Tag Archives: electrodiagnostic functional assessment

Better Approach to Soft Tissue Injury

Musculoskeletal diseases, defined as injuries to the soft tissues, currently affect more than one out of every two persons in the U.S. age 18 and older, and nearly three out of four over the age of 65. Low back pain affects at least 80% of adults at some point, with an estimated annual cost of more than $100 billion. Trauma, back pain and arthritis — the three most common musculoskeletal conditions — are the most common reason for patient visits to physicians’ offices, emergency departments and hospitals every year. With the aging U.S. population, musculoskeletal diseases are becoming a greater burden every year.

A determination must be made if the pain generator is muscular or structural, and incorrect diagnoses can lead to inappropriate treatments and, in the worst case, unnecessary surgeries.

About 80% of healthcare and social costs related to low back pain are attributed to just 10% of patients with chronic pain and disability. This statistic suggests that improved interventions to reduce the recurrence of low back pain can underpin significant cost savings and improvement in patient outcomes.

The standard approach to managing soft tissue injuries is to obtain a medical history and perform a physical examination. Imaging or testing usually is not needed in the early phases of treatment. In most cases, the natural history of a soft tissue injury resolves without intervention.

There are excellent tools to diagnose structural abnormalities or nerve injuries. These include imaging studies, nerve condition tests and disograms. X-rays can be used to assess the possibility of fracture or dislocation. Nerve conduction studies may be used to localize nerve dysfunction.

But they are not adequate for soft tissue injury or functional assessments. MRI and CT scans, while excellent tests to evaluate structure, are generally static and not designed to assess muscle function dynamically. In addition, these standard tests all carry a high rate of false positives.

There is no magic bullet or one test that does everything. While many tests are good for what they are designed to evaluate, they are not appropriate to diagnose a soft tissue injury.

Enter electrodiagnostic functional assessment — EFA testing. The EFA is a diagnostic tool that combines and enhances five medically accepted tests: electromyography, range of motion, functional capacity evaluation, pinch and grip strength. The EFA is non-invasive and non-loading. The advantage the EFA presents over performing these tests individually is that it performs all tests simultaneously and in a dynamic fashion.

This equipment has a 510 (k) registration with the Food and Drug Administration as a Class II diagnostic device. Furthermore, the FDA has recognized in the intended use section that the technology can distinguish between acute and chronic pathology, is able to look at referred pain patterns and is useful with treatment recommendations and baseline testing.

Physicians encounter patients daily with complaints of injuries to the soft tissues, particularly the paraspinal muscles. In many cases, objective findings are obvious, but many patients may have injuries that are subtle but continue to cause symptoms. In other cases, the injuries may be less recent, and the physical findings may not be apparent. Direct palpation of soft tissues can, in some cases, reveal the nature or type of injury, but this manner of diagnosis relies on static testing. For some individuals, problems may only be encountered during activity. Measuring muscle activity during range-of-motion testing is difficult at best. The extent to which a patient exerts herself also presents a subjective bias with soft tissue injury.

Better outcomes will be demonstrated by using the correct tools to evaluate the underlying pathology. In Adam Seidner’s paper “Assessing disease and wellness in the occupational setting: Electrodiagnostic Functional Assessment from wired to wireless,” he demonstrated that, when the EFA was implemented as a case management tool, it enhanced the level of discussion among treating providers, injured workers and claim professionals. The study demonstrated that medical and lost wage payments to injured workers and their healthcare providers were 25% lower in the EFA group, for an average savings of $10,000 per claim versus the control group. Most importantly, the average return to work was 213 days in the EFA group versus 275 for the control group, or an average of 62 days sooner. The EFA was able to provide better diagnostic information on soft tissue injuries and return the individual back to activities of daily living sooner. Better patient care leads to better outcomes.

The EFA results are further demonstrated in the paper “Musculoskeletal disorders early diagnosis: A retrospective study in the occupational medicine setting.” The study found EFA test results affected the course of treatment, improved clinical and functional outcomes, increased patient satisfaction and decreased dispute litigation. In fact, 98 of the 100 cases resulted in return to maximum medical improvement with no rateable impairment and full release to active duty. Only 2% of the cases were challenged, and 98% of those in the EFA control group returned to their pre-injury jobs. These cases were tracked over a three-year period.

