Chapter DWD 81

DWD 81.09(9)(e) (e) If there is not progressive improvement in at least 2 categories specified in pars. (b) to (d), the modality shall be discontinued or significantly modified or a health care provider shall reconsider the diagnosis. The evaluation of the effectiveness of the treatment modality may be delegated to an allied health professional directly providing the treatment but remains the ultimate responsibility of the treating health care provider.

DWD 81.09(10) (10) Medication management.

DWD 81.09(10)(a) (a) Prescription of controlled substance medications scheduled under ch. 450, Stats., including opioids and narcotics, are necessary primarily for the treatment of severe acute pain. Therefore, these medications are not generally recommended in the treatment of patients with upper extremity disorders.

DWD 81.09(10)(b) (b) A health care provider shall document the rationale for the use of any scheduled medication. Treatment with nonscheduled medication may be appropriate during any phase of treatment and intermittently after all other treatment has been discontinued. The prescribing health care provider shall determine that ongoing medication is effective treatment for the patient’s condition.

DWD 81.09(11) (11) Specific treatment guidelines for epicondylitis.

DWD 81.09(11)(a) (a) A health care provider shall use initial nonsurgical management for all patients with epicondylitis and this shall be the first phase of treatment.

DWD 81.09(11)(a)1. 1. The passive, active, injection, durable medical equipment, and medication treatment modalities and procedures specified in subs. (3), (4), (5), (8), and (10) may be used in sequence or simultaneously during the period of initial nonsurgical management depending on the severity of the condition. After the first week of treatment, initial nonsurgical care shall at all times include active treatment modalities under sub. (4).

DWD 81.09(11)(a)2. 2. Initial nonsurgical management shall be provided in the least intensive setting consistent with quality health care practices.

DWD 81.09(11)(a)3. 3. Except as provided in sub. (3), the use of passive treatment modalities in a clinic setting or requiring attendance by a health care provider for a period in excess of 12 weeks is not necessary.

DWD 81.09(11)(a)4. 4. Use of home-based treatment modalities with monitoring by the treating health care provider may continue for up to 12 months. At any time during this period the patient may be a candidate for chronic management if surgery is ruled out as an appropriate treatment.

DWD 81.09(11)(b) (b) If the patient continues with symptoms and objective physical findings after initial nonsurgical management and if the patient’s condition prevents the resumption of the regular activities of daily life, including regular vocational activities, then surgical evaluation or chronic management is necessary. The purpose and goal of surgical evaluation is to determine whether surgery is necessary for the patient who has failed to recover with appropriate nonsurgical care or chronic management.

DWD 81.09(11)(b)1. 1. Surgical evaluation, if necessary, shall begin no later than 12 months after beginning initial nonsurgical management.

DWD 81.09(11)(b)2. 2. Surgical evaluation may include the use of appropriate laboratory and electrodiagnostic testing within the guidelines of sub. (1), if not already obtained during the initial evaluation. Repeat testing is not necessary unless there has been an objective change in the patient’s condition that in itself would warrant further testing. Failure to improve with therapy does not, by itself, warrant further testing.

DWD 81.09(11)(b)3. 3. Plain films may be appropriate if there is a history of trauma, infection, or inflammatory disorder and are subject to the general guidelines in s. DWD 81.05 (1). Other medical imaging studies are not necessary.

DWD 81.09(11)(b)4. 4. Surgical evaluation may also include personality or psychological evaluation consistent with the guidelines of sub. (1) (i).

DWD 81.09(11)(b)5. 5. Consultation with other health care providers is an important part of surgical evaluation of a patient who fails to recover with appropriate initial nonsurgical management. The need for consultation and the choice of consultant will be determined by the diagnostic findings and the patient’s condition.

DWD 81.09(11)(b)6. 6. If surgery is necessary, it may be performed after initial nonsurgical management fails.

DWD 81.09(11)(b)7. 7. If surgery is not necessary or if the patient does not wish to proceed with surgery, then the patient is a candidate for chronic management. An initial recommendation or decision against surgery does not preclude surgery at a later date.

DWD 81.09(11)(c) (c) If the patient continues with symptoms and objective physical findings after surgery or the patient refused surgery or the patient was not a candidate for surgery, and if the patient’s condition prevents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management under s. DWD 81.13.

DWD 81.09(12) (12) Specific treatment guidelines for tendinitis of forearm, wrist, and hand.

