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Guideline Summary
Guideline Title
Pain (chronic).
Bibliographic Source(s)
Work Loss Data Institute. Pain (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 chronic pain

Guideline Category
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Anesthesiology
Family Practice
Internal Medicine
Neurology
Physical Medicine and Rehabilitation
Rheumatology
Intended Users
Advanced Practice Nurses
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 work-related chronic pain

Interventions and Practices Considered

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

  1. Acetaminophen (APAP)
  2. Acupuncture
  3. Antidepressants for chronic pain
  4. Anti-epilepsy drugs (AEDs) for pain/anticonvulsants
  5. Anti-inflammatory medications
  6. Anxiety medications in chronic pain
  7. Aquatic therapy
  8. Autonomic test battery
  9. Behavioral interventions
  10. Bier's block
  11. Bisphosphonates
  12. Boswellia serrata resin (frankincense)
  13. Botulinum toxin (Botox®, Myobloc®) for cervical dystonia
  14. Buprenorphine
  15. Calcitonin
  16. Capsaicin, topical (chili pepper/cayenne pepper)
  17. Causality (determination)
  18. Chronic pain programs for early intervention, intensity, and opioids
  19. Clonidine, intrathecal
  20. Cod liver oil
  21. Codeine (Tylenol with Codeine®)
  22. Comorbid psychiatric disorders
  23. Complex regional pain syndrome (CRPS), diagnostic criteria, medications, prevention, spinal cord stimulators, sympathetic and epidural blocks, and treatment
  24. Curcumin (turmeric)
  25. Delayed recovery
  26. Detoxification
  27. Diabetic neuropathy screening
  28. Drug testing/urine drug testing in patient-centered clinical situations
  29. Duloxetine (Cymbalta®)
  30. Education of patient and family
  31. Electrodiagnostic testing (electromyography [EMG]/nerve conduction studies [NCS])
  32. Embeda (morphine sulfate and naltrexone hydrochloride)
  33. Epidural steroid injections (ESIs)
  34. Evoked potential studies
  35. Exercise
  36. Facet blocks
  37. Functional improvement measures
  38. Functional restoration programs (FRPs)
  39. Glucosamine (and chondroitin sulfate)
  40. Green tea
  41. Herbal medicines
  42. Home health services
  43. Honey and cinnamon
  44. Hospital length of stay (LOS)
  45. Hypnosis
  46. Implantable drug-delivery systems (IDDSs)
  47. Insomnia treatment
  48. Intrathecal drug delivery systems, medications
  49. Limbrel (flavocoxid/arachidonic acid)
  50. Lumbar sympathetic block
  51. Manual therapy and manipulation
  52. Massage therapy
  53. Medical food
  54. Medications for acute pain (analgesics) and for subacute and chronic pain
  55. Metaxalone (Skelaxin®)
  56. Methadone
  57. Muscle relaxants (for pain)
  58. Nabilone (Cesamet®) (for chemotherapy-induced nausea)
  59. Naltrexone (Vivitrol® extended-release injectable suspension)
  60. Nonprescription medications
  61. Number needed to treat (NNT)
  62. Office visits
  63. Opioids for chronic pain, dealing with misuse and addiction, differentiation between dependence and addiction, dosing, long-term assessment, pain treatment agreement, psychological intervention, and screening for risk of addiction (tests)
  64. Opioid hyperplasia
  65. Phentolamine infusion test
  66. Physical medicine treatment
  67. Piriformis injections
  68. Polysomnography
  69. Proton pump inhibitors (PPIs)
  70. Psychological evaluations
  71. Psychological treatment
  72. Pycnogenol (maritime pine bark)
  73. Return to work
  74. Salicylate topicals
  75. Spinal cord stimulators (SCS)
  76. Stellate ganglion block
  77. Tai chi
  78. Tapentadol (Nucynta™)
  79. Testosterone replacement for hypogonadism (related to opioids)
  80. Topical analgesics
  81. Transcutaneous electrical nerve stimulation (TENS), post-operative pain
  82. Trigger point injections (TPIs)
  83. Uncaria tomentosa (cat's claw)
  84. Urine drug testing (UDT) in patient-centered clinical situations
  85. Venlafaxine (Effexor®)
  86. Vitamin D
  87. Weaning of medications (opioids, benzodiazepines, carisoprodol)
  88. White willow bark
  89. Work conditioning, work hardening
  90. Yoga
  91. Ziconotide (Prialt®)