The EFA-STM baseline program is just another example of better diagnostics providing better patient care. This book-end solution allows for the best care possible for the work-related injury. If a condition is not deemed to be work-related, the individual can still receive the best care and a quicker resolution.

The EFA does not replace the other, well-established diagnostic tests; it is simply a better diagnostic alternative for soft tissue injuries. All the tests can complement one another.

At the end of the day, when it comes workers’ compensation, the issue is providing better patient care. It’s a win-win for all parties.

 

Is Baseline Testing Worth It? (Part 2)

In our first article on this subject, we gave an overview of baseline testing, compared it with a post-offer physical exam, updated recent legal decisions under the Americans With Disabilities Act (ADA) that allow baseline testing and concluded with a legal case highlighting the benefits of a baseline program. While all stakeholders won in the case we cited, we all need to remember that the focus in workers’ comp needs to be the injured worker.

That isn’t always the case, as recent court rulings have shown. Last week, a Pottawatomie County judge in Oklahoma issued a ruling that may erode the exclusive remedy provision for workers’ compensation (Duck vs Morgan Tire). This ruling comes after Miami-Dade District Judge Jorge Cueto ruled in August that the exclusive-remedy provision of the state’s comp statute was unconstitutional. Both cases make a strong case that the rights of injured workers have been deteriorating and that workers no longer have enough protection. (The cases are under appeal.)

The workers’ compensation system is overburdened with red tape: In some states, there are onerous mandates for doctors, delays in legal proceedings, disputes over acceptance of cases…and on and on. An injured person is caught in the middle. Frequently, necessary care is delayed — which often results in even greater damage and costs. Carriers and employers are frustrated, too. With increasing federal mandates complicating this already tangled system, they feel they are being asked to accept claims that “aren’t ours.” They worry about liability and uncontrolled costs, even while knowing that delaying appropriate care can lead to prolonged disability, inefficient medical care and higher costs.

So the question remains: How do we do the best for the injured worker while protecting ourselves?

This article focuses on the heart of the matter: Better diagnosis leads to better patient care. Peel away the layers of comp laws and reforms, and this is what the industry should be about.

Baseline testing helps identify a change in condition, so the person can get the best care possible for work-related injuries. Does this actually happen? Does baseline testing work with soft-tissue injuries, specifically those that appear to be based on subjective complaints, with typically little or no objective findings? (Soft-tissue injuries, although often unsupported by clear and convincing evidence, are the leading drivers of cost in the system.)

Here is a case that shows that it’s possible to use baseline testing to avoid over-treating or under-treating and to do the right thing:

Mr. Jones works for the same employer as was mentioned in Part 1 of this article. He is 34 years old and is employed as truck driver. He underwent a baseline test in June 2014 and was injured at work in September 2014. He was driving his truck when he hit a bump. He was wearing a seat belt but hit his head. He continued to work. He later felt diffuse neck pain and reported the incident.

The following day, he saw a doctor, who couldn’t issue a diagnosis. Mr. Jones had a history of chronic neck pain, so the doctor couldn’t tell if anything was “new.” He thought the pain would go away, but it persisted.

Because Mr. Jones had undergone a baseline evaluation, he was sent for the post-incident, electrodiagnostic functional assessment (EFA). The comparison of the two evaluations revealed a change in condition. The testing indicated he could have an industrially related left cervical radiculopathy. Treatment was redirected to this area, and he received the appropriate care on an expedited basis.

This is a person who had diffuse pathology and a substantial pre-existing condition. As a result, his workman’s comp carrier delayed care, and he pursued treatment by his chiropractor on a non-industrial basis. He was off work, not receiving benefits, while waiting for the causation of his injury to be determined. He potentially could have gotten lost in the system with unresolved treatment and escalating bills while without benefits and out of work.

The employer truly wants the best care for its injured workers and, as soon as the comparison demonstrated a change, ensured that he received all the appropriate care and benefits for his work-related injury.

We truly believe that everyone in this workers’ compensation system wants to do the “right thing” but that is hard to do without objective evidence. Accurate diagnoses lead to better patient care, which is the very basis of workers’ compensation. So is baseline testing really worth the effort? You bet it is!

Better Way to Handle Soft-Tissue Injuries

The most costly problem facing employers today is work-related, soft-tissue injuries, more commonly known as work-related musculoskeletal disorders (WRMSD). According to OSHA, WRMSD account for 34% of lost work days in the U.S., as well as a third of the dollars spent in workers’ compensation and of all work-related injury cases.

