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Guideline Summary
Guideline Title
Low back - lumbar & thoracic (acute & chronic).
Bibliographic Source(s)
Work Loss Data Institute. Low back - lumbar & thoracic (acute & chronic). Encinitas (CA): Work Loss Data Institute; 2011. Various p.
Guideline Status

Note: This guideline had been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • August 1, 2013 – Acetaminophen External Web Site Policy: The U.S. Food and Drug Administration (FDA) notified healthcare professionals and patients that acetaminophen has been associated with a risk of rare but serious skin reactions. Acetaminophen is a common active ingredient to treat pain and reduce fever; it is included in many prescription and over-the-counter (OTC) products. These skin reactions, known as Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP), can be fatal. These reactions can occur with first-time use of acetaminophen or at any time while it is being taken. Other drugs used to treat fever and pain/body aches (e.g., non-steroidal anti-inflammatory drugs, or NSAIDS, such as ibuprofen and naproxen) also carry the risk of causing serious skin reactions, which is already described in the warnings section of their drug labels.

Scope

Disease/Condition(s)

Work-related low back pain

Guideline Category
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Anesthesiology
Chiropractic
Family Practice
Internal Medicine
Neurological Surgery
Orthopedic Surgery
Physical Medicine and Rehabilitation
Radiology
Rheumatology
Surgery
Intended Users
Advanced Practice Nurses
Chiropractors
Health Care Providers
Health Plans
Nurses
Physician Assistants
Physicians
Utilization Management
Guideline Objective(s)

To offer evidence-based step-by-step decision protocols for the assessment and treatment of workers' compensation conditions

Target Population

Workers with low back pain

Interventions and Practices Considered

The following interventions/procedures were considered and recommended as indicated in the original guideline document:

  1. Adjacent segment disease/degeneration (fusion)
  2. Aerobic exercise
  3. Age adjustment factors
  4. Antidepressants (for chronic low back pain)
  5. Aquatic therapy
  6. Back schools
  7. Behavioral treatment
  8. Biofeedback
  9. Causation determination
  10. Coccygectomy
  11. Cold/heat packs
  12. Conservative care
  13. Corticosteroids (oral/parenteral/intramuscular [IM] for low back pain)
  14. Dehydroepiandrosterone (DHEA)
  15. Differential diagnosis
  16. Discectomy/laminectomy
  17. Education
  18. Electromyography (EMG)/H-reflex tests
  19. Epidural steroid injections (ESIs), diagnostic and therapeutic
  20. Ergonomics
  21. Evoked potential studies (as a diagnostic tool for unexplained myelopathy and/or in unconscious spinal cord injury patients)
  22. Exercise
  23. Facet joint diagnostic blocks (injections)
  24. Facet joint pain, signs and symptoms
  25. Fear-avoidance beliefs questionnaire (FABQ)
  26. Flexibility
  27. Fluoroscopy (for ESIs)
  28. Functional improvement measures
  29. Fusion (spinal)
  30. Gabapentin (Neurontin®)
  31. Godelive Denys-Struyf (GDS) method
  32. Hardware injection (block)
  33. Heat therapy
  34. Herbal medicines
  35. Home health services
  36. Hospital length of stay (LOS)
  37. Hyperbaric oxygen therapy (HBOT)
  38. Iliac crest donor-site pain treatment
  39. Implantable drug-delivery systems (IDDSs)
  40. Intraoperative neurophysiological monitoring (during surgery)
  41. Kyphoplasty
  42. Laminectomy/laminotomy
  43. Lumbar extension exercise equipment/Cybex® exercise machine/MedX® lumbar extension machine
  44. Lumbar supports (for compression fractures and specific treatment of spondylolisthesis, documented instability, or post-operative treatment)
  45. Magnetic resonance imaging (MRI)
  46. Manipulation/chiropractic
  47. Massage
  48. McKenzie method
  49. Microdiscectomy
  50. Muscle relaxants
  51. Myelography
  52. Nonprescription medications/anti-inflammatory medications (e.g., acetaminophen, aspirin, non-steroidal anti-inflammatory drugs [NSAIDS])
  53. Office visits
  54. Percutaneous electrical nerve stimulation (PENS)
  55. Physical therapy/occupational therapy
  56. Piriformis injections
  57. Psychological screening
  58. Return to work
  59. Sacroiliac joint injections (SJI)
  60. Segmental rigidity (diagnosis)
  61. Sequestrectomy
  62. Shoe insoles/shoe lifts
  63. Skilled nursing facility care
  64. Spinal cord stimulation (SCS)
  65. Straight leg raising test
  66. Stretching
  67. Transcutaneous electrical nerve stimulation (TENS)
  68. Work/activity restrictions
  69. Work conditioning/work hardening
  70. Wound closure
  71. Wound dressings
  72. Yoga

