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DIVISION OF WORKERS' COMPENSATION

COLORADO DIVISION OF WORKERS’

COMPENSATION

MEDICAL TREATMENT

GUIDELINES: REFERENCE GUIDE FOR

CLAIMS ADJUSTERS

LOW BACK PAIN MEDICAL TREATMENT GUIDELINES

Adopted: February 3, 2014; Effective March 31, 2014

This Reference Guide links directly to and incorporates the

principals and tenets set forth in the Low Back Pain Medical

Treatment Guidelines. The Guide is intended for use by

claims adjusters, recognizing that their role is strategically

central to the timely review, authorization and payment of

medical benefits. The format is designed to provide access

to specific information on medical procedures:

recommendations for and against; indications for

appropriate use, time to produce an effect, and requirements

for prior authorization. The purpose is to ensure compliance,

provide clarity and encourage dialog between provider and

payer for the most timely and effective care of injured

workers in Colorado.

Instructions on Use

1. To access the General Sections of Low Back Pain Treatment Guideline

Reference Guide, click on the desired links on the Table of Contents on

the next page.

2. Go to the Index to find categories such as: “Prior Authorization,” “Time

Parameters,” and other categories specific to managing the Workers’

Compensation Claim.

3. To go to either the Table of Contents or the Index, select the one of the

links at the top of the page.

4. The adjuster should review the General Guideline Principles (The

General Principals may vary slightly from Guideline to Guideline). The

full guidelines are available online at www.colorado.gov/cdle/medical-

treatment-guidelines

The General Guideline Principles for Low Back Pain are as

follows:

GENERAL GUIDELINE PRINCIPLES

1. APPLICATION OF GUIDELINES

2. EDUCATION

3. INFORMED DECISION MAKING

4. TREATMENT PARAMATER DURATION

5. ACTIVE INTERVENTIONS

6. ACTIVE THERAPEUTIC EXERCISE PROGRAM

7. POSITIVE PATIENT RESPONSE

8. RE-EVALUATION OF TREATMENT EVERY THREE TO FOUR

WEEKS

9. SURGICAL INTERVENTIONS

10. SIX-MONTH TIME FRAME

11. RETURN TO WORK

12. DELAYED RECOVERY

13. GUIDELINE RECOMMENDATIONS AND INCLUSION OF

MEDICAL EVIDENCE

14. CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI)

5. Absent a final order to the otherwise, payment must be made for

treatment consistent with the Guidelines on admitted injuries.

6. Effective January 1, 2016, Rule 16-10 (B) requires that payers contesting

a request for prior authorization must have the request reviewed by a

Level I or Level II accredited, licensed physician or chiropractor

7. There is an index near the end of this document which contains

hyperlinks to the body of the Adjuster’s Guide. These hyperlinks are

designed specifically for the adjuster to locate diagnostic and

therapeutic interventions, recommendations, prior authorization

requirements, time parameters, and other important notes.

As a claims adjuster, you are often the first point of contact when a medical

provider requests an intervention that lies outside of the guidelines. There are a

several considerations to keep in mind.

a. First, determine whether the requested service requires prior

authorization, as time requirements are very stringent. The prior

authorization procedure can be found under Rule 16, 16-9, 16-10, and

16-11.

b. In considering payment of the procedure the first question that should

be posed to the physician is whether the requested treatment is

expected to improve function, such as return-to-work, or activities of

daily living? The reader must keep in mind two of the Division’s

Guidelines Principles: Positive Patient Response; and Surgical

Interventions (if surgery is under consideration).

It is appropriate for the director or an administrative law judge to consider the

medical treatment guidelines adopted under section 8-42-101(3) in determining

whether certain medical treatment is reasonable, necessary, and related to an

industrial injury or occupational disease. However, the director or administrative

law judge is not required to utilize the medical treatment guidelines as the sole

basis for such determinations. C.R.S. 8-43-201 (2)

If you would like to give feedback on this guide, please visit

https://www.surveymonkey.com/r/WYMFTS7.