Not surprisingly, soft tissue injuries — to the ligaments, tendons and fibers of the body that connect the bones — are difficult to diagnose. Standard diagnostic tests such as X-rays or imaging are frequently unable to document the presence of pain and loss of function. As a result, diagnoses are often subjective, leading to poor treatment (including unnecessary surgery and overuse of narcotics), extra lost work time, precariously high medical costs and, at times, fraudulent claims.

There is a need for accurate, timely and evidence-based diagnosis and treatment to curtail escalating costs and improve clinical outcomes, as these case studies show:

Case 1

A 44-year-old gentleman had undergone a baseline EFA. (The Electrodiagnostic Functional Assessment, or EFA, combines mutltichannel wireless electromyography (EMG) with range-of-motion testing and integrates that with a functional output). He is employed as an unloader in the shipping department. He alleged a work-related injury in October 2014, five weeks into his employment. He stated that he injured his shoulders when he put his hands out to block a fall. He complained of bilateral shoulder pain, radiating to the right upper extremity. He rated the pain as an eight on a scale of one to 10. But an EFA found no change from the baseline test.

Outcome: Because there was no change from his baseline, he was released from treatment and advised to see his primary care physician for any further medical needs.

Case 2

A 37-year-old gentleman was employed as a loader. He alleged a work injury in October 2014; when he bent to lift some ice, he felt a pain in his lower back. He complained of radiating lower back pain, into the left lower extremity, rated as a 6/10. He was referred by his occupational medicine doctor, as there were no objective findings, and his subjective complaints seemed out of proportion. An EFA revealed normal EMG activity, with chronic, unrelated pathology.

Outcome: When he returned for his follow-up evaluation after the EFA, he still had the same subjective complaints. After his doctor reviewed the EFA findings, he stated that he felt much better and asked for a release to return to  full duty at work.

Case 3

A 34-year-old gentleman was employed as a mix/truck driver. He had undergone a baseline EFA in June 2014 and had a work-related motor vehicle accident in September 2014. His head struck the roof of his truck, and he was not wearing a hard hat. He complained of neck, shoulder and head pain. When an EFA was compared with the baseline, chronic, unrelated pathology was noted. However, the comparison also revealed a change in the paracervical region. This change was consistent with the date and mechanism of injury and with his subjective complaints.

Outcome: The EFA comparison was able to identify and redirect care, away from the chiropractic care that he was receiving. After imaging studies were performed and the results found to be consistent with the EFA findings, he received site-specific, conservative care for his work-related injury, and his symptoms improved.

It is our opinion that the EFA-STM provides a book end solution, comparing a pre-injury test to a post-injury assessment to objectively and accurately determine AOECOE (arising out of employment/course of employment) status. One must base a medical evaluation on facts, not subjective complaints. When that is accomplished, proper diagnosis and treatment are rendered, and outcomes improved.

The authors invite you to join them at the NexGen Workers’ Compensation Summit 2015, to be held Jan. 13 in Carlsbad, CA. The conference, hosted by Emerge Diagnostics, is dedicated to past lessons from, the current status of and the future for workers’ compensation. The conference is an opportunity for companies to network and learn, as well as contribute personal experience to the general knowledge base for workers’ compensation. Six CEU credits are offered. For more information, click here.

New Data on Whether to Remove Surgical Hardware

Whether to remove hardware implanted in a patient during an earlier surgery raises questions because, while it’s obviously preferable to not leave hardware inside someone, removing the hardware requires cutting through scar tissue and can cause complications.A method we have begun to use and found beneficial after cervical and lumbar surgery is an electrodiagnostic functional assessment (EFA). The EFA combines electromyography (EMG), range of motion (ROM) and a functional capacity evaluation (FCE) to provide additional data about whether hardware removal is necessary.The approach could have broad implications because hardware removal accounts for as much as 33% of all planned orthopedic surgery.Two illustrative cases have been reviewed using the EFA to assess patients after lumbar fusion.The first case involves Mr. P. He is a 34-year-old who sustained a work-related injury on June 7, 2011. He complained of low back pain and right hip pain. He had an MRI that showed degenerative central disk herniation at L5-S1 with retrolisthesis. He failed eight weeks of physical therapy and a lumbar epidural steroid injection. His symptoms improved after this injection for more than three months, but he continued to complain of pain and had not worked for more than a year.