DWD 81.09(12)(a) (a) Except as provided in par. (b) 3., a health care provider shall use initial nonsurgical management for all patients with tendonitis and this shall be the first phase of treatment. Any course or program of initial nonsurgical management shall meet all of the guidelines of sub. (11) (a).

DWD 81.09(12)(b) (b) If the patient continues with symptoms and objective physical findings after initial nonsurgical management and if the patient’s condition prevents the resumption of the regular activities of daily life, including regular vocational activities, then surgical evaluation or chronic management is necessary. Surgical evaluation and surgical therapy shall meet all of the guidelines of sub. (11) (b), with the following modifications:

DWD 81.09(12)(b)1. 1. For patients with a specific diagnosis of de Quervain’s syndrome, surgical evaluation and surgical therapy, if necessary, may begin after only 2 months of initial nonsurgical management.

DWD 81.09(12)(b)2. 2. For patients with a specific diagnosis of trigger finger or trigger thumb, surgical evaluation and potential surgical therapy may begin after only one month of initial nonsurgical management.

DWD 81.09(12)(b)3. 3. For patients with a locked finger or thumb, surgery may be necessary immediately without any preceding nonsurgical management.

DWD 81.09(12)(c) (c) If the patient continues with symptoms and objective physical findings after surgery, or the patient refused surgery or the patient was not a candidate for surgery, and if the patient’s condition prevents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management. Any course or program of chronic management for patients with tendonitis shall be provided under the guidelines of s. DWD 81.13.

DWD 81.09(13) (13) Specific treatment guidelines for nerve entrapment syndromes.

DWD 81.09(13)(a) (a) A health care provider shall use initial nonsurgical management for all patients with nerve entrapment syndromes, except as specified in par. (b) 2., and this shall be the first phase of treatment. Any course or program of initial nonsurgical management shall meet all of the guidelines of sub. (11) (a), with the following modifications: Nonsurgical management may be inappropriate for patients with advanced symptoms and signs of nerve compression, such as abnormal two-point discrimination, motor weakness, or muscle atrophy, or for patients with symptoms of nerve entrapment due to acute trauma. In these cases, immediate surgical evaluation may be necessary.

DWD 81.09(13)(b) (b) If the patient continues with symptoms and objective physical findings after 12 weeks of initial nonsurgical management and if the patient’s condition prevents the resumption of the regular activities of daily life, including regular vocational activities, then surgical evaluation or chronic management is necessary. Surgical evaluation and surgical therapy shall meet all of the guidelines of sub. (11) (b), with the following modifications:

DWD 81.09(13)(b)1. 1. Surgical evaluation may begin and surgical therapy may be provided, if necessary, after 12 weeks of initial nonsurgical management, except where immediate surgical evaluation is necessary under par. (a).

DWD 81.09(13)(b)2. 2. Surgery is necessary if an electromyography confirms the diagnosis or if there has been temporary resolution of symptoms lasting at least 7 days with local injection.

DWD 81.09(13)(b)3. 3. If there is neither a confirming electromyography nor appropriate response to local injection or if surgery has been previously performed at the same site, surgery is not necessary.

DWD 81.09(13)(c) (c) If the patient continues with symptoms and objective physical findings after all surgery, or the patient refused surgery therapy, or the patient was not a candidate for surgery therapy, and if the patient’s condition prevents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management. Any course or program of chronic management for patients with nerve entrapment syndromes shall be provided under the guidelines of s. DWD 81.13.

DWD 81.09(14) (14) Specific treatment guidelines for muscle pain syndromes.

DWD 81.09(14)(a) (a) A health care provider shall use initial nonsurgical management for all patients with muscle pain syndromes and this shall be the first phase of treatment. Any course or program of initial nonsurgical management shall meet all of the guidelines of sub. (11) (a).

DWD 81.09(14)(b) (b) Surgery is not necessary for the treatment of muscle pain syndromes.

DWD 81.09(14)(c) (c) If the patient continues with symptoms and objective physical findings after initial nonsurgical management and if the patient’s condition prevents the resumption of the regular activities of daily life, including regular vocational activities, then the patient may be a candidate for chronic management. Any course or program of chronic management for patients with muscle pain syndromes shall be provided under the guidelines of s. DWD 81.13.

DWD 81.09(15) (15) Specific treatment guidelines for shoulder impingement syndromes.