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

  1. Botulinum toxin (Botox®, Myobloc®)
  2. Buprenorphine
  3. Chi machine
  4. Ketamine
  5. Milnacipran (Savella, Ixel®)
  6. Opioids for chronic pain, osteoarthritis
  7. Vitamin D
  8. Vitamin K

The following interventions were considered, but are not recommended:

  1. Actiq® (oral transmucosal fentanyl citrate)
  2. A-delta fiber electrodiagnostic testing
  3. Axon-II neural scan
  4. Barbiturate-containing analgesic agents (BCAs)
  5. Benzodiazepines (including alprazolam [Xanax®] and others) for long-term use
  6. Biofeedback (as a stand-alone treatment)
  7. Botulinum toxin (Botox®, Myobloc®) for chronic pain disorders
  8. Cannabinoids
  9. Carisoprodol (Soma®)
  10. Chi machine (for chronic pain)
  11. Compound drugs as first-line therapy
  12. Complex regional pain syndrome, sympathectomy
  13. Current perception threshold (CPT) testing
  14. Cytokine DNA testing
  15. Duragesic® (fentanyl transdermal system)
  16. Electroceutical therapy (bioelectric nerve block)
  17. Fentora® (fentanyl effervescent buccal tablet)
  18. Functional imaging of brain responses to pain
  19. Functional magnetic resonance imaging [MRI]
  20. Galvanic stimulation
  21. H-wave stimulation (HWT)
  22. Interferential current stimulation (ICS)
  23. Internal qigong
  24. Intravenous regional sympathetic blocks (for reflex sympathetic dystrophy [RSD]/CRPS, nerve blocks)
  25. Ketamine
  26. Lidoderm® (lidocaine patch)
  27. Low level laser therapy (LLLT)
  28. Lymph drainage therapy
  29. Magnet therapy
  30. Meperidine (Demerol®)
  31. Microcurrent electrical stimulation (MENS devices)
  32. Modafinil (Provigil®)
  33. Monofilament testing
  34. Neuromuscular electrical stimulation (NMES devices)
  35. Neuroreflexotherapy
  36. Nucleoplasty
  37. Onsolis™ (fentanyl buccal film)
  38. Opioids for neuropathic pain
  39. Opioids for osteoarthritis
  40. Oral morphine
  41. Percutaneous electrical nerve stimulation (PENS)
  42. Percutaneous neuromodulation therapy (PNT)
  43. Power mobility devices (PMDs)
  44. Prolotherapy
  45. Propoxyphene (Darvon®) (withdrawn from the U.S. market)
  46. Pulsed radiofrequency treatment (PRF)
  47. Quantitative sensory threshold (QST) testing
  48. Rapid detox
  49. Selective serotonin reuptake inhibitors (SSRIs)
  50. Sympathetic therapy
  51. TENS, chronic pain
  52. Thermography (infrared stress thermography)
  53. Tumor necrosis factor (TNF) modifiers
  54. Ultrasound, therapeutic
  55. Vioxx® (rofecoxib) (withdrawn from the U.S. and worldwide market)
  56. Vitamin B
Major Outcomes Considered
  • Adverse effects of medications
  • Effectiveness of treatments for 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 May 13, 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.

Introduction

Pain has been classified in multiple ways. One common methodology is to temporally classify the condition according to duration, with the most common categories given as acute and chronic. Acute pain is a sign of real or impending tissue damage and usually disappears with healing. It is the normal predicted physiologic response and is usually of short duration. Chronic pain, a common and expensive problem in occupational and disability medicine, has been defined by multiple different time durations (generally from 6 weeks to 3 months after the onset of symptoms). It has also been defined as pain that persists for at least 30 days beyond the usual course of an illness. Chronic pain is a condition that ultimately adversely affects the patient's well being, level of function and quality of life. This chapter of Official Disability Guidelines (ODG) Treatment focuses on chronic pain.

Pain has also been classified according to presumed neurophysiologic mechanisms. There is no real consistency to this type of classification, but texts on pain suggest that pain is either of somatic/nociceptive origin, or a non-nociceptive origin; the latter commonly classified as neuropathic and/or idiopathic/psychogenic. (Definition: somatic pain is a pain arising in the body tissues typically associated with injury or trauma, and nociceptive pain is a normal and expected pain response to injury.) Nociceptive pain is not necessarily synonymous with acute pain. Examples of chronic pain conditions that have been classified as nociceptive include arthritis and other degenerative conditions such as rotator cuff disease.

