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The Industrial Medical Council recommends treatment of industrial injury to
the low back, consistent with the “Treatment
Guideline for Low Back Problems,” as adopted by the Industrial Medical
Council on April 17, 1997 as set forth below.
TREATMENT GUIDELINES FOR LOW BACK PROBLEMS
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 (non anatomic or superficial tenderness,
inconsistent response between supine vs. seated straight leg raising, pain on
simulated axial loading or spine rotation, over reaction, 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 not recommended 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 their prevention;
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 twelve 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
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 laminectomy 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 (3).
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.
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.
Appendix 7.1 Pain Scale / Pain Drawing Example / Visual Analog Scale
View Graphic
Appendix 7.2 Appropriateness Levels
View Graphic
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.
NOTE
Authority cited: Section 139(e)(8), Labor Code. Reference: Section 139(e)(8)
Labor Code.
HISTORY
1. Editorial correction changing placement of article 7 heading (Register
97, No. 23).
2. New section filed 6-3-97; operative 7-3-97 (Register 97, No. 23).
3. Amendment filed 4-14-2000; operative 5-14-2000 (Register 2000, No. 15).
4. Change without regulatory effect amending section filed 7-12-2001 pursuant
to section 100, title 1, California Code of Regulations (Register 2001, No.
28). Pursuant to this filing, material adopted pursuant to the Administrative
Procedure Act that had previously been incorporated by reference in the California
Code of Regulations was instead printed in full in the California Code of Regulations.
Go Back to Article 7 Table of Contents
| The above information is provided free of charge by the Department of Industrial Relations from its web site at www.dir.ca.gov. |