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: