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Medical Unit - Low back problems

(Adopted April 17, 1997)

Introduction

Low back problems are common among workers. In the majority of injured workers with low back problems, recovery occurs within the first month of symptoms. Those who have not improved at the end of one month of treatment may need further diagnostic evaluation and consideration of other treatment options. Management of low back problems in injured workers includes consideration of environmental and personal factors which may be causing or aggravating the problem, as well as providing appropriate treatment that leads to a return to productive work.

Scope of the guideline

This guideline deals with the assessment and treatment of common low back problems in working age people. Initial assessment to rule out uncommon low back problems is discussed, but definite diagnosis and treatment of uncommon disorders is beyond the scope of this guideline. This guideline does not deal with legal issues of causation or work-relatedness. Treatment guidelines are designed to assist providers by offering an analytical framework for the evaluation and treatment of the more common problems of injured workers. These guidelines are educational and descriptive of generally accepted practices for the assessment and treatment of low back problems. The guidelines are intended to assure appropriate and necessary care for injured workers diagnosed with these types of industrial conditions. Due to many factors which must be considered when providing quality care, health care providers shall not be expected to always provide care within the stated guidelines. Treatment authorization, or payment for treatment, shall not be denied based solely on a health care provider's failure to adhere to the IMC guideline. These guidelines are not intended to be the basis for the imposition of civil liability or professional sanctions. They are not intended to either replace a treating provider's clinical judgment or to establish a protocol for all patients with a particular condition. It is understood that some patients will not fit the clinical conditions contemplated by a guideline. This includes those patients demonstrating "red flag" concerns described in the guideline.

Symptom duration is classified as acute (one month), subacute (one to three months), and chronic (> three months). If an injured worker experiences more than one recurrence of low back pain in a year, except in cases of a new injury, it should not be classified and treated as an acute back problem. In this case, it is considered a chronic recurrent low back problem, and secondary assessment and treatment methods should be utilized along with an emphasis on active therapy and prevention strategies. Chronic low back problems are outside the scope of this guideline.

For the purpose of this document, a provider is defined as any health care provider acting within the scope of his/her practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician.

All health care providers acting within the scope of their practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician, shall be allowed to bill and be reimbursed in accordance with the official medical Fee schedule.

A provider may vary from these guidelines, if in his or her judgment, variance is warranted to meet the health care needs of the injured worker and that variance remains within the standards of practice generally accepted by the health care community, and the provider documents the need for the variance in the evaluation report or the medical treatment record in the manner that is generally accepted by the health care community.

Not every medical situation can be addressed in these regulations and medical standards change constantly. The documentation required of the provider is necessary to monitor and explain the use of variances.

In all cases, the provider shall document no later than six months from the date of the injury, whether further treatment is warranted and whether the injured worker has any significant subjective and objective findings of the condition still not having plateaued.

1.0 Initial assessment of low back problems

1.1 Purpose

The purpose of the initial assessment is to establish a working diagnosis and assign the injured worker into one of five initial clinical categories of low back problems:

1) Conditions involving the bony spinovertebral axis such as cancer, infection or fracture

2) Intraspinal pathology involving the neuraxis such as cauda equina syndrome or radiculopathy

3) Arthritic or inflammatory conditions

4) Mechanical conditions or

5) Referred low back pain due to viscerogenic and/or other causes.

In addition, the initial assessment looks for (and documents for the chart) other factors which might have an impact upon an injured worker's symptoms and/or response to treatment (e.g., work, personal, psychosocial, and economic factors).

1.2 Appropriate initial assessment methods

1.2.1 History and physical

The history and physical examination are the bases upon which any assessment and treatment decisions are to be made. Decisions about diagnostic imaging, laboratory testing, and specialist referral should be guided by the clinical features of the history and exam. Only a small minority of injured workers will require further diagnostic testing after the initial history and physical.

On the history, document the characteristics of pain (type, location, duration, severity, radiation), associated symptoms, precipitating factors, positions and activities that aggravate or relieve the symptoms, as well as its impact on function at home and work. Information concerning previous back injuries, diagnostic and treatment procedures, and response to previous therapies (including home treatments and use of appliances) should be obtained. The use of a pain drawing and/or pain scale (e.g., visual analog scale) may assist in the evaluation of the location, characteristics, and severity of pain, and may be utilized in the assessment of treatment response. (One example of a pain drawing and pain scale appears in Appendix 7.1.)