The following interventions/procedures are under study and are not specifically recommended:

  1. Adhesiolysis, spinal endoscopic
  2. Back brace, post operative (fusion)
  3. Bone growth stimulators (BGS)
  4. Botulinum toxin (Botox)
  5. Disc prosthesis (in the cervical spine)
  6. Facet joint intra-articular injections (therapeutic blocks)
  7. Facet joint radiofrequency neurotomy/facet rhizotomy
  8. Feldenkrais
  9. Lumbar supports (for treatment of nonspecific low back pain [LBP])
  10. Magnetic resonance (MR) neurography
  11. Oxygen-ozone therapy (injection)
  12. Prostaglandin E1 (PGE1)
  13. Standing MRI for patients with equivocal findings on conventional MRI
  14. Stem cell autologous transplantation
  15. Topiramate (Topamax®)
  16. Tubular discectomy
  17. Tumor necrosis factor (TNF) modifiers
  18. Vacuum-assisted closure wound-healing

The following interventions/procedures were considered, but are not recommended:

  1. Acupuncture
  2. Acupressure
  3. Adhesiolysis, percutaneous
  4. Bed rest
  5. Biofeedback
  6. Bone-morphogenetic protein (BMP)
  7. Bone scan
  8. Bupropion (Wellbutrin®)
  9. Chemonucleolysis (chymopapain)
  10. Colchicine
  11. Computed tomography (CT) and CT myelography
  12. Corticosteroids (oral/parenteral/IM for acute non-radicular pain [i.e., axial pain] or chronic pain)
  13. Current perception threshold (CPT) testing
  14. Delayed treatment
  15. Device for intervertebral assisted motion (DIAM)
  16. Diathermy
  17. Disc prosthesis/disc replacement
  18. Discography
  19. DRX® (traction)
  20. Dynamic neutralization system (Dynesys®)
  21. Electromagnetic pulsed therapy
  22. Epidural steroid injections, "series of three"
  23. Evoked potential studies (for radiculopathies and peripheral nerve lesions)
  24. Facet joint intra-articular injections (therapeutic blocks)
  25. Facet joint chemical rhizotomy
  26. Facet joint injections, multiple series and thoracic
  27. Facet joint medial branch blocks (therapeutic injections)
  28. Flexibility (as a primary criteria)
  29. Flexion/extension imaging studies
  30. Functional anesthetic discography (FAD)
  31. Fusion, spinal and endoscopic
  32. F-wave tests
  33. Glucosamine
  34. Gym memberships
  35. Hospitalization
  36. H-wave stimulation (devices)
  37. Infrared therapy
  38. Interferential therapy
  39. Intradiscal electrothermal annuloplasty/intradiscal electrothermal therapy (IDET)
  40. Intradiscal steroid injection
  41. Iontophoresis
  42. Ligamentous injections
  43. Low level laser therapy (LLLT)
  44. Lumbar supports for prevention/braces/corsets
  45. Magnet therapy
  46. Manipulation under anesthesia (MUA)
  47. Mattress selection
  48. Microcurrent electrical stimulation (MENS devices)
  49. NC-stat nerve conduction studies/nerve conduction studies (NCS)
  50. Neuromuscular electrical stimulators (NMES)
  51. Neuroreflexotherapy
  52. Nucleoplasty
  53. Opioids/narcotics
  54. Orthotrac vest
  55. Percutaneous discectomy (PCD)
  56. Percutaneous electrical nerve stimulation (PENS)
  57. Percutaneous endoscopic laser discectomy (PELD)
  58. Percutaneous intradiscal radiofrequency (thermocoagulation)
  59. Percutaneous neuromodulation therapy (PNT)
  60. Powered traction devices/Lordex®/vertebral axial decompression (VAX-D®)
  61. Prolotherapy (sclerotherapy)
  62. Pulsed radiofrequency treatment (PRF)
  63. Radiography (x-rays)
  64. Reflexology
  65. Single photon emission computed tomography (SPECT)
  66. Standing MRI
  67. Surface electromyography (SEMG)
  68. Sympathetic therapy
  69. Thermography (infrared stress thermography)
  70. Traction/IDD therapy (intervertebral disc decompression)
  71. TENS as an isolated intervention
  72. Transplantation, intravertebral disc
  73. Trigger point injections in the absence of myofascial pain syndrome
  74. Ultrasound, diagnostic and therapeutic
  75. Vertebroplasty
  76. Videofluoroscopy (for range of motion)
Major Outcomes Considered
  • Reliability and value of diagnostic assessments
  • Effectiveness of treatment in relieving pain and restoring normal function