Pain has also been described as an experience rather than a sensation. Chronic pain may occur without obvious tissue damage, and psychological components have a substantial impact on its development and chronicity. Pain societies have recognized that psychological input to pain may include components of cognitive, behavioral, emotional, and certain predisposing factors (such as childhood trauma or abuse), as well as a potential role of traumatic stress. In addition, in workers' compensation cases and other cases involving personal injury, the "sick role" is further reinforced by the promise that compensation (indemnification) may play in the process. Additionally, there is an increasing emphasis on the role psychiatric co-morbidities such as anxiety disorder, bipolar disease and addictive disease may play in the pathogenesis of the condition.

Initial Evaluation for Chronic Pain

History

  1. Determine the chief complaint
  2. Determine if there was a specific incident that caused or triggered the onset of pain or if pain was insidious in onset
  3. Determine the severity and specific anatomic location of the pain (including radiation patterns)
  4. Determine if the pain has remained localized, or if it has become more multifocal/generalized
  5. Determine the character of pain including the following:
    1. Quality of pain (by descriptions such as aching, dull, sharp, allodynia, burning, electric, dysesthesia, paresthesias, and/or neuralgia)
    2. Continuous or intermittent
    3. Associated neurological factors (weakness, numbness, balance problems)
    4. Factors that exacerbate or relieve
    5. Effect of activity, body position
    6. Effect of stress
  6. Determine previous tests and results
  7. Determine the effect of previous treatment including medications
  8. Assess the ability of the patient to perform functions such as walking, lifting, sitting, and standing including job-related limitations
  9. Assess for evidence of substance abuse in the patient in the past or currently (including alcohol, smoking, or illicit drugs). A family history should also be ascertained
  10. Examine for evidence of concordant depression, anxiety, other mood disturbance, sleep disturbance, or eating disturbance
  11. Assess the effect that pain has had on quality of life in regards to social and family interactions and sexual function
  12. Assess for involvement of litigation or evidence of secondary gain
  13. Assess the patient's goals of treatment

Physical Examination

  1. Assess vital signs, weight, and body mass index. Assess pain using an instrument such as the visual analog scale (VAS), and functionality
  2. Observe appearance, attitude and behavior (such as response on examination maneuvers), and gait
  3. Observe for musculoskeletal defects: deformity, atrophy, masses or lesions, signs of trauma, alignment of spine, range of motion. Determine muscle strength, and evaluate for evidence of myofascial dysfunction
  4. Assess neurologic status: mental status sensory examination (including hyperalgesia, hyperpathia, paresthesias, dysesthesias, allodynia, hypesthesia, hyperesthesia), muscle stretch reflexes
  5. Assess pain-exacerbating maneuvers
  6. Assess for Waddell's signs and inconsistencies in the above examination

Begin an Assessment of the Presumed Chronic Pain Mechanism Based on the History and Physical

The Institute for Clinical Systems Improvement (ICSI) has differentiated distinct biological mechanisms that contribute to chronic pain. Each patient may have multiple and/or overlapping contributors. The criteria and suggested treatment of specific conditions listed are given in the Procedure Summary of the original guideline document.

Neuropathic Pain: Defined as "pain initiated or caused by a primary lesion or dysfunction of the nervous system." Neuropathic pain can be classified according to several methodologies. The first includes a classification into categories of peripheral, central, or a controversial category that includes "dysfunction of the nervous system." An alternative mechanism is to classify neuropathies associated with pain into the following: 1) mononeuropathies, either traumatic or from other causes; 2) polyneuropathies, with etiologies including metabolic, nutritional, drugs, toxins, hereditary, malignant, infective, or an "other" category. See the Procedure Summary in the original guideline document for recommendations concerning the use of various treatments and, in particular, medications such as antidepressants and anticonvulsants (e.g., gabapentin [Neurontin®]) for neuropathic pain.

Muscle Pain: Includes fibromyalgia and myofascial pain.

Inflammatory Pain: This type of pain mechanism is commonly associated with acute pain (postoperative pain and acute tissue injury). An example of chronic inflammatory pain includes arthritis.

Mechanical Pain: Examples of chronic conditions include etiologies that create pressure or stretching, resulting in pain including fracture, dislocation. Another chronic pain example would include compression of tissue by bony structures.