The relationship of the symptoms to performance of specific activities should be sought (e.g., work tasks and ergonomic factors, sitting, walking, driving, coughing, hobbies, recreational activities, etc.). In addition, ask key questions pertinent to serious spinal, intraspinal or viscerogenic conditions [see below]). The initial history should also document relevant past medical and surgical history, occupational history, social (including hobbies, recreational activities, and the use of tobacco, alcohol and other drugs), and any relevant psychosocial issues such as financial, family, or workplace difficulties.

A thorough physical examination that is based upon the appropriate history and presentation of the patient is expected. The examination includes, but is not limited to, general appearance, visual inspection and palpation, manual testing of range of motion, vascular and neurologic inspection. A focused neurologic exam that includes reflexes, strength and sensation testing in the lower extremities should be performed. Bilateral supine and seated straight leg raising is also recommended during the initial evaluation. Examination of the hip joint can help exclude referred back or leg pain from an abnormal joint. Although most patients have localized, non radiating pain and/or limited range of motion, these findings are non specific for most back problems. Limited spinal motion may be useful for planning and monitoring response to treatment and for developing appropriate work restrictions.

1.2.1.1 Conditions involving the bony spinovertebral axis such as cancer, infection or fracture

Certain key findings on the medical history and physical examination may raise suspicion of a possible serious underlying condition of the spine which requires immediate diagnosis and prompt treatment, including appropriate referral for specialty consultation. The following serious underlying conditions of the spine are suggested by, but not limited to, the "red flags" listed below:

For cancer or infection: age greater than 50 years, history of prior cancer, unexplained weight loss, back pain not improved with rest, fever, immunosuppression, intravenous drug use, history of urinary infection and/or incapacitating pain.

For spinal fracture: history of significant trauma (e.g., motor vehicle accident or fall from height), age greater than 60, prolonged use of corticosteroids, alcohol or substance abuse.

Injured workers with clinical findings that suggest underlying disease may require further studies, such as laboratory tests, x-rays, or specialized tests to evaluate for these conditions. The provider should clearly document the need for any additional tests for other serious pathologies during the initial assessment. Other pathologies should be ruled out.

1.2.1.2 Referred low back pain due to viscerogenic and/or other causes

Referred pain from visceral diseases or other musculoskeletal disorders unrelated to the lumbar spine may be distinguished by a careful history and physical examination. A history of urinary tract, abdominal or pelvic symptoms suggests visceral disease. Abdominal and pelvic disorders which may cause low back pain include abdominal aortic aneurysm, pyelonephritis, nephrolithiasis, gynecological problems, prostatitis, pancreatitis, and other gastrointestinal conditions. Examination of the hip and sacroiliac joints may reveal findings consistent with a localized joint or muscle problem.

1.2.1.3 Arthritic or inflammatory conditions

Inflammatory arthritides of the spine that can cause back symptoms include ankylosing spondylitis and other rare spondyloarthropathies. A suspicion of these and other related conditions should suggest a referral to the appropriate specialist for further evaluation. Work-up of these conditions is not discussed in this guideline, but should be guided by the clinical findings and suspicion of a systemic illness.

1.2.1.4 Distinguish between mechanical conditions and radiculopathy or other neurological conditions

For the purpose of determining the appropriate management of low back problems and estimating prognosis, it is helpful to classify injured workers into diagnostic categories, as well as to consider symptom duration. Most injured workers can be separated into diagnostic categories based on the location and characteristics of their symptoms and the clinical findings.

1.2.1.4.1 The symptoms of mechanical low back conditions are predominantly low back pain, with possible referral of pain to the buttock and/or leg above the knee in a non-dermatomal pattern.

1.2.1.4.2 Radiculopathy or other neurological conditions result from spinal or intraspinal pathology involving one or more nerve roots. Presenting symptoms are related to specific nerve root(s) and type of pathology and may include pain, alteration in sensation, loss of strength, and altered reflexes in various combinations.

1.2.1.4.3 Cauda equina syndrome results from injury to multiple lumbosacral nerve roots. It may present with bowel and/or bladder dysfunction, saddle hypesthesia or anesthesia. This serious condition is a red flag requiring immediate referral to an appropriate specialist.

1.2.1.5 Documentation of other relevant factors

A detailed work history should be obtained, including a description of current job duties, and the relationship of symptoms to performance of job tasks.

