General Guideline Principles for Injection Therapies
for workers compensation patients
The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Injection Therapies.
These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.
The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.
Injection Therapies
- Botulinum Injections for CRPS
Botulinum Injections for CRPS is not recommended in the management of CRPS.
- Intrathecal Baclofen for CRPS
Intrathecal Baclofen for CRPS is recommended selectively for treatment of dystonia associated with CRPS.
Indications: Highly limited indication of severe dystonia accompanying severe CRPS.
- Intrapleural Bupivacaine Infusions for CRPS
Intrapleural Bupivacaine Infusions for CRPS is not recommended in the management of CRPS.
- Lidocaine Infusion for CRPS
Lidocaine Infusions for CRPS is not recommended in the management of CRPS.
- Stellate and Other Ganglion Blocks
Stellate and Other Ganglion Blocks for CRPS is recommended corresponding to the body region affected by CRPS are recommended for treatment of acute or an acute flare-up of CRPS as an adjunct to a functional restoration approach.
Indications: Acute CRPS or an acute flare-up of CRPS that is unresponsive to or insufficiently treated by drugs, progressive strengthening, graded exercise, physical therapy, and occupational therapy Should be carried out when it is included in a thorough treatment plan that has a focus on functional restoration.
Frequency/Dose/Duration:Following injection for the second block, the temperature should have changed by at least 1 degree. Almost always, benefits are contained in a block of one to three. If there is clear evidence of ongoing, gradual functional improvement, blocks after that. Generally speaking, should also show a reduction in opioids of three to five blocks, if applicable.
- Guanethidine Bier Blocks for CRPS
Guanethidine Bier Blocks for CRPS is not recommended in the management of CRPS.
- Phentolamine Bier Blocks
Phentolamine Bier Blocks for CRPS is not recommended in the management of CRPS.
- Bretylium Bier Blocks for CRPS
Bretylium Bier Blocks for CRPS is recommended for treatment of severe cases of CRPS.
Indications: severe CRPS unresponsive to or insufficiently treated by progressive exercise, bisphosphonates, glucocorticoids, NSAIDs, active exercise, physical therapy/occupational treatment, and maybe mirror therapy.
Before taking bretylium into consideration, it may be reasonable to try controlling the condition with clonidine, anticonvulsants, tricyclic antidepressants, or hyperbaric oxygen. should be carried out as a supplement to a functional rehabilitation programme to enhance physical capacities.
Frequency/Dose/Duration: Lidocaine 40 ml with 1.5 mg/kg bretylium Should show at least a 1-degree shift in measured temperature postinjection for the second block. Benefits are almost often found inside a block of one to three.
Blocks after that if there is unmistakable proof of continuous, gradual functional progress. If relevant, should also generally demonstrate a three to five block reduction in opioids. Blockades should only be added if there is concrete proof that conditions are getting better.
- Methylprednisolone Bier Blocks for CRPS
Methylprednisolone Bier Blocks for CRPS is not recommended in the management of CRPS.
- Reserpine Bier Blocks for CRPS
Reserpine Bier Blocks for CRPS is not recommended in the management of CRPS.
- Brachial Plexus Blocks and Infusions for CRPS
Brachial Plexus Blocks and Infusions for CRPS is not recommended in the management of CRPS. Phentolamine, or Reserpine Bier Blocks
- Intrathecal Drug Delivery Systems for Chronic Persistent Pain
Intrathecal Drug Delivery Systems for Chronic Persistent Pain is recommended when all other (often more conservative and less invasive) methods have failed to relieve the symptoms of CRPS in a particular patient group.
Targeted drug delivery (Pain Pumps) is not included on the list of pre- authorized procedures.
- Before carrying out the operation, providers that wish to do so must obtain pre-authorization from the carrier.
- In consultation with the primary treating physician, the patient must undergo evaluation and get the recommendation of at least one physician qualified in chronic pain management.
- A doctor with verified experience performing this technique must execute the procedure.
- Indications: In CRPS patients with severe, persistent, intractable pain who have failed to respond to all conservative therapy approaches, targeted medication delivery with an intrathecal pump may be considered as a last resort. The tiny qualifying subgroup of patients must satisfy each of the requirements listed below:
- On the basis of objective data, a diagnosis of CRPS has been determined; all appropriate surgical and nonsurgical treatments, including active and/or passive therapy, medication management, or therapeutic injections have failed; and
- There are no practical concerns (such as severe cognitive impairment, morbid obesity, or body sizes insufficient to sustain the size and weight of the implanted device) that would prevent the installation, maintenance, or assessment of the device;
As with SCS, a pre-trial psychiatric or psychological evaluation should show that the following:
- no primary psychiatric warning signs or risk factors;
- a drive to follow through on treatment recommendations;
- As opioid dependency and tolerance are not addictive behaviours, they do not rule out implantation. There is no proof of present addictive behaviour.
- Encourage the patient to receive care at a functional restoration programme, if one is offered, before a pain pump trial is taken into consideration. Before a screening trial is scheduled, all evaluation requirements must be satisfied.
- no primary psychiatric warning signs or risk factors;
- Before carrying out the operation, providers that wish to do so must obtain pre-authorization from the carrier.
- Pain Pump Screen Trial
To determine efficacy and confirm there are no side effects, a successful trial of continuous infusion by a percutaneous spinal infusion pump for at least 24 hours or a bolus trial as an outpatient is needed.
An effective screening test is one in which the patient:
Notices a 50% reduction in pain, which VAS may validate, and
Shows measurable functional improvements or reduces use of painkillers,
Prior to and before the trail’s termination, objective functional gains should be assessed and documented.
- Pain Pump Implantation
The treating physician must ask the carrier for preauthorization before implanting a permanent pain pump if the screening trial is successful.
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