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Work Loss Data Institute (WLDI) conducted a comprehensive medical literature review (now ongoing) with preference given to high quality systematic reviews, meta-analyses, and clinical trials published since 1993, plus existing nationally recognized treatment guidelines from the leading specialty societies. WLDI primarily searched MEDLINE and the Cochrane Library. In addition, WLDI also reviewed other relevant treatment guidelines, including those in the National Guideline Clearinghouse, as well as state guidelines and proprietary guidelines maintained in the WLDI guideline library. These guidelines were also used to suggest references or search terms that may otherwise have been missed. In addition, WLDI also searched other databases, including MD Consult, eMedicine, CINAHL, and conference proceedings in occupational health (i.e., American College of Occupational and Environmental Medicine [ACOEM]) and disability evaluation (i.e., American Academy of Disability Evaluating Physicians [AADEP], American Board of Independent Medical Examiners [ABIME]). Search terms and questions were diagnosis, treatment, symptom, sign, and/or body-part driven, generated based on new or previously indexed existing evidence, treatment parameters and experience.

In searching the medical literature, answers to the following questions were sought: (1) If the diagnostic criteria for a given condition have changed since 1993, what are the new diagnostic criteria? (2) What occupational exposures or activities are associated causally with the condition? (3) What are the most effective methods and approaches for the early identification and diagnosis of the condition? (4) What historical information, clinical examination findings or ancillary test results (such as laboratory or x-ray studies) are of value in determining whether a condition was caused by the patient's employment? (5) What are the most effective methods and approaches for treating the condition? (6) What are the specific indications, if any, for surgery as a means of treating the condition? (7) What are the relative benefits and harms of the various surgical and non-surgical interventions that may be used to treat the condition? (8) What is the relationship, if any, between a patient's age, gender, socioeconomic status and/or racial or ethnic grouping and specific treatment outcomes for the condition? (9) What instruments or techniques, if any, accurately assess functional limitations in an individual with the condition? (10) What is the natural history of the disorder? (11) Prior to treatment, what are the typical functional limitations for an individual with the condition? (12) Following treatment, what are the typical functional limitations for an individual with the condition? (13) Following treatment, what are the most cost-effective methods for preventing the recurrence of signs or symptoms of the condition, and how does this vary depending upon patient-specific matters such as underlying health problems?

Criteria for Selecting the Evidence

Preference was given to evidence that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reports a cohort study, whether prospective or retrospective, or (5) The article reports a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

More information about the selection of evidence is available in the "Methodology Outline" and "Appendix A. ODG Treatment in Workers' Comp. Methodology description using the AGREE instrument" (see "Availability of Companion Documents" field).