Psychological work factors that are known to increase the reporting of a back injury and lead to prolonged symptoms and disability include job monotony and job dissatisfaction. If psychological distress is suspected from the history, pain drawing, and/or the physical examination such as the presence of several "non-organic" physical signs (nonanatomic or superficial tenderness, inconsistent response between supine vs. seated straight leg raising, pain on simulated axial loading or spine rotation, overreaction, and regional sensory and motor disturbances), the injured worker may be at risk for a delayed recovery or poor response to any surgical procedure.

The medical and social history may help the provider evaluate for other risks of delayed recovery and plan therapy accordingly. A history of previous back injuries or surgery, failed previous treatments, prolonged or contentious litigation or disability claims, family or financial problems, or secondary gain may affect treatment response and prolong disability. Chronic pain, depression, and alcohol or substance abuse may prolong disability and influence the choices for therapy. Recreational and other non work activities which might contribute to low back problems must also be considered in the evaluation and management of low back problems.

1.2.2 Laboratory studies

Laboratory tests should not be ordered routinely in the initial assessment unless an underlying illness is suspected. If the history, age, or examination suggests cancer, infection, inflammatory arthritis (such as ankylosing spondylitis), metabolic- endocrine disorders or visceral disease, then appropriate laboratory tests may be indicated. The physician must provide a clear rationale of the indications for the tests ordered.

1.2.3 Diagnostic imaging

Plain X-Rays

The most commonly used x-ray views of the lumbar spine (the standard anteroposterior and lateral views) permit assessment of lumbar alignment, comparison of vertebral body and disc space size, assessment of bone density and architecture, and gross evaluation of soft tissue structures. Oblique views of the lumbar spine are used in the detection of unilateral or bilateral spondylolysis. Other special views include sacroiliac views to evaluate possible ankylosing spondylitis. The diagnostic objective of x-rays is to reveal structural abnormalities associated with back symptoms.

Plain x-rays are not recommended for routine evaluation of patients with acute low back problems within the first month of symptoms unless a red flag is noted on the clinical examination (such as specified below).

Plain x-rays of the lumbar spine are recommended for ruling out fractures in patients with acute low back problems when any of the following red flags are present: recent significant trauma (any age), recent mild trauma (patient over age 50), history of prolonged steroid use, osteoporosis, patient over age 60.

Plain x-rays in combination with clinically appropriate laboratory studies may be useful for ruling out tumor or infection in patients with acute low back problems when any of the following red flags are present: prior cancer or recent infection, fever over 100 degrees F, IV drug abuse, prolonged steroid use, low back pain worse with rest, unexplained weight loss.

In the presence of red flags, especially for tumor or infection, the use of other imaging studies such as bone scan, CT, or MRI may be clinically indicated even if plain x-rays are negative.

The routine use of oblique views on plain lumbar x-rays is notrecommended in light of the increased radiation exposure.

1.2.4 Ergonomic evaluation

Clinical indications:

Work history, job analysis/description, or workplace inspection may be useful to identify physical work factors contributing to the development or exacerbation of low back problems, which prevent return to usual work. A worksite evaluation with the affected injured worker should be performed by a professional trained in these types of evaluations.

1.3 Inappropriate initial assessment methods

All of the following assessment methods have been determined inappropriate during the initial phase of assessment. (All are Appropriateness level 1.)

Routine use of:

1.3.1 Laboratory studies

1.3.2 Lumbar x-rays

1.3.3 CT, MRI, myelography, CT-myelography, and bone scan

1.3.4 Discography

1.3.5 Electromyography (EMG)

1.3.6 Computerized strength and range of motion testing

Computerized testing of strength and range of motion is not recommended in the initial assessment of acute low back problems.

2.0 Initial treatment of low back problems

2.1 Purpose

The purpose of the initial treatment of low back problems is to relieve pain and suffering and to restore functional capacity. The goal is to allow the injured worker to resume necessary activities, including return to modified or full work according to the favorable natural history for low back problems. Injured workers with radiculopathy or other neurological conditions may require more aggressive management and closer monitoring for further neurologic deterioration that may require additional diagnostic testing with possible surgery.

Treatment may include: 1) education about back problems and theirprevention 2) activity and environmental modifications 3) exercise 4) medication and/or 5) physical treatments as delineated later in this section. This guideline does not address treatment for spinal conditions of cancer, infection, fracture, cauda equina syndrome, arthritic or inflammatory conditions, viscerogenic back symptoms or chronic low back problems.