DWD 81.09(15)(a) (a) A health care provider shall use initial nonsurgical management for all patients with shoulder impingement syndromes without clinical evidence of rotator cuff tear, and this shall be the first phase of treatment. Any course or program of initial nonsurgical management shall meet all of the guidelines of sub. (11) (a), except for the following:

DWD 81.09(15)(a)1. 1. Continued nonsurgical management may be inappropriate, and early surgical evaluation may be necessary, for patients with any of the following:

DWD 81.09(15)(a)1.a. a. Clinical findings of rotator cuff tear.

DWD 81.09(15)(a)1.b. b. Acute rupture of the proximal biceps tendon.

DWD 81.09(15)(a)2. 2. Use of home-based treatment modalities with monitoring by a health care provider may continue for up to 6 months. At any time during this period the patient may be a candidate for chronic management if surgery is ruled out as necessary treatment.

DWD 81.09(15)(b) (b) If the patient continues with symptoms and objective physical findings after 6 months of initial nonsurgical management and if the patient’s condition prevents the resumption of the regular activities of daily life, including regular vocational activities, then surgical evaluation or chronic management is necessary. Surgical evaluation and surgical therapy shall meet all of the guidelines of sub. (11) (b), with any of the following modifications:

DWD 81.09(15)(b)1. 1. Surgical evaluation shall begin no later than 6 months after beginning initial nonsurgical management.

DWD 81.09(15)(b)2. 2. Diagnostic injection, arthrography, computed tomography-arthrography, or magnetic resonance imaging scanning may be necessary as part of the surgical evaluation.

DWD 81.09(15)(b)3. 3. The only surgical procedures necessary for patients with shoulder impingement syndromes and related conditions are rotator cuff repair, acromioplasty, excision of distal clavicle, excision of bursa, removal of adhesion, or repair of proximal biceps tendon, all of which shall meet the guidelines of s. DWD 81.12 (2).

DWD 81.09(15)(c) (c) If the patient continues with symptoms and objective physical findings after surgery, or the patient refused surgery or was not a candidate for surgery, and if the patient’s condition prevents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management. Any course or program of chronic management for patients with shoulder impingement syndromes shall be provided under the guidelines of s. DWD 81.13.

DWD 81.09(16) (16) Specific treatment guidelines for traumatic sprains and strains of the upper extremity.

DWD 81.09(16)(a) (a) A health care provider shall use initial nonsurgical management for the first phase of treatment for all patients with traumatic sprains and strains of the upper extremity without evidence of complete tissue disruption. Any course or program of initial nonsurgical management shall meet all of the guidelines of sub. (11).

DWD 81.09(16)(b) (b) Surgery is not necessary for the treatment of traumatic sprains and strains, unless there is clinical evidence of complete tissue disruption. Patients with complete tissue disruption may need immediate surgery.

DWD 81.09(16)(c) (c) If the patient continues with symptoms and objective physical findings after 12 weeks of initial nonsurgical management and if the patient’s condition prevents the resumption of the regular activities of daily life, including regular vocational activities, then the patient may be a candidate for chronic management. Any course or program of chronic management for patients with traumatic sprains and strains shall be provided under the guidelines of s. DWD 81.13.

DWD 81.09 History History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07.

DWD 81.10 DWD 81.10 Complex regional pain syndrome of the upper and lower extremities.

DWD 81.10(1) (1) Scope.

DWD 81.10(1)(a) (a) Complex regional pain syndrome of the upper and lower extremities encompasses any condition of the upper or lower extremity characterized by findings in all of the following categories:

DWD 81.10(1)(a)1. 1. One or more findings reported by the patient in 3 or more of the following categories:

DWD 81.10(1)(a)1.a. a. Positive sensory abnormalities, which include spontaneous pain, mechanical hyperalgesia, thermal hyperalgesia, and deep somatic hyperalgesia.

DWD 81.10(1)(a)1.b. b. Vascular abnormalities, which include vasodilation, vasoconstriction, skin temperature asymmetries, and skin color changes.

DWD 81.10(1)(a)1.c. c. Swelling or sweating abnormalities.

DWD 81.10(1)(a)1.d. d. Motor and trophic changes, which include motor weakness, tremor, abnormal movements, coordination deficits, nail changes, hair changes, skin atrophy, joint stiffness, and soft tissue changes.

DWD 81.10(1)(a)2. 2. One or more findings observed by the health care provider in 2 or more of the following categories:

DWD 81.10(1)(a)2.a. a. Positive sensory abnormalities, which include spontaneous pain, mechanical hyperalgesia, thermal hyperalgesia, and deep somatic hyperalgesia.

