office visit. DWD 81.08(3)(e)(e) Electrical muscle stimulation. For purposes of this paragraph “electrical muscle stimulation” includes galvanic stimulation, transcutaneous electrical nerve stimulation, interferential, and microcurrent techniques. All of the following guidelines apply to electrical muscle stimulation: DWD 81.08(3)(e)1.b.b. Maximum treatment frequency is up to 5 times per week for the first one to 3 weeks decreasing in frequency until the end of the maximum treatment duration period in subd. 1. c. DWD 81.08(3)(e)1.c.c. Maximum treatment duration is 12 weeks of treatment in a clinical setting but only if given in conjunction with other therapies. DWD 81.08(3)(e)2.2. Home use of an electrical stimulation device may be prescribed at any time during a course of treatment. Initial use of an electrical stimulation device shall be in a supervised setting in order to ensure proper electrode placement and patient education. All of the following guidelines apply to home use of an electrical stimulation device: DWD 81.08(3)(e)2.b.b. Patient may use the electrical stimulation device for one month, at which time effectiveness of the treatment shall be reevaluated by a health care provider before continuing home use of the device. DWD 81.08(3)(f)(f) Mechanical traction. All of the following guidelines apply to mechanical traction: DWD 81.08(3)(f)1.b.b. Maximum treatment frequency is up to 3 times per week for the first one to 3 weeks decreasing in frequency until the end of the maximum treatment duration period in subd. 1. c. DWD 81.08(3)(f)1.c.c. Maximum treatment duration is 12 weeks in a clinical setting but only if used in conjunction with other therapies. DWD 81.08(3)(f)2.2. Home use of a mechanical traction device may be prescribed as follow-up to use of traction in a clinical setting if it has proven to be effective treatment and is expected to continue to be effective treatment. Initial use of a mechanical traction device shall be in a supervised setting in order to ensure proper patient education. All of the following guidelines apply to home use of a mechanical traction device: DWD 81.08(3)(f)2.b.b. A patient may use the mechanical traction device for one month, at which time effectiveness of the treatment shall be reevaluated by a health care provider before continuing home use of the device. DWD 81.08(3)(g)(g) Acupuncture treatments. For purposes of this paragraph, “acupuncture treatments” include endorphin-mediated analgesic therapy that includes classic acupuncture and acupressure. All of the following guidelines apply to acupuncture treatments: DWD 81.08(3)(g)2.2. Maximum treatment frequency is up to 3 times per week for one to 3 weeks and decreasing in frequency until the end of the maximum treatment duration period in subd. 3. DWD 81.08(3)(h)(h) Manual therapy. For purposes of this paragraph, “manual therapy” includes soft tissue and joint mobilization, therapeutic massage, and manual traction. All of the following guidelines apply to manual therapy: DWD 81.08(3)(h)2.2. Maximum treatment frequency is up to 5 times per week for the first one to 2 weeks decreasing in frequency until the end of the maximum treatment duration period in subd. 3. DWD 81.08(3)(i)(i) Phoresis. For purposes of this paragraph, “phoresis” includes iontophoresis and phonophoresis. All of the following guidelines apply to phoresis: DWD 81.08(3)(i)2.2. Maximum treatment frequency is up to 3 times per week for the first one to 3 weeks and decreasing in frequency until the end of the maximum treatment duration period in subd. 3. DWD 81.08(3)(j)(j) Bedrest. Prolonged restriction of activity and immobilization are detrimental to a patient’s recovery. Bedrest may not be prescribed for more than 7 days. DWD 81.08(3)(k)(k) Spinal braces and other movement restricting appliances. Spinal braces and other movement-restricting appliances required for longer than 2 weeks shall be accompanied by active muscle strengthening exercise to avoid deconditioning and prolonged disability. All of the following guidelines apply to spinal braces and other movement-restricting appliances: DWD 81.08(3)(k)2.2. Maximum treatment frequency is limited to intermittent use during times of increased physical stress or prophylactic use at work. DWD 81.08(3)(k)3.3. Maximum continuous duration is 3 weeks unless patient is status postfusion. DWD 81.08(4)(a)(a) Active treatment modalities shall be used as set forth in pars. (b) to (f). A