He underwent an L5-S1 posterior lumbar interbody fusion on July 17, 2012. He underwent a reoperation on March 26, 2013, for pseudoarthrosis at L5-S1 and had a fusion revision with bone morphogenic protein and an external bone stimulator.

Despite the operation and revision, he complained of persistent pain, and in September 2013 he continued to be taking Norco. He was still unable to work.

He had a CAT scan of the lumbar spine that showed what appeared to be a solid bony fusion at L5-S1. To try to determine the cause for his pain, he had an EFA test, which revealed appropriate EMG activity while sitting. He had moderate bilateral muscle spasms in the paraspinous muscles, and all other muscle groups evaluated exhibited appropriate EMG activity except for severe weakness in the bilateral quadratus lumborum muscles with compensation in the paraspinous muscles and hamstring muscles.

With these results, it was doubtful that the patient would benefit significantly from hardware removal. He had a hardware block with Marcaine and exhibited only transient benefit.

Nevertheless, because he remained disabled and on narcotics, he underwent a hardware removal and fusion exploration on Dec. 10, 2013. After this operation, he failed to improve, had the same pain, had weakness in his back muscles and still was on narcotic pain medication. He was ultimately released to pain management for weaning of pain medication.

With Mr. P, the EFA suggested he would not benefit from hardware removal, and he did not clinically benefit.

The next case is of Mr. M, a 48-year-old who sustained a work-related injury on Aug. 14, 2011. He underwent workup and had a decompression and fusion with instrumentation from L4 to the sacrum.

Before surgery, he failed physical therapy. After surgery, he had another course of physical therapy that did not benefit him. He continued to complain of bilateral low back pain and increased pain on the left radiating into the leg and foot. In addition, he complained of pins and needles in the same pattern into the left big toe. He was taking Lortab, OxyContin and Flexeril.

Because of his persistent pain, despite the fusion surgery and high doses of narcotics, he was scheduled for an EFA. The EFA revealed minimal bilateral vasoconstriction in the paraspinous muscles from L1 to the sacrum, quadratus lumborum and gluteal muscles that decreased with stretching, indicating a lack of clinical significance. The EFA thus provided objective evidence of noncompliance and lack of effort with all range-of-motion activities.

Taking into consideration the post-operative X-rays, MRI scans and EFA, it was deemed that the patient had reached maximal medical improvement and did not require hardware removal. Rapid weaning of his pain medication was recommended. He was ultimately released to return to work, with no lifting of more than 100 pounds and alternating sitting and standing as required. No further surgery was recommended.

Getting better data on whether to remove hardware is of overwhelming importance because this type of surgery not only requires a second surgical procedure in tissue that is already scarred but poses a risk for nerve injury, delayed fusion failure or progressive spinal deformity. Most series of patients undergoing hardware removal report a complication rate ranging from 3% to 20%. Additionally, hardware removal may not fully correct the problem because retained hardware may be only one of several pain generators in the post-operative spine—pain is the predominant indication for removal of the hardware.

Stabilization and fusion of the lumbar spine may be performed by using various anterior and posterior surgical techniques and a wide range of devices, including pedicle screws, facet screws and different types of vertebral cages and wiring techniques. The instrumentation is designed to stabilize and realign the spine and thereby enhance bone fusion. Post-operative imaging is typically used to determine positioning of the hardware and the progress of the fusion. But there is no reference standard for non-invasive imaging evaluation of spinal fusion. Radiography is the non-invasive procedure most commonly used for the assessment of fusion. Plain films can have limited benefits and frequent inaccuracy. Plain films can document broken or mal-positioned hardware, which is clinically useful. Flexion and extension plain X-rays are recommended for routine assessment of instrumented fusion, but it can be challenging to document translational motion and instability.

An MRI scan is one of the better imaging tools to evaluate post-operative changes in the spine. It is particularly useful for detecting and monitoring infection or post-operative fluid collections and scar formation. It is also excellent at showing soft tissue and neural compression and is beneficial in identifying new pathology above or below the level of fusion. However, MRI is less sensitive in identifying bone healing than plain films or CT scans and, thus, is not the best test to assess fusion of the lumbar spine. The sensitivity of the MRI scan is significantly affected by magnetic-susceptibility artifact, which is often a problem, particularly in the presence of stainless-steel devices or implants. Recent hardware is made of titanium alloys, which produce less severe magnetic artifacts but still present a significant obstacle to visualization of areas near spinal implants.