2.2 Appropriate Initial Treatment Methods

2.2.1 Education

2.2.1.1 General information (appropriateness level 4)

Education is the most effective method of reducing the injured worker's concerns about persistent pain problems. Accurate information concerning connective soft tissue injury and repair, including expectations for both rapid recovery and recurrences, should be provided to allay the injured worker's fear. Patients should be taught principles related to pertinent anatomy, proper back mechanics, postural information, and safe work methods. Safe and reasonable modifications of work, home, and recreational activities should be given. Instructions for self-management of symptoms and lifestyle modifications should also be provided (e.g., use of cold or heat therapy at home, medications, exercises, rest periods). Reassurance about the benign nature of most low back problems and its compatibility with various activities should be given.

A collaborative partnership among the physician, employer and injured worker is an essential component of any plan to return the injured employee to work.

Specific functional goals, including home and work activities, time frame for expected improvements, and return to work should be given by the provider to the injured worker. Effectiveness and risks of commonly available diagnostic and treatment measures should be considered if symptoms persist and should be discussed with the patient. Education should be provided by the treating provider and may be supplemented by a physical or occupational therapist as part of a referral for flexibility and strengthening exercise training (see below).

2.2.1.2 Back education program (appropriateness level 3)

A back educational program that promotes exercise as a rehabilitation and prevention method is recommended for an injured worker with low back problems.

2.2.2 Activity and environmental modifications

2.2.2.1 Work restrictions (appropriateness level 4)

Modifications of activities including specific work restrictions that are based on the injured worker's job requirements and clinical status, are acceptable if functional limitations do not allow continuation of regular work duties. Complete work cessation should be avoided, if possible, through the use of modified duty. Written work restrictions should be as specific as possible, and it may be necessary to contact the employer to discuss alternative work within the prescribed restrictions. Injured workers with work restrictions should be re-evaluated within two weeks for determination of work status, response to treatment, and for making appropriate decisions concerning progression to full activities.

2.2.2.2 Bed rest (appropriateness level 4)

The majority of injured workers with low back pain will not require bed rest. Short-term continuous bed rest may be appropriate for up to two days. Bed rest for more than four days may lead to debilitation and is not recommended for treating low back problems. A gradual return to normal activities is more effective than prolonged bed rest for treating low back problems.

2.2.2.3 Environmental/job modification (appropriateness level 3)

Environmental modifications including engineering (e.g., work station adjustment) and administrative controls (e.g., job rotation) to limit or eliminate work activities that might lead to or aggravate back problems should be considered early on for symptomatic workers who have work-related risk factors for low back problems.

2.2.3 Exercise (appropriateness level 4)

2.2.3.1 Rehabilitative exercise recommendations

Up to 12 visits for rehabilitative exercise may be implemented in the first month. A step-wise program using exercise goals that are gradually increased over time is appropriate in uncomplicated cases of most low back problems. Aerobic (walking, biking, swimming, or similar activities) and stretching exercises can begin early on to increase mobility. Progressive strengthening exercises for abdominal and back muscles may promote recovery and prevent prolonged disability due to deconditioning. Adequate instruction in exercises and positioning may require supervision by a provider. An active progressive exercise program designed to achieve or maintain an increase in range of motion and strength should be promoted as the best method of limiting recurrences of low back problems. The exercise program should be included in the treatment plan and/or referenced in the progress reports. The rehabilitative exercise visits shall be limited to a maximum of three times per week in the initial phase, with emphasis placed on home exercise.

2.2.3.2 Referral for physical treatment (appropriateness level 3)

Referral for physical treatment may be appropriate within the first 30 days.

2.2.4 Medications

2.2.4.1 Acetaminophen (appropriateness level 4)

Acetaminophen, a non-narcotic analgesic, has commonly been regarded as having an analgesic effect, but little or no known anti-inflammatory mechanism. The therapeutic objective for its use in acute low back problems is pain relief. Acetaminophen is reasonably safe and is acceptable for treating patients with acute low back problems.

2.2.4.2 Non-steroidal anti-inflammatory drugs (NSAIDs) (appropriateness level 4)

NSAIDs are a class of medications, including aspirin, ibuprofen, indomethacin, and other medications. They have anti-inflammatory and analgesic properties as well as being prostaglandin inhibitors. The therapeutic objective of NSAIDs in treating acute low back problems is to decrease pain, presumably by reducing inflammation and promoting healing. NSAIDs, including aspirin, are acceptable for treating patients with acute low back problems but have a number of potential side effects. The most frequent complication is gastrointestinal irritation. The decision to use these medications can be guided by comorbidity, side effects, cost, and patient and provider preference.