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Ranking by Type of Evidence

  1. Systematic Review/Meta-Analysis
  2. Controlled Trial - Randomized (RCT) or Controlled
  3. Cohort Study-Prospective or Retrospective
  4. Case Control Series
  5. Unstructured Review
  6. Nationally Recognized Treatment Guideline (from www.guideline.gov External Web Site Policy)
  7. State Treatment Guideline
  8. Other Treatment Guideline
  9. Textbook
  10. Conference Proceedings/Presentation Slides

Ranking by Quality within Type of Evidence

  1. High Quality
  2. Medium Quality
  3. Low Quality
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

The Work Loss Data Institute (WLDI) reviewed each article that was relevant to answering the question at issue, with priority given to those that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reported a cohort study, whether prospective or retrospective, or (5) The article reported a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

Especially when articles on a specific topic that met the above criteria were limited in number and quality, WLDI also reviewed other articles that did not meet the above criteria, but all evidence was ranked alphanumerically (see the "Rating Scheme for the Strength of the Evidence" field) so that the quality of evidence could be clearly determined when making decisions about what to recommend in the Guidelines. Articles with a Ranking by Type of Evidence of Case Reports and Case Series were not used in the evidence base for the Guidelines. These articles were not included because of their low quality (i.e., they tend to be anecdotal descriptions of what happened with no attempt to control for variables that might affect outcome). Not all the evidence provided by WLDI was eventually listed in the bibliography of the published Guidelines. Only the higher quality references were listed. The criteria for inclusion was a final ranking of 1a to 4b (the original inclusion criteria suggested the methodology subgroup), or if the Ranking by Type of Evidence was 5 to 10, the quality ranking should be an "a."

Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation
External Peer Review
Description of Method of Guideline Validation

Prior to publication, select organizations and individuals making up a cross-section of medical specialties and typical end-users externally reviewed the guideline.

Recommendations

Major Recommendations

Note: This guideline had been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Note from the Work Loss Data Institute (WLDI) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of March 14, 2011. However, because the Work Loss Data Institute updates their guidelines frequently, users may wish to consult the WLDI Web site External Web Site Policy for the most current version available.

Identify Radicular Signs

  • First visit: may be with Primary Care Physician MD/DO (50%), Orthopedist (33%), or Chiropractor (17%) (or rarely other specialists, including pain specialists)
  • Determine presence or absence of radiculopathy:
    • Medical history
    • Sensation: Feeling pain radiating below the knee (calf or lower), not just referred pain (pain radiating to buttocks or thighs), and dermatological sensory loss
    • Straight leg raising test (sitting and supine), productive of leg pain
    • Motor strength and deep tendon reflexes
    • Document flexibility/range of motion (ROM) (fingertip test), muscle atrophy (calf measurement), local areas of tenderness, visual pain analog, sensation alternation

    Note: Radiculopathy is often over-diagnosed. For unequivocal evidence of radiculopathy, refer to the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition, pg. 382-83.

  • Rule out "red flag" diagnoses, including diagnostic studies, for specialist referral:
    • Cauda Equina Syndrome (Schedule emergency procedure) (Refer to the original guideline document for International Classification of Diseases, Ninth Revision [ICD-9] codes for this and other diagnoses)
    • Fracture, Compression fracture, Dislocation, Wound
    • Cancer, Infection
    • Dissecting/Ruptured Aortic Aneurysm
    • Others (prostate problems, endometriosis/gynecological disorders, urinary tract infections, and renal pathology)

Note: This guideline should not be used to suggest appropriate procedures for other conditions or comorbidities. When the treating doctor suspects any other diagnosis, they may decide what necessary testing should be performed, which may include laboratory tests such as erythrocyte sedimentation rate (ESR), complete blood count (CBC), and urinalysis (UA) to screen for nonspecific medical diseases (especially infection and tumor) of the low back.