Table of Contents

Initial Diagnostic Procedures ..................................................................... 6

Follow-Up Diagnostic Imaging and Testing Procedures .......................... 8

Note: Specific Diagnostic Injections Included Here ......................... 10

Therapeutic Procedures – Non-Operative ............................................... 18

Note: Non-Operative Therapeutic Injections Included Here ............ 21

Therapeutic Procedures – Operative ....................................................... 40

Index ........................................................................................................... 49

General Guidelines Principles .................................................................. 54

INITIAL DIAGNOSTIC PROCEDURES

Imaging is Not Recommended for at least 6 weeks after the initial injury unless it is

necessary prior to a spinal injection or necessary to diagnose conditions such as

fracture, occult cancer, infection, lower extremity weakness, or signs of myelopathy. The

Division recommends the following diagnostic procedures be considered the

responsibility of the workers’ compensation insurer, at least initially. In other words, it is

recommended that the insurer pay the cost of the following diagnostic procedures,

where indicated, for the purpose of evaluating compensability:

History of Present Injury: Taken in temporal proximity to time of injury

Past History: Includes past medical, review of systems, smoking history psychosocial

history, vocational/recreational pursuits

Physical Examination: Should include accepted tests and exam techniques applicable

to the area being examined

Relationship to Work and Other Activity: Includes a statement of the probability that

the illness or injury is medically work-related.

Radiographic Imaging: Suggested indications include:

• History of significant trauma, especially blunt trauma or fall from a height;

• Age over 55 years;

• Suspicion of fracture, dislocation, instability, or objective evidence of neurologic

deficit;

• Unexplained or persistent low back pain for at least 6 weeks or pain that is worse

with rest;

• Localized pain, fever, constitutional symptoms, or history or exam suggestive of

intravenous drug abuse, prolonged steroid use, or osteomyelitis;

• Suspected lesion in the lumbosacral spine due to tumor or systemic illness, such

as a rheumatic/rheumatoid disorder or endocrinopathy. Suspected lesions may

require special views;

• Flexion and extension views to evaluate instability; and

• Past medical history suggestive of pre-existing spinal disease, osteoporosis,

spinal instrumentation, or cancer;

• Optionally, prior to any manipulative treatment.

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Laboratory Testing:

1. Complete blood count (CBC) with differential

2. Blood-glucose level, erythrocyte sedimentation rate (ESR), rheumatoid factor

(RF), anti-nuclear antigen (ANA), human leukocyte antigen (HLA), and C-reactive

protein (CRP),

3. Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid

phosphatase, vitamin D levels;

4. Urinalysis;

5. Liver and kidney function.

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FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES

Imaging Studies: 6 to 8 weeks of treatment is usually an adequate period of time

before an imaging procedure is in order, but clinicians should use judgment in this

regard

Magnetic Resonance Imaging (MRI):

Useful in suspected nerve root compression, myelopathy, masses, infections,

metastatic disease, disc herniation, annular tear, and cord contusion. MRI scanners

compatible with pacemakers are now available.

Specialized MRI Scans:

MRI with 3-dimensional Reconstruction: May be used as a pre-surgical diagnostic

procedure to obtain accurate information of characteristics, location, and spatial

relationships among soft tissue and bony structures.

Dynamic-kinetic MRI of the Spine: Not Recommended. Enables upright, weight

bearing patient positioning.

Contrast MRI: Usually required for those with prior lumbar surgery, possible infection,

possible malignancy, or tumor.

Computed Axial Tomography (CT): Visualization of bone and evaluation of bony

masses.

Myelography: Injection of radiopaque material into the spinal subarachnoid space, with

x-rays then taken to define anatomy. May be a pre-surgical diagnostic procedure.

Indications include:

• when CT/MRI are unavailable;

• when CT or MRI is contraindicated;

• when other tests prove non-diagnostic in the surgical candidate.

CT Myelogram:

• multiple prior operations,

• tumorous conditions,

• or those that cannot have MRIs due to implants, etc.

Lineal Tomography: Infrequently used. May be helpful in the evaluation of bone

surfaces, bony fusion, or pseudarthrosis.

Bone Scan (Radioisotope Bone Scanning): May be useful in diagnosing

metastatic/primary bone tumors, occult or stress fractures, osteomyelitis, infection, and

other inflammatory lesions, but it cannot distinguish between these conditions.

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Other Radioisotope Scanning: Utilized for localizing infection or inflammation and is

usually not used for the lumbar spine.

Dynamic [Digital] Fluoroscopy: Not recommended for use in the diagnosis of lumbar

instability.

Electrodiagnostic Testing:

Electromyography (EMG), Nerve Conduction Studies (NCS): May be useful for patients

with suspected neural involvement.

Portable Automated Electrodiagnostic Device (also known as Surface EMG): Not a

substitute for conventional diagnostic testing in clinical decision-making, and therefore,

is Not Recommended.

Somatosensory Evoked Potential (SSEP): Not Recommended to identify

radiculopathy. It may be used to evaluate myelopathy and other rare neurological

disorders, such as neurogenic bladder and sexual dysfunction.

Current Perception Threshold (CPT) Evaluation: Not