2.2.4.3 Muscle relaxants (appropriateness level 3)

Muscle relaxants are an option in the treatment of patients with acute low back problems. While probably more effective than a placebo, muscle relaxants have not been shown to be more effective than NSAIDs. No additional benefit is gained by using muscle relaxant in combination with NSAIDs over using NSAIDs alone. Muscle relaxants have potential side effects, including drowsiness in up to 30 percent of patients. When considering the optional use of a muscle relaxant, the clinician should balance the potential for drowsiness against a patient's intolerance of other agents.

2.2.4.4. Oral corticosteroids (appropriateness level 2)

Oral steroids are used by some clinicians in the treatment of patients with acute low back problems. The therapeutic objective is to reduce inflammation in an attempt to promote healing and reduce pain. However, oral steroids are not recommended for the treatment of acute low back pain without radiculopathy.

2.2.4.5 Opioid Analgesics (appropriateness level 3)

Oral opioid analgesics commonly given to patients with acute low back problems include morphine derivatives (opioids) and synthetic opioids. The therapeutic objective in treating low back problems is temporary pain relief. When used only for a time-limited course, opioid analgesics are an option in the management of patients with acute low back problems. The decision to use opioids should be guided by consideration of their potential complications relative to other options. Routine prescription of opioids is not recommended and when prescribed for severe pain, should be limited in duration and quantity.

2.2.5 Physical treatments (appropriateness level 4)

2.2.5.1 Manual medicine, manipulative techniques, manual therapy/ mobilization include treatments performed by a physician or another appropriately licensed health care provider as defined by their scope of practice.

2.2.5.2 Other physical modalities (appropriateness level 3)

Active treatments such as manual medicine/therapy may be combined with passive modalities, including but not limited to iontophoresis, phonophoresis, electrical stimulation, ultrasound, diathermy, traction, and other physical agents, during the first four weeks of treatment. These passive modalities should not be used as the sole form of treatment. They shall be combined with an active treatment program that emphasizes progressive exercises.

2.2.5.3 Frequency of physical treatment methods (appropriateness level 3)

The frequency of the physical treatments listed above within the initial four weeks of treatment may be up to 12 visits in the first month.

2.2.5.4 Transcutaneous electrical nerve stimulation (TENS) (appropriateness level 2)

TENS may be useful for management of low back problems. If no functional and symptomatic benefit has been demonstrated after two weeks, treatment should be discontinued.

2.2.5.5 Acupuncture (appropriateness level 2)

Acupuncture may be useful to relieve acute low back pain. The frequency of acupuncture treatments within the initial four weeks of treatment may be up to three times per week for four weeks, or up to 12 office visits. During this initial treatment, if there is not substantial improvement, in a maximum of 12 treatments, the patient is to be re-evaluated by a more extensive physical examination, laboratory testing, imaging or referral to another physician.

2.2.5.6 Epidural Steroid Injections (appropriateness level 2)

An epidural steroid injection may be helpful for reducing tissue inflammation and short-term pain relief in a patient with an acute radicular low back problem who is unable to participate in an active treatment program because of severe leg pain and/or neuromotor deficit. If successful, a progressive active treatment program should be implemented with the goal of avoiding prolonged disability and possible surgical intervention.

2.2.5.7 Lumbar supports (e.g., corsets, support belts, braces) (appropriateness level 2)

Immobilization with lumbar supports may provide symptomatic relief of pain and movement reduction in cases of severe acute low back problems. The injured worker should be advised of the potential harm from using a lumbar support for a greater period of time than that prescribed.

2.2.6 Hospitalization for non-surgical treatment (appropriateness level 2)

Hospitalization is rarely necessary for the non-surgical management of severe low back pain.

2.2.7 Myofascial and trigger point injections (appropriateness level 2)

Up to three trials of injection therapy within the first 30 days may be helpful for short term pain relief in patients with mechanical back conditions.

Trigger point and myofascial injections are not for use as the exclusive method of treatment.

2.3 Case Management (appropriateness level 4)

An adequate re-evaluation of the problem, with determination of treatment effectiveness and patient compliance, should be performed at appropriate intervals during the first 30 days of treatment.

2.4. Inappropriate initial treatments

The following initial treatment methods are inappropriate in the initial treatment phase: (All are Appropriateness level 1.)

2.4.1 Surgical treatments

Except for those further conditions cited earlier as 'red flags' relevant to intraspinal pathology such as cauda equina syndrome or radiculopathy, surgery for acute radicular pain within the first 30 days is usually not indicated. Surgical treatment is rarely, if ever, indicated for low back pain without radicular symptoms.