DWD 81.10(1)(a)2.b. b. Vascular abnormalities, which include vasodilation, vasoconstriction, skin temperature asymmetries, and skin color changes.

DWD 81.10(1)(a)2.c. c. Edema or sweating abnormalities, which include swelling, hyperhidrosis, and hypohidrosis.

DWD 81.10(1)(a)2.d. d. Motor and trophic changes, which include motor weakness, tremor, abnormal movements, coordination deficits, nail changes, hair changes, skin atrophy, joint stiffness, and soft tissue changes.

DWD 81.10(1)(b) (b) Complex regional pain syndrome of the upper and lower extremities includes the diagnoses of complex regional pain syndrome, reflex sympathetic dystrophy, causalgia, Sudek’s atrophy, algoneurodystrophy, shoulder-hand syndrome, including ICD-9-CM codes 337.9, 354.4, and 733.7.

DWD 81.10(1)(c) (c) Complex regional pain syndrome occurs as a complication of another preceding injury. The treatment guidelines of this section refer to the treatment of the body part affected by the complex regional pain syndrome. The treatment for any condition not affected by complex regional pain syndrome continues to be subject to whatever treatment guidelines otherwise apply. Any treatment under this section for complex regional pain syndrome may be in addition to treatment received for the original condition.

DWD 81.10(1)(d) (d) Thermography may be used in the diagnosis of complex regional pain syndrome and is considered an adjunct to physical examination.

DWD 81.10(1)(e) (e) For a patient with continued clinical signs and symptoms of complex regional pain syndrome, further diagnostic testing may be appropriate.

DWD 81.10(2) (2) Initial nonsurgical involvement.

DWD 81.10(2)(a) (a) A health care provider shall use initial nonsurgical management for all patients with complex regional pain syndrome and this shall be the first phase of treatment. Any course or program of initial nonsurgical management is limited to the modalities specified in pars. (b) to (i).

DWD 81.10(2)(b) (b) The only therapeutic injection modalities necessary for complex regional pain syndrome are sympathetic block, intravenous infusion of steroids or sympatholytics, or epidural block.

DWD 81.10(2)(b)1. 1. Unless medically contraindicated, sympathetic blocks or the intravenous infusion of steroids or sympatholytics shall be used if complex regional pain syndrome has continued for 4 weeks and the patient remains disabled as a result of the complex regional pain syndrome. All of the following guidelines apply to therapeutic injection modalities:

DWD 81.10(2)(b)1.a. a. Time for treatment response is within 30 minutes.

DWD 81.10(2)(b)1.b. b. Maximum treatment frequency permits a repeat injection at a site if there was a positive response to the first injection. If subsequent injections demonstrate diminishing control of symptoms or fail to facilitate objective functional gains, then injections shall be discontinued. Only 3 injections to different sites per patient visit.

DWD 81.10(2)(b)1.c. c. Maximum treatment duration may be continued as long as injections control symptoms and facilitate objective functional gains if the period of improvement is progressively longer with each injection.

DWD 81.10(2)(b)2. 2. Epidural block may only be performed in patients who had an incomplete improvement with sympathetic block or intravenous infusion of steroids or sympatholytics.

DWD 81.10(2)(c) (c) Only the passive treatment modalities set forth in pars. (d) to (g) are necessary. These passive treatment modalities in a clinical setting or requiring attendance by a health care provider are not necessary beyond 12 weeks from the first modality initiated for treatment of complex regional pain syndrome.

DWD 81.10(2)(d) (d) For purposes of this paragraph, “thermal treatment” includes all superficial and deep heating 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 81.10(2)(d)1. 1. Treatment given in a clinical setting:

DWD 81.10(2)(d)1.a. a. Time for treatment response is 2 to 4 treatments.

DWD 81.10(2)(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 81.10(2)(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 specified in this subsection.

DWD 81.10(2)(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 professional 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 81.10(2)(e) (e) For purposes of this paragraph, “desensitizing procedures” includes stroking or friction massage, stress loading, and contrast baths. All of the following guidelines apply to desensitizing procedures:

DWD 81.10(2)(e)1. 1. Time for treatment response is 3 to 5 treatments.

DWD 81.10(2)(e)2. 2. Maximum treatment frequency in a clinical setting 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 81.10(2)(e)3. 3. Maximum treatment duration in a clinical setting is 12 weeks. Home use of desensitizing procedures may be prescribed at any time during the course of treatment.