health care provider’s use of active treatment modalities may extend past the 12-week limit on passive treatment modalities, so long as the maximum durations for the active treatment modalities are not exceeded. DWD 81.08(4)(b)(b) Education shall teach the patient about pertinent anatomy and physiology as it relates to spinal function for the purpose of injury prevention. Education includes training on posture, biomechanics, and relaxation. The maximum number of treatments is 3 visits, which include an initial education and training session and 2 follow-up visits. DWD 81.08(4)(c)(c) Posture and work method training shall instruct the patient in the proper performance of job activities. Topics include proper positioning of the trunk, back and arms, use of optimum biomechanics in performing job tasks, and appropriate pacing of activities. Methods may include didactic sessions, demonstrations, exercises, and simulated work tasks. The maximum number of treatments is 3 visits. DWD 81.08(4)(d)(d) Worksite analysis and modification shall examine the patient’s work station, tools, and job duties. A health care provider may make recommendations for the alteration of the work station, selection of alternate tools, modification of job duties, and provision of adaptive equipment. The maximum number of treatments is 3 visits. DWD 81.08(4)(e)(e) Exercise, which is important to the success of an initial nonsurgical treatment program and a return to normal activity, shall include active patient participation in activities designed to increase flexibility, strength, endurance, or muscle relaxation. Exercise shall, at least in part, be specifically aimed at the musculature of the thoracic spine. Aerobic exercise and extremity strengthening may be performed as adjunctive treatment but may not be the primary focus of the exercise program. DWD 81.08(4)(f)(f) Exercises shall be evaluated to determine if the desired goals are being attained. Strength, flexibility, and endurance shall be objectively measured. A health care provider may objectively measure the treatment response as often as necessary for optimal care after the initial evaluation. Subdivisions 1. and 2. govern supervised and unsupervised exercise, except for computerized exercise programs and health clubs, which are governed by s. DWD 81.13. DWD 81.08(4)(f)1.1. ‘Guidelines for supervised exercise.’ One goal of an exercise program shall be to teach the patient how to maintain and maximize any gains experienced from exercise. Self-management of the condition shall be promoted. All of the following guidelines apply to supervised exercise: DWD 81.08(4)(f)1.a.a. Maximum treatment frequency is 3 times per week for 3 weeks and may decrease with time until the end of the maximum treatment duration period in subd. 1. b. DWD 81.08(4)(f)2.2. ‘Guidelines for unsupervised exercise.’ Unsupervised exercise shall be provided in the least intensive setting appropriate to the goals of the exercise program and may supplement or follow the period of supervised exercise. All of the following guidelines apply to unsupervised exercise: DWD 81.08(4)(f)2.a.a. Maximum treatment frequency is one to 3 visits for instruction and monitoring. DWD 81.08(5)(a)(a) Injection modalities are necessary as set forth in pars. (b) to (d). A health care provider’s use of injections may extend past the 12-week limit on passive treatment modalities, so long as the maximum treatment for injections is not exceeded. DWD 81.08(5)(b)(b) For purposes of this subsection, “therapeutic injections” include trigger points injections, facet joint injections, facet nerve blocks, sympathetic nerve blocks, epidurals, nerve root blocks, and peripheral nerve blocks. Therapeutic injections may only be given in conjunction with active treatment modalities directed to the same anatomical site. DWD 81.08(5)(b)1.1. All of the following guidelines apply to trigger point injections: DWD 81.08(5)(b)1.b.b. Maximum treatment frequency is once per week if there is a positive response to the first injection at that site. If subsequent injections at that site demonstrate diminishing control of symptoms or fail to facilitate objective functional gains, then trigger point injections shall be redirected to other areas or discontinued. Only 3 injections per patient visit. DWD 81.08(5)(b)2.2. All of the following guidelines apply to facet joint injections and facet nerve blocks:
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