Psychological: In addition to the ICSI mechanisms, it is suggested in guidelines (such as the Chronic Pain Disorder Medical Treatment Guidelines, 2003) to also evaluate for psychological contributors. Specific examples of psychological contributors/comorbidities that are either associated with or contribute to chronic pain include depression, anxiety, personality disorders somatization, and post-traumatic stress. The possibility of the contribution of underlying substance abuse problems must also be assessed. Specific guidelines for both suggested and required psychological testing for specific treatment interventions are included in the Procedure Summaries of the original guideline document. Descriptions of specific standardized psychological tests are provided in "Psychological Tests Commonly Used in the Assessment of Chronic Pain Patients."

Secondary Gain Issues: Issues such as indemnity and current litigation may have impact on resolution of pain. Some authors also suggest even more important social contributors including the primary loss of physical health and functioning, as well as secondary losses such as loss of financial stability and relationships (both on a personal and work-related level).

Determine the Need for Specific Diagnostic Studies

Specific recommendations for diagnostic tests are given in the Procedure Summaries of the original guideline document for both the Pain Chapter and specific body-part chapters.

General Treatment Management

Specific recommendations for each condition are given in the Procedure Summaries of the original guideline document for both the Pain Chapter and specific body-part chapters. General management suggestions as suggested by ICSI also include the following:

  1. Develop a written plan of care that addresses the patient's personal goals, sleep, physical activity, stress management, and recommendations to improve pain control
  2. Provide adequate information to the patient, including opportunities for education on their condition
  3. Include the patient in the treatment plan
  4. Acknowledge that the treatment team recognizes that their pain is considered as "real"
  5. Provide all patients with an exercise and fitness program
  6. Consider the use of a cognitive behavioral program when indicated
  7. Schedule routine appointments to avoid the incidence of visits secondary to increased pain
  8. Stress self-management by the patient
  9. Enlist family and friends to both support the patient and reinforce gains
  10. Assist in return to work
  11. Assist in appropriate attainment of entitlements

At a certain point in the course of care, there are two general treatment options for claimants with chronic pain. One is medication, and the second is cognitive therapy/pain management programs. See the Procedure Summary in the original guideline document for more details and links to the medical evidence.

Medication Issues (See also Medications in the Procedure Summary of the original guideline document for links to specific choices)

Non-neuropathic pain is generally treated with analgesics and anti-inflammatories. First-line treatment for neuropathic pain requires treatment with medications that influence the various transmitters involved in the underlying pain pathology, with opioids reserved for refractory pain. When considering opioids for either type of pain, discussion should include duration of treatment and when to discontinue their use (as occasionally suggested as "detoxification" by many reviewers). This area of opioid treatment remains extremely controversial, and research remains ongoing. It is generally felt that "detoxification" should not be proposed without offering another treatment solution, although alternative options also remain controversial.

Anticonvulsants are also currently suggested medications for neuropathically related chronic pain. When dealing with neuropathic pain, and in particular, neuropathic pain of possible spinal origin, treatment issues are confounded due to the presence of underlying non-work-related conditions that also can present with neuropathic pain such as impaired glucose tolerance/type 2 diabetes (i.e., diabetic peripheral neuropathy) and/or aging (possible neurogenic claudication secondary to spinal stenosis). The question often arises as to the actual indication of the use of anti-convulsant medication in these instances, and their compensability in regards to the work-related injury. These questions include how the medications should be prescribed and how outcomes should be recorded. Antidepressants have also been indicated for both neuropathic and non-neuropathic pain. Not only do compensability issues arise for this class of medications in regards to the underlying issues of etiologies of neuropathy, but also in regards to their use for pre-existing conditions of depression and anxiety. Needless to say, the issues involved with medication for chronic pain are controversial, and current literature addressing the above issues is included in the Procedure Summary in the original guideline document.

Note: In workers' compensation cases, providers may need to shift focus from a "cure and relieve" strategy to a "functional restoration" paradigm. Too much attention may be focused on the "pain" and not enough on functional restoration and gain that encourages "coping" strategies and the desirable outcome of "working" with pain. Also consider the possibility of patients developing "Wounded Worker Syndrome," a chronic pain condition characterized by failure of an injured worker to respond to conventional healthcare measures, and prolonged disability with continued absence from the workplace. The main contributor of this condition may be the healthcare system itself, which reinforces the "sickness" role of the injured worker and provides many misguided interventions due to a lack of adequate assessment of underlying psychosocial factors.

Refer to the original guideline document for information on regulatory/legal issues of pain management.