2.4.2 Exclusive use of physical modalities

2.4.3 Biofeedback

2.4.4 Implantable spinal techniques such as infusion pumps or stimulators

2.4.5 Back school

A formal back school is usually not appropriate for an injured worker with acute low back problems.

2.4.6 Facet injections

3.0 Secondary assessment of low back problems

3.1 Purpose

The purpose of secondary assessment is to determine the reason for delayed recovery in a patient who has not symptomatically or functionally improved after one month of appropriate treatment (i.e., progressed to a subacute low back problem). The first step in secondary assessment is a re-evaluation with assignment of the patient into one of the five clinical categories:

1) Conditions involving the bony spinovertebral axis such as cancer, infection or fracture

2) Intraspinal pathology involving the neuraxis such as cauda equina syndrome or radiculopathy

3) Arthritic or inflammatory conditions

4) Mechanical conditions or

5) Referred low back pain due to viscerogenic and/or other causes.

Depending on the findings, diagnostic evaluation during the subacute phase (one to three months) may include diagnostic imaging, laboratory tests, bone scan, electrophysiologic tests, functional capacity testing, ergonomic evaluation and/or psychological testing. The clinical indications for each of these diagnostic methods is given below.

Referral for consultation is appropriate for problems of delayed recovery or questions about diagnosis. Referral may be made to appropriate physician specialists.

3.2 Appropriate secondary assessment methods

3.2.1 Plain film x-rays (AP and lateral views)

Clinical indications

Persistent low back problems and/or suspicion of systemic disease, cancer, infection, inflammatory arthritis, fracture or spondylolisthesis.

The routine use of oblique or special views on plain lumbar x-rays is not recommended in light of the increased radiation exposure.

3.2.2 Specialized imaging tests (CT, MRI)

Clinical indications:

3.2.2.1 Findings that suggest lumbar nerve root compromise (radiculopathy from herniated disc and/or spinal stenosis) or a severe or progressive neurologic deficit has occurred. These studies are most suitable when surgery or epidural steroid injections are being considered and/or when the injured worker has failed an appropriate course of treatment.

3.2.2.2 Findings that suggest tumor or infection.

3.2.2.3 Findings that suggest a fracture and lumbar x-rays are inconclusive.

3.2.3 Other specialized imaging tests (myelography and CT- myelography)

Clinical indications:

When imaging tests (CT, MRI) are inconclusive, contradictory or contraindicated, other specialized imaging tests, such as myelography and CT-myelography, are warranted. These studies are invasive and should only be ordered in special situations.

3.2.4 Bone scan

Clinical indications: Findings on history, exam, lab or other imaging studies are suggestive for but not limited to tumor, infection, fracture and arthritis. Bone scans demonstrate abnormal metabolic activity and are not diagnostic for these conditions.

3.2.5 Laboratory testing

Clinical indications: As deemed appropriate by the reassessment.

3.2.6 Needle electromyography/nerve conduction study (EMG/NCS)

Clinical indications:

Diagnosis of lumbosacral radiculopathy can usually be made based upon the neurologic examination. EMG/NCS may occasionally be helpful for evaluating suspected nerve root dysfunction, peripheral neuropathy, or peripheral nerve entrapment when the findings on the exam are equivocal or confusing. They may be useful preoperatively to confirm a radiculopathy and may be of some assistance in determining the location and severity of nerve root injury.

3.2.7 Functional capacity testing

Clinical indications:

The injured worker's perception of his or her capabilities might be inaccurate, or there is an issue about ability to do a specific job. Comprehensive and objective measurements and tests that are specific to the patient's condition and the functional requirements for return to work may be performed. Functional capacity testing is performed to determine the injured worker's physical capacities. This in correlation with the physical findings may be used to determine the injured worker's ability to return to work.

3.2.8 Ergonomic evaluation

Clinical indications:

Work history, job analysis/description, or workplace inspection may be useful to identify physical work factors contributing to the development or exacerbation of low back problems that can prevent return to usual work. A worksite evaluation with the affected injured worker should be performed by a professional trained in these types of evaluations.

3.2.9 Psychiatric evaluation and/or appropriate psychological testing

Clinical indications:

Findings on history and exam that suggest that psychosocial factors (e.g. stress, job dissatisfaction, depression, substance abuse, symptom magnification) may be contributing to delayed recovery, noncompliance or lack of response to appropriate treatment in subacute and chronic low back problems.