The CAT scan with sagittal and coronal reconstructions of the lumbar spine is the most sensitive test to determine fusion vs. pseudoarthrosis. It is the best at demonstrating bony union in multiple planes of imaging and is the least affected by metal artifact.

Many spine surgeons would agree that there are some absolute indications for removal of pedicle screw fixation of the lumbar spine. These more absolute indications include:  pseudoarthrosis, persistent infection or abscess after post-surgical debridement, mal-positioned hardware causing neural impingement and migration of hardware or interbody grafts causing neurologic injury. More relative indications for hardware removal include:  broken hardware, prominent hardware, adjacent-level disease, bony erosion around the pedicle screws and metal allergy.

Most studies show that even with hardware removed for absolute or strong relative indications there are favorable outcomes in only 50% to 60% of patients, with high failure rates. These studies are limited because they are retrospective and not evidence-based.

Currently, if well-positioned hardware is painful, there is a method for testing whether removal could be beneficial. The patient is asked to show the doctor the point of tenderness. A local anesthetic is injected at the site. If the patient reports decrease in pain, then it is concluded that the hardware is contributing to the pain. But there are no level 1 evidence-based studies that conclude that there is a high correlation of good outcome with patients who have favorable responses to hardware blocks.

Hardware injections are fraught with subjectivity. Untested findings may subject patients to unnecessary surgery to remove hardware. This is especially problematic in the occupational setting because secondary gain and symptom magnification can play a major role in work-related injuries and their ultimate treatment.

In conclusion: Patients undergoing back fusion are highly complicated cases. Persistent pain after a lumbar fusion can stem from numerous factors, including both physical and psychological ones. In patients who lack objective evidence radiographically for absolute indications for hardware removal, it can be extremely challenging to identify the pain generator.

The EFA could prove instrumental in providing further objective information to identify the cause of dysfunction, pain and disability in patients and could accelerate return to work, while minimizing potential highly complicated and unnecessary surgeries.

Certainly, further studies evaluating outcome are indicated in patients who have persistent pain after lumbar-fusion surgery, using EFA as part of the pre-operative assessment.

The author invites you to join him at the NexGen Workers’ Compensation Summit 2015, to be held Jan. 13 in Carlsbad, CA. The conference, hosted by Emerge Diagnostics, is dedicated to past lessons from, the current status of and the future for workers’ compensation. The conference is an opportunity for companies to network and learn, as well as contribute personal experience to the general knowledge base for workers’ compensation. Six CEU credits are offered. For more information, click here.

What An Employer Can Do To Reduce Soft Tissue Injuries In The Transportation Industry

The trucking industry accounted for nearly 20 percent of all days-away-from-work cases in 2011. Correspondingly, trucking was among the seven occupations which had an incidence rate greater than 300 cases per 10,000 full-time workers and who had greater than 20,000 days-away-from-work cases.

OSHA defines a Musculoskeletal Disorder (MSD) as an injury of the muscles, nerves, tendons, ligaments, joints, cartilage and spinal discs. They identify examples of Musculoskeletal Disorders to include: carpal tunnel syndrome, rotator cuff syndrome, De Quervain’s disease, trigger finger, tarsal tunnel syndrome, sciatica, epicondylitis, tendinitis, Raynaud’s phenomenon, carpet layers knee, herniated spinal disc, and low back pain.

The average cost of a work-related soft tissue injury in the trucking industry exceeds any other industry. According to the U.S. Bureau of Labor Statistics (BLS), Musculoskeletal Disorders nationwide typically account for 33% of work-related injuries, while the incidence of Musculoskeletal Disorders in the transportation industry is 60-67%. The Bureau of Labor Statistics also noted that there were 1.4 million total transportation workers, and each year 1 in 18 is injured or made ill by the job.

These higher rates of injury can be attributed in part to several factors. Due to the nature of their work, many drivers maintain a poor diet, rarely get enough sleep, and are sedentary. As a result, they find themselves more susceptible to heart attacks and diabetes, as well as a myriad of strains, sprains and various other Musculoskeletal Disorders.