Without Radiculopathy (90% of cases)

  • Also first visit (day 1):
    • Prescribe activity modification, if necessary, based on severity and difficulty of job, while encouraging return to activity as much as possible; limited passive therapy with heat/ice (3 to 4 times/day); stretching/exercise (training by physical therapist OK); appropriate analgesia (i.e., acetaminophen) and/or anti-inflammatory (i.e., ibuprofen) [Benchmark cost: $14]; back to work except for severe cases in 72 hours, possibly modified duty; AVOID bed rest.
    • REASSURE PATIENT: Patient education - common problem (90% of patients recover spontaneously in 4 weeks)
    • No x-rays unless significant trauma (e.g., a fall)
    • If muscle spasms, then consider muscle relaxant with limited sedative side effects [Benchmark cost: $44]

      Note: The purpose of muscle relaxants is to facilitate return to activity, but muscle relaxants have not been shown to be more effective than non-steroidal anti-inflammatory drugs [NSAIDs].

    Official Disability Guidelines (ODG) Return-To-Work Pathways (lumbar sprain and lumbago)

    Modified Duty --
    Mild, (Grade I)1, clerical/modified work: 0 days
    Severe, (Grade II-III)1, clerical/modified work: 3 days

    (See ODG Capabilities & Activity Modifications for Restricted Work under "Work" in the Procedure Summary for Ergonomic accommodations of the original guideline document)

    1 Definition of Sprain/Strain Severity Grade: In general, a Grade I or mild sprain/strain is caused by overstretching or slight tearing of the ligament/muscle/tendon with no instability, and a person with a mild sprain usually experiences minimal pain, swelling, and little or no loss of functional ability. Although the injured muscle is tender and painful, it has normal strength. A Grade II sprain/strain is caused by incomplete tearing of the ligament/muscle/tendon and is characterized by bruising, moderate pain, and swelling, and a Grade III sprain/strain means complete tear or rupture of a ligament/muscle/tendon. A sprain is a stretch and/or tear of a ligament (a band of fibrous tissue that connects two or more bones at a joint). A strain is an injury to either a muscle or a tendon (fibrous cords of tissue that connect muscle to bone).

    • Second visit (day 3 to 10 - about 1 week after first visit, or sooner, because delayed treatment is not recommended)
      • Document progress (flexibility, areas of tenderness, motor strength, straight leg raise--sitting and supine)
      • If still 50% disabled (i.e., cannot return to work) then consider referral for exercise/instruction/manual therapy [Benchmark cost: $250]: Options are physical therapist, chiropractor, massage therapist, or occupational therapist (3 visits in first week), or by treating DO/MD (Choose providers supporting active therapy and not just passive modalities. The focus of treatment should not be symptom reduction, but improving function with a goal to return to work.) Consider screening for psychosocial symptoms in cases with expectations of delayed recovery.
      • Discontinue muscle relaxant
    ODG Return-To-Work Pathways (lumbar sprain and lumbago)

    Manual Work --
    Mild, manual work: 7 to 10 days
    Severe, manual work: 14 to 17 days

    • Third visit (day 10 to 17 - about 1 week after second visit)
      • Document progress
      • Prescribe muscle-conditioning exercises
      • At this point 66% to 75% should be back to regular work
      • While not indicated in the absence of red flags, if still disabled, then consider imaging study (anterior-posterior [AP]/lateral 2-view x-ray of lumbar) [Benchmark cost: $150] to rule out tumor, fracture, osteoporosis, myelopathy
      • Maintain therapy, continue focus on active therapy and not passive modalities, 2 visits in next week, teach home exercises
      • End manual therapy at 4 weeks (1 visit in last week)
    ODG Return-To-Work Pathways (lumbar sprain and lumbago)

    Manual & Heavy Manual Work --
    Severe, manual work: 14 to 17 days
    Severe, heavy manual work: 35 days

    With Radiculopathy (10% of cases)

    • Also first visit (day 1)
      • Same as non-radicular
    ODG Return-To-Work Pathways (intervertebral disc disorders)

    Disc bulge --
    Mild cases with back pain, avoid strenuous activity: 0 days
    Herniated disc --
    Initial conservative medical treatment, clerical/modified work: 3 days