If an injured worker is at risk for delayed recovery, a psychiatric evaluation and/or appropriate psychological testing may be helpful for determining if significant psychological or personality factors are contributing to the disability.

The presence of several "non organic" physical signs may also identify patients who need further psychological testing and evaluation. These patients may need specific behavioral or psychiatric treatment.

Psychological and personality evaluations may be utilized preoperatively in a patient who is being considered for surgical treatment to assist in selection and planning whether behavioral intervention is necessary.

3.2.10 Somatosensory evoked potentials (SEP)

Clinical indications:

SEP may be helpful in evaluation of neurological involvement in conditions such as spinal stenosis or myelopathy.

3.3 Inappropriate secondary assessment methods (all appropriateness level 1)

The following methods have been determined inappropriate for secondary assessment:

3.3.1 Discography

3.3.2 Surface EMG

3.3.3 Diagnostic blocks and injections including facet joint injections

3.3.4 Computerized strength and range of motion testing

4.0 Secondary treatment of low back problems

4.1 Purpose

The purpose of secondary treatment is to provide appropriate symptomatic relief for the injured worker with low back problems while continuing to intensify efforts in active treatments, such as exercise. The aim of secondary treatment is to prevent progressive deconditioning and permanent disability, while promoting return to full work for those who are either off work or on modified duty. Treatment is based on the findings of the diagnostic re-evaluation at four weeks. This phase of treatment may be extended up to two months beyond the initial phase of treatment.

4.2 Appropriate secondary treatment methods

4.2.1 Rehabilitative exercise recommendations (appropriateness level 4)

A step-wise program using exercise goals that are gradually increased over time is appropriate in uncomplicated cases of most low back problems. Aerobic (walking, biking, swimming, or similar activities) and stretching exercises can begin early on to increase mobility. Progressive strengthening exercises for abdominal and back muscles may promote recovery and prevent prolonged disability due to deconditioning. Adequate instruction in exercises and positioning may require supervision by a provider. An active progressive exercise program designed to achieve or maintain an increase in range of motion and strength should be promoted as the best method of limiting recurrences of low back problems. The exercise program is recommended to be included in the treatment plan and/or referenced in the progress reports. Supervised exercise sessions should be limited to a maximum of four weeks,without re-establishing medical necessity.

4.2.2. Medication

4.2.2.1 Acetaminophen (appropriateness level 4)

4.2.2.2 NSAID's (appropriateness level 4)

4.2.2.3 Muscle relaxants (appropriateness level 2)

4.2.2.4 Oral corticosteroids (appropriateness level 2)

4.2.2.5 Opioid analgesics (appropriateness level 3)

Opioids have significant adverse effects such as decreased reaction time, clouded judgment, drowsiness, habituation and potential for physical dependence.

4.2.2.6 Antidepressants (appropriateness level 3)

4.2.3 Physical treatment (appropriateness level 3)

Treatment following the initial trial of four weeks generally should not exceed two times per week. The continuation of treatments is based on reported improvement in subjective complaints, objective factors/clinical findings, and functional capacity.

Management may also include active care, education and therapeutic/rehabilitative exercise.

Exacerbations may warrant a short course (up to two weeks) treatment of up to three times a week.

4.2.3.1 Traction - static/mechanical for up to two weeks in combination with other physical medicine ((appropriateness level 2))

4.2.4 Work conditioning (appropriateness level 3)

Work conditioning programs which include general conditioning exercises and graduated performance of simulated job tasks may be useful in preparing the injured worker to return to a specific job or in determining work restrictions. The duration of the program should be guided by the documentation of objective functional improvement. The duration of the program may be up to a maximum of four weeks without re-establishing medical necessity.

4.2.5 Transcutaneous electrical nerve stimulation (TENS) (appropriateness level 2)

TENS may be useful for management of low back problems. If no functional and symptomatic benefit has been demonstrated after two weeks, this treatment should be discontinued.

4.2.6 Epidural steroid injections ((appropriateness level 2))

Clinical indications:

For a patient with a subacute radicular low back problem who is unable to progress in an active treatment program because of severe leg symptoms and/or neuromotor deficit, an epidural steroid injection may be helpful for symptomatic relief. If successful, a progressive active treatment program should be continued with the goal of avoiding prolonged disability and possible surgical intervention. In general, more than three injections are not recommended. Epidural steroid injections are inappropriate for non-radicular back problems. They should not be used as the sole form of treatment for radicular pain.

