7 Colo. Code Regs. § 1101-3-17-08-7
Recommendation 48. Active therapies are acceptable. They require intrinsic motivation by the patient to complete a specific exercise or task, in contrast with passive therapies. Interventions may include, but are not limited to, the following:
* activities of daily living (ADLs) therapy,
* aquatic therapy,
* functional activities therapy,
* in-office use of functional electrical stimulation or neuromuscular electrical stimulation (NMES) in which the patient is active,
* a home exercise program,
* neuromuscular re-education,
* therapeutic exercise,
* work conditioning,
* working modified duty with gradual advancement of activities, and
* work simulation.
Recommendation 49. Providing education alongside active therapies is acceptable. Education may include, but is not limited to, the following:
* a favorable prognosis for recovery,
* the importance of continuing daily activities,
* promotion of self-efficacy,
* problem-solving,
* engagement of support systems,
* pain neuroscience education, and
* relaxation techniques.
Recommendation 50. Specialist medical clearance is required prior to participation in active therapies if a patient has any of the following unexplained symptoms:
* angina/dyspnea on exertion or at rest, or
* paroxysmal nocturnal dyspnea and/or orthopnea, or
* syncope or presyncope, or
* arrhythmia or palpitations, or
* cardiac murmur.
Recommendation 51. Patients in active therapy must:
* demonstrate functional progress that is documented through validated sequential functional assessment measures;
* return to work with decreased restrictions; and/or
* have improvement in clinical measures (e.g., strength, range of motion [ROM], and activities of daily living [ADLs]).
If there is no documented evidence of functional progress after 6 treatments, the therapy will be discontinued and the patient must be referred back to their treating provider for further evaluation. Each patient is limited to a maximum of 4 discrete active therapy trials without documented functional progress. (See examples of functional outcome measures in the Appendix.)
Recommendation 52. It is acceptable for adjunct passive therapy to occur concurrently with active therapy, and the frequency of passive therapies will decrease over time. See the Passive Therapies section.
Recommendation 53. Functional electrical stimulation or neuromuscular electrical stimulation (NMES) home units require prior authorization, documenting medical justification for home use. For transcutaneous electrical nerve stimulation (TENS) home units see Recommendation 69.
Recommendation 54. A patient is allowed up to 6 active therapy visits to advance their active home exercise program. These visits are contingent on documented demonstration of previously instructed exercises, performance of their home program at the recommended frequency, and progress in their exercise program.
Recommendation 55. Time frames for active therapies are as follows:
* Time to produce effect: 6 treatments.
* Frequency: up to 4 times per week.
* Maximum duration: 8 weeks.
Recommendation 56. Durations of care beyond those listed as "time to produce effect" and "maximum" are acceptable in the following circumstances:
* once scheduled for a surgery, preoperative active treatment while waiting for the surgery without expectation of typical functional gains; or
* after surgery, particularly after multiple surgeries; or
* re-injury, interrupted continuity of care, specific diagnoses (such as fracture, post-traumatic stiff shoulder, non-surgical management of rotator cuff or labral tears, aggravated arthritis), returning to a highly physically demanding job, and/or comorbidities when treatment to date has resulted in measurable and clinically meaningful functional improvement.
Recommendation 57. Early initiation of behavioral and psychological interventions is acceptable if psychosocial or behavioral factors appear to be interfering with functional recovery (see Recommendation 19 and Recommendation 20). See the Chronic Pain Disorder Medical Treatment Guidelines (MTGs) for recommendations and treatment time frames.
All Passive Therapies.
Recommendation 58. Passive therapies include treatments that do not require a patient's energy expenditure. Patients in passive therapy must demonstrate functional progress through validated functional assessment measures. If there is no evidence of functional progress within the time to produce effect, the therapy shall be discontinued and the patient must be referred back to their treating provider for evaluation. Each patient is limited to a maximum of 4 discrete passive therapy trials.
Recommendation 59. Passive therapies must occur concurrently with self-directed exercise or formal active therapy programs.
Recommendation 60. The frequency of passive therapy must decrease over time.
Recommendation 61. Durations of care beyond those listed as "time to produce effect" and "maximum" are acceptable in the following circumstances:
* after surgery, particularly after multiple surgeries; or
* re-injury, interrupted continuity of care, specific diagnoses (such as fracture, post-traumatic stiff shoulder, non-surgical management of rotator cuff or labral tears, aggravated arthritis), and/or comorbidities when treatment to date has resulted in measurable and clinically meaningful functional improvement.
Acupuncture.
Recommendation 62. Acupuncture is acceptable within the following parameters:
* Time to produce effect: up to 6 sessions.
* Frequency: up to 3 sessions per week. See Recommendation 60 regarding the expected decreasing frequency over time.
* Maximum duration: 15 treatments.
Bone Growth Stimulation.
Recommendation 63. Electrical bone growth stimulation requires prior authorization.
Recommendation 64. Low-intensity pulsed ultrasound (LIPUS) is not recommended for clavicular fracture.
Continuous Passive Motion.