    • Second visit (day 3 to 10 - about 1 week after first visit)
      • Same as non-radicular, but
      • Reassure, but if increased numbness or weakness of either leg, get back to provider in one day
      • Consider referral to nonsurgical musculoskeletal physician (Orthopedist/Physical Medicine/Sports Medicine)
    • Third visit (day 10 to 17 - about 1 week after second visit)
      • Same as non-radicular, but
      • About 50% can be back at modified duty
      • If improvement, then add strengthening exercises, increased activity
    • Fourth visit (day 21 to 28 - about 1 to 2 weeks after third visit)
      • Document objective findings, if no improvement then:
      • First magnetic resonance imaging (MRI) (about 3% of total cases, or 30% of radicular cases) to confirm extruded disk with nerve root displacement (≥1 month conservative therapy) [Benchmark cost: $1,600]
      • MRI or computed tomography (CT) not indicated without obvious clinical level of nerve root dysfunction, clear radicular findings, or before 3 to 4 weeks
      • EMGs (electromyography) may be useful to obtain unequivocal evidence of radiculopathy, after 4 to 8 weeks conservative therapy, but EMGs are not necessary if radiculopathy is already clinically obvious
      • Consider an epidural steroid injection (ESI) for severe cases hoping to avoid surgery [Benchmark cost: $676]

      Note: The purpose of ESI is to reduce pain and inflammation, restoring range of motion and thereby facilitating progress in more active treatment programs, but this treatment alone offers no significant long-term functional benefit.

      • If psychological factors retarding recovery are suspected, possibly refer to psychologist for testing [Benchmark cost: $540].
      • Education: Consider back school as an option, if available.
      • If no improvement 7 to 14 days after the first ESI, consider prescribing 2nd ESI [Benchmark cost: $615]; there should be a maximum of two ESIs, and the second ESI can be 7 to 14 days after the first, depending upon the patient's response and functional gain
    ODG Return-To-Work Pathways (intervertebral disc disorders)

    Initial conservative medical treatment, manual work: 28 days
    Initial conservative medical treatment, regular work if cause of disability: 84 days

    • Surgery (three months or more -- after appropriate work-up and consultation, concordance between radicular findings on radiologic evaluation and physical exam findings) (about 2% of total cases, or 20% of radicular cases) (See also ODG Indications for Surgery™ -- Discectomy in Procedure Summary of the original guideline document). Unequivocal objective findings are required based on neurological examination and testing.
      • Refer to fellowship trained Spine Surgeon: Neurosurgeon (50%), Orthopedist (50%)
      • Before surgery, screen for psychological symptoms that could affect surgical outcome (e.g., substance abuse, child abuse, work conflicts, somatization, verbalizations, attorney involvement, smoking)
      • Review options/outcomes with patient, let patient be part of decision making
      • Simple discectomy/laminectomy, minimally invasive [Benchmark cost: $17,400]
      • Post-operative pain, walking exercises, physical therapy
    ODG Return-To-Work Pathways (intervertebral disc disorders)

    Discectomy, clerical/modified work: 28 days
    Discectomy, manual work: 56 days
    Discectomy, heavy manual work: 126 days to indefinite
    Laminectomy, clerical/modified work: 28 days
    Laminectomy, manual work: 70 days
    Laminectomy, heavy manual work: 105 days to indefinite

    • Failure to recover: See the Procedure Summary (in the original guideline document) for options that may be available, along with links to the medical evidence. Also, see the NGC summary of the Work Loss Data Institute's guideline Pain (chronic).
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

During the comprehensive medical literature review, preference was given to high quality systematic reviews, meta-analyses, and clinical trials over the past ten years, plus existing nationally recognized treatment guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure Summary (see the original guideline document), which provides a concise synopsis of effectiveness, if any, of each treatment method based on existing medical evidence. Each summary and subsequent recommendation is hyper-linked into the studies on which they are based, in abstract form, which have been ranked, highlighted and indexed.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

These guidelines unite evidence-based protocols for medical treatment with normative expectations for disability duration. They also bridge the interests of the many professional groups involved in diagnosing and treating work-related low back pain.

Potential Harms
  • Muscle relaxants have potential side effects, including drowsiness in up to 30 percent of patients.
  • Gabapentin is associated with increased sedation and dizziness.
  • There should be caution about daily doses of acetaminophen and liver disease if over 4,000 mg per day or in combination with other non-steroidal anti-inflammatory drugs (NSAIDs).