4.2.7 Biofeedback (appropriateness level 3)

Used occasionally to train the patient to control the symptoms by self regulation of somatic activity developed through instrumentation-enhanced proprioception. Particularly indicated if it reduces the medication usage and/or increases function. If there is no functional and symptomatic benefit after a three week trial, treatment should be discontinued.

4.2.8 Surgical treatment methods

Clinical indications:

Surgical treatment may be appropriate for injured workers with radicular or other neurological conditions in the following circumstances: 1) Their clinical exam demonstrates persistent symptoms and exam findings that prevent resumption of normal activities, and are unresponsive to an appropriate course of active non-surgical treatment and 2) Diagnostic test findings objectively verify a surgically remediable condition that correlates with the clinical exam and 3) There is no significant physical and/or psychological co-morbidity that is likely to lead to a poor surgical outcome for the injured worker.

Surgical treatment for mechanical low back problems is rarely indicated.

4.2.8.1 Standard iaminectomy with discectomy (appropriateness level 3)

Standard laminectomy with discectomy is recommended using the clinical indications listed above. Includes decompression procedures such as standard laminectomy and/or microdiscectomy or variants thereof.

4.2.8.2 Spinal fusion (appropriateness level 2)

Spinal fusion for low back problems such as herniated or painful discs is not recommended unless a specific anatomic site of lumbar instability has been identified. Potential sources of instability include degenerative spondylolisthesis, unstable fracture, and surgically induced instability.

4.2.9 Injection therapies

4.2.9.1 Trigger point injections (appropriateness level 2)

Trigger point and myofascial injections are not for use as the exclusive treatment modality. When used, they should be limited to three trials of injection therapy.

4.2.9.2 Sacroiliac joint injections (appropriateness level 2)

Sacroiliac joint injections should not be used as a sole treatment method. These should be limited to a maximum of three.

4.2.10 Acupuncture (appropriateness level 2)

Acupuncture treatment is a physical treatment which may be useful following initial treatment to manage pain and to relieve the effects of injury and disease. After a maximum of 12 treatments, the patient is to be re-evaluated for subjective and objective evidence of improvement. If significant subjective and objective improvement is not demonstrated, treatment is to be discontinued.

4.3 Inappropriate secondary treatments

The following treatments have been determined as inappropriate for secondary treatment: (all are appropriateness level 1.)

4.3.1 Ligamentous injections (sclerotherapy/prolotherapy)

4.3.2 Laser discectomy

4.3.3 Bed rest

4.3.4 Chemonucleolysis

4.3.5 Percutaneous discectomy

5.0 Prophylactic treatment

5.1 Purpose

Injured workers whose low back problems have improved may benefit from the following measures to help maximize functioning for individuals with persistent mild low back symptoms and to prevent or reduce the impact of recurrent episodes. Appropriate back care strategies should be incorporated into all phases of the assessment and treatment process.

5.2 Appropriate back care (appropriateness level 4)

5.2.1 Exercise

5.2.2 Back education and training

5.2.3 Workplace modifications

5.2.4 Personal risk factor reduction

6.0 Primary references submitted and reviewed in developing the treatment guideline for low back problems

The complete list of 216 references considered and reviewed in developing this guideline are available upon request from the Executive Medical Director, Industrial Medical Council, P.O. Box 8888, San Francisco, CA 94128-8888, Telephone No. 1-800-794-6900.

7.0 Appendices

Appendix 7.1: Visual analog scale and pain drawing (attached)

Appendix 7.2: Appropriateness levels (attached)

Four levels of appropriateness are noted for these sections.

These are based upon the extent of consensus documented and/or degree of evidence for the treatment.

Level 4

Level 3

Level 2

Level 1


Good research based evidence

Yes

No

No

No


Clinical evidence

Yes

Yes

Some

No


Consensus of the health care community

Yes

Yes

Partial

No

Clinical utility of appropriateness level for common low back problems Appropriate and recommended Acceptable or appropriate in most cases Appropriate in uncommon individual cases. Document the case-specific clinical factors or circumstances which make this procedure reasonable and necessary for this injured worker. Inappropriate

Appendix 7.3: The list of physicians and providers who assisted the Industrial Medical Council by serving on the General Consensus Panels and the Evidence Panel is available upon request from the

Executive Medical Director
Industrial Medical Council
P.O. Box 8888
San Francisco, CA 94128- 8888

Telephone No. 1-800-794-6900.

Fnl/5/30/97