ODG Return-To-Work Pathways for Selected Generalized Pain Syndromes

(See body-part chapters for disability duration information for pain that is the result of conditions in specific body parts, such as low back, neck or extremity pain)

ODG Return-To-Work Pathways

Myalgia and Myositis, Unspecified (Muscle Pain or Inflammation) (see the original guideline document for International Classification of Diseases, Ninth Revision [ICD-9] codes for this and other diagnoses)

Moderate pain: 0 days
Debilitating pain, with hospitalization, modified work: 14 days
Debilitating pain, with hospitalization, regular work: 42 days
Myofascial pain syndrome, trigger point injection: 1 to 7 days
Myofascial pain syndrome, acupuncture: 7 to 21 days
Myofascial pain syndrome, physical therapy: 14 to 21 days
Fibromyalgia: Controversial and self-perpetuating diagnosis - see related conditions and return to regular activities as soon as possible

Reflex Sympathetic Dystrophy (including complex regional pain syndrome [CRPS]-I)
Note: this is a controversial diagnosis

Sympathetic nerve block: 3 to 7 days
Complex regional pain syndrome (CRPS-I), early stage: 28 to 84 days
Complex regional pain syndrome (CRPS-I), late stage: 210 days to indefinite
Late stage reflex sympathetic dystrophy (RSD) (CRPS-I): 365 days to indefinite

Causalgia of Upper Limb (including CRPS-II)
Note: this is a controversial diagnosis

Medical treatment: 0 days
Sympathetic nerve block: 2 days
Complex regional pain syndrome (CRPS-II): 28 to 84 days

Causalgia of Lower Limb (including CRPS-II)
Note: this is a controversial diagnosis

Medical treatment: 0 days
Sympathetic nerve block: 2 days
Complex regional pain syndrome (CRPS-II): 28 to 84 days

Mononeuritis of Unspecified Site (including CRPS-II)
Note: this is a controversial diagnosis

Sympathetic nerve block: 3 to 7 days
Complex regional pain syndrome (CRPS-II), early stage: 28 to 84 days
Complex regional pain syndrome (CRPS-II), late stage: 210 days to indefinite

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 pain.

Potential Harms
  • Adverse effects of medications (refer to the original guideline document for details)
  • Side effects of implanted catheters for complex regional pain syndrome (CRPS) include technical failure and infection.

Contraindications

Contraindications
  • Tricyclic antidepressants are contraindicated in patients with cardiac conduction disturbances and/or decompensation as well as those patients with epilepsy.
  • All nonsteroidal anti-inflammatory drugs (NSAIDs) are relatively contraindicated in patients with renal insufficiency, congestive heart failure, or volume excess (such as cirrhosis).
  • Ziconotide (Prialt®) is contraindicated in patients with a pre-existing history of psychosis.
  • Trigger point injections (TPIs) are contraindicated in patients with acute cases of muscle trauma, allergies to anesthetic agents, bleeding disorders, local or systemic infection, and anticoagulant use.
  • Sepsis, spinal infection, anticoagulation or coagulopathy are contraindications to implantable drug-delivery systems.

Qualifying Statements

Qualifying Statements
  • Disclaimer: limitations of scope. See body-part chapters for condition specific information, especially the Low Back Chapter. The Pain Chapter is focused on chronic pain, and also covers causalgia, complex regional pain syndrome (CRPS), myofascial pain, and generalized pain syndromes. Users interested in pain that is the result of conditions in specific body parts (e.g., low back, neck, or extremity pain), should also access those other chapters for management of pain of those body parts, although those chapters may refer to the Pain Chapter for certain generalized evidence summaries.
  • 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.

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. Pain (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 13 May 2011)
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. This summary was updated by ECRI on June 16, 2005, following the U.S. Food and Drug Administration advisory on COX-2 selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs). This NGC summary was updated by ECRI on January 13, 2006, April 11, 2006, November 13, 2006, April 2, 2007, and on August 29, 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 28, 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 May 26, 2009, following the U.S. Food and Drug Administration advisory on Botox, Botox Cosmetic (Botulinum toxin Type A), and Myobloc (Botulinum toxin Type B). This summary was updated by ECRI Institute on August 17, 2009, following the updated FDA advisory on Botox and Botox Cosmetic (Botulinum toxin Type A), and Myobloc (Botulinum toxin Type B). This NGC summary was updated by ECRI Institute on June 10, 2011. This summary was updated by ECRI Institute on October 28, 2013 following the U.S. Food and Drug Administration advisory on Acetaminophen.

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

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