Contraindications

Contraindications
  • Potential cautions or contraindications to manipulations include coagulopathy, fracture, and progressive neurologic deficit.
  • Diagnostic facet blocks should not be performed in patients in whom a surgical procedure is anticipated and in those who have had a previous fusion procedure at the planned injection level.
  • In patients with a positive discography finding and equivocal magnetic resonance imaging or plain radiographic findings, a thorough psychological evaluation is recommended. A diagnosis of a somatization disorder, or the presence of hysteria or hypochondriasis, are relative contraindications to surgical intervention of any type.

Qualifying Statements

Qualifying Statements
  • The Treatment Planning section is not designed to be a rule, and therefore should not be used as a basis for Utilization Review. The Treatment Planning section outlines the most common pathways to recovery, but there is no single approach that is right for every patient and these protocols do not mention every treatment that may be recommended. See the Procedure Summaries (in the original guideline document) for complete lists of the various options that may be available, along with links to the medical evidence. The Procedure Summaries are the most important section of Official Disability Guidelines (ODG) Treatment, and that section, not the Treatment Planning section, should be used as a basis for Utilization Review.
  • This guideline should not be used to suggest appropriate procedures for other conditions or comorbidities. When the treating doctor suspects any other diagnosis, they may decide what necessary testing should be performed.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Patient Resources
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Work Loss Data Institute. Low back - lumbar & thoracic (acute & chronic). Encinitas (CA): Work Loss Data Institute; 2011. Various p.
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2003 (revised 2011 Mar 14)
Guideline Developer(s)
Work Loss Data Institute - For Profit Organization
Source(s) of Funding

Not stated

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Editor-in-Chief, Philip L. Denniston, Jr. and Senior Medical Editor, Charles W. Kennedy, Jr., MD, together pilot the group of approximately 80 members. See the ODG Treatment in Workers Comp Editorial Advisory Board External Web Site Policy.

Financial Disclosures/Conflicts of Interest

There are no conflicts of interest among the guideline development members.

Guideline Status

Note: This guideline had been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Guideline Availability

Electronic copies of the updated guideline: Available to subscribers from the Work Loss Data Institute Web site External Web Site Policy.

Print copies: Available from the Work Loss Data Institute, 169 Saxony Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992, Fax: 760-753-9995; www.worklossdata.com External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Methodology outline is available from the Work Loss Data Institute (WLDI) Web site External Web Site Policy.
  • Appendix A. Official Disability Guidelines (ODG) Treatment in Workers' Comp. Methodology description using the AGREE instrument. Available from the WLDI Web site External Web Site Policy.
  • ODG for eReader. Treatment and disability duration guidelines are available for purchase from the WLDI Web site External Web Site Policy.
Patient Resources

The following is available:

  • Appendix C. Official Disability Guidelines (ODG) Treatment in Workers' Comp. Patient information resources. Electronic copies: Available to subscribers from the Work Loss Data Institute Web site External Web Site Policy.

Print copies: Available from the Work Loss Data Institute, 169 Saxony Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992, Fax: 760-753-9995; www.worklossdata.com External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was completed by ECRI on February 2, 2004. The information was verified by the guideline developer on February 13, 2004. This NGC summary was updated by ECRI on March 28, 2005, January 3, 2006, April 11, 2006, November 10, 2006, and March 30, 2007. This summary was updated by ECRI Institute on May 17, 2007 following the U.S. Food and Drug advisory on Colchicine. This NGC summary was updated by ECRI Institute on August 28, 2007. This summary was updated by ECRI Institute on October 31, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This NGC summary was updated by ECRI Institute on January 22, 2009. This summary was updated by ECRI Institute on May 1, 2009 following the U.S. Food and Drug Administration advisory on antiepileptic drugs. This summary was updated by ECRI Institute on July 20, 2009 following the U.S. Food and Drug Administration advisory on Varenicline and Bupropion. This summary was updated by ECRI Institute on June 9, 2011. This summary was updated by ECRI Institute on October 28, 2013 following the U.S. Food and Drug Administration advisory on Acetaminophen.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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