Recommendation 65. Continuous passive motion is not generally recommended. It is acceptable if there is a diagnosis of post-traumatic stiff shoulder and access to therapy is limited.
Diathermy.
Recommendation 66. Radio wave diathermy is not recommended.
Dry Needling.
Recommendation 67. Dry needling is acceptable within the following parameters:
* Time to produce effect: up to 4 sessions.
* Frequency: up to 2 sessions per week. See Recommendation 60 regarding the expected decreasing frequency over time.
* Maximum duration: 8 weeks.
Elastic Taping (e.g., Kinesiotaping).
Recommendation 68. Elastic taping is acceptable as part of active therapy sessions (see Recommendation 55 for time frames). Discontinue use if there is no documented functional benefit.
Electrical Stimulation (In-Clinic Use).
Recommendation 69. In-office electrical stimulation in which the patient is passive is acceptable within the following parameters:
* Time to produce effect: up to 4 sessions.
* Frequency: up to 3 sessions per week. See Recommendation 60 regarding the expected decreasing frequency over time.
* Maximum duration: 4 weeks.
* If transcutaneous electrical nerve stimulation (TENS) treatment results in documented functional benefit and is anticipated to extend beyond 4 treatments, consider purchase of a home TENS unit.
Hyperbaric Oxygen Therapy.
Recommendation 70. Hyperbaric oxygen therapy is not recommended.
Iontophoresis.
Recommendation 71. Iontophoresis is acceptable within the following parameters:
* Time to produce effect: up to 4 sessions.
* Frequency: 3 sessions per week with at least 48 hours between sessions. See Recommendation 60 regarding the expected decreasing frequency over time.
* Maximum duration: 10 treatments.
Laser Therapy.
Recommendation 72. Low-level laser therapy is not recommended.
Manual Treatment.
Recommendation 73. Manual treatment is acceptable, including manipulation, joint mobilization, soft tissue mobilization, and myofascial release, within the following parameters:
* Time to produce effect: up to 6 sessions.
* Frequency: up to 3 sessions per week. See Recommendation 60 regarding the expected decreasing frequency over time.
* Maximum duration: 8 weeks.
Massage.
Recommendation 74. Massage is acceptable within the following parameters:
* Time to produce effect: 6 sessions.
* Frequency: up to 2 sessions per week. See Recommendation 60 regarding the expected decreasing frequency over time.
* Maximum duration: 8 weeks.
Shockwave Therapy.
Recommendation 75. Shockwave therapy is not a first-line therapy. It is not recommended in the absence of a documented calcium deposit but is acceptable for patients with calcific tendonitis who have not achieved functional goals after at least 2 months of conservative care emphasizing Active Therapies as outlined in Section 7.a.i. within the following parameters:
* Time to produce effect: 3 days after a treatment.
* Frequency: every 4 days. See Recommendation 60 regarding the expected decreasing frequency over time.
* Maximum duration: 4 sessions.
Recommendation 76. Anesthesia and conscious sedation are not recommended during shockwave therapy.
Superficial Heat and Cold Therapy.
Recommendation 77. Superficial heat and cold therapy is acceptable within the following parameters:
* Time to produce effect: up to 4 sessions.
* Frequency: up to 3 sessions per week. See Recommendation 60 regarding the expected decreasing frequency over time.
* Maximum duration: 8 weeks.
Ultrasound, including Phonophoresis (In-Clinic Use).
Recommendation 78. Therapeutic ultrasound, including phonophoresis, is acceptable for calcific tendinopathy within the following parameters:
* Time to produce effect: up to 15 sessions.
* Frequency: 3 sessions per week. See Recommendation 60 regarding the expected decreasing frequency over time.
* Maximum duration: 2 months.
Recommendation 79. Fabrication and modification of orthotics is acceptable to facilitate better motion response, stabilize a joint with insufficient muscle or proprioceptive/reflex competencies, protect subacute conditions as needed during movement, and/or correct biomechanical problems. The time frames are as follows:
* Maximum Duration: 4 sessions of evaluation, casting, fitting, and re-evaluation.
Recommendation 80. Training on the proper use of orthotic devices and/or prosthetic limbs is acceptable. Instruction and training includes, but is not limited to, stump preparation, donning and doffing limbs, wearing schedule, orthotic/prosthetic maintenance, and techniques for activities of daily living and self-care. The time frames are as follows:
* Frequency: 4 times per week.
* Maximum Duration: 4 months.
Recommendation 81. Splints, slings, braces, immobilizers, and adaptive equipment are acceptable if used to improve safety, reduce stress on the injury, and reduce risk of re-injury. Sessions for their design, fabrication, modification, and/or training on their use are acceptable. The time frames are as follows:
* Maximum Duration: 3 sessions.
Recommendation 82. Adaptive equipment is acceptable if used to improve safety, reduce stress on the injury, and reduce risk of re-injury. Equipment includes high and low-technology assistive options such as workplace modifications, computer interface or seating, and self-care aids. Sessions for training on their use are acceptable. The time frames are as follows:
* Maximum Duration: 3 sessions.
7 CCR 1101-3-17-08-7