Additionally, the percentage of older workers is higher in transportation than in most industries, with the Transportation Research Board estimating that up to 25 percent of truck drivers will be older than 65 by 2025, translating into more severe Musculoskeletal Disorder claims.

These factors are contributing to more workers’ compensation claims for drivers which increase employers’ costs. As part of the job, many truck drivers are required to unload the goods they transport, leading to serious sprains and strains. Heavy lifting after long periods of sitting can increase the likelihood of severe sprains and strains. In addition, drivers often rush at the delivery site in an effort to meet the demands of tight schedules. This combination contributes to 52% of the non-fatal injuries in this industry, with trunk and back claims accounting for 70% of these cases.

Due to its unique workplace circumstances, the commercial transportation industry is at higher risk for increased frequency of injuries and costs to the industry. The following describes the framework of this dilemma:

  1. Commercial transportation jobs expose workers to high physical demands and extended hours of exposure.
  2. The transportation industry experiences one of the highest work-related injury rates among all workplace sectors.
  3. The transportation industry experiences a high level of turnover on an annual basis, which results in a high number of newly hired employees exposed to unfamiliar and physically demanding tasks.

While this is an industry-wide issue, we will focus on California in order to illustrate how problematic it truly is. In March of 2010, the California Workers’ Compensation Institute (CWCI) issued its latest scorecard for the California Trucking Industry. Over eight years, $480 million dollars was paid in medical and indemnity costs alone. The study found that, even though this industry accounted for only 1% of all California industrial claims, they accounted for 1.8% of the state’s workers’ compensation paid benefits. It was also found that medical and indemnity payments were higher than any other industry. The average lost-time direct claim cost at $18,587 is 41% higher than the industry average in California. The indirect costs in this industry range from a 2x to a 10x multiple, and in an industry known for low profit margins, controlling costs is critical.

It should also be noted that California can retain jurisdiction of a workers’ compensation claim even if the injury did not occur in that state; the employee only has to live in California, drive through California or have been hired out of California. This is such a significant problem that in 2010 the U.S. Department of Transportation initiated the Compliance Safety Accountability measure of driver’s fitness. This is specific to transportation, is publicly available, and the ratings are tied to insurance rates and letters of credit.

With the numerous reforms taking place in 2013 and the Centers for Medicare and Medicaid Services (CMS) Mandatory Reporting Act, it is now essential that employers become proactive and only accept claims that arise out of the course and scope of employment. Medicare has mandated all work-related and general liability injuries be reported to CMS in an electronic format. This means that CMS has the mechanism to look back and identify work comp-related medical care payments made by Medicare. This is a retroactive statute that will ultimately hold the employer and/or insurance carrier responsible for these payments.

Should CMS have to pursue the employer in court, the amount owed is doubled. The insured or employer could pay the future medical cost twice — once to the claimant at settlement and later when Medicare seeks reimbursement of the medical care they paid on behalf of the claimant. There is no statute of limitations on compliance with the MSA requirements. CMS can review claims closed last year, five years ago, or even longer to check for compliance. Penalties and fees for noncompliance are $1,000 per day if medical care is not paid within 30 days.

Historically, soft tissue injuries have been difficult to diagnose and even harder to treat due to the broad spectrum of disorders related to soft tissue. Most diagnostic tests are not designed to address Musculoskeletal Disorders and are unable to document the presence of pain or loss of function … two key complaints.

Employers need a way to manage their Musculoskeletal Disorder exposure and provide better care to their injured workers. The key to managing this problem is for employers to obtain the ability to only accept claims that arise out of the course and scope of employment. The only viable solution for employers is to conduct a baseline soft tissue assessment in order to establish pre-injury status. The baseline must be job and body part specific and objective to comply with the Americans with Disabilities Act Amendments Act of 2008.

The baseline assessments are not read or interpreted unless and until there is an injury. By not identifying a potential disability, employers are able to conduct baseline assessments on new hires as well as existing employees while maintaining compliance with the Americans with Disabilities Act Amendments Act. If there is a soft tissue injury, the employee is sent for a post-loss assessment to determine what and if there is any change from the baseline assessment. If no change is noted (no acute pathology), then there is no valid claim. This proven baseline program is known as the EFA Soft Tissue Management Program (EFA-STM Program), which utilizes the Electrodiagnostic Functional Assessment to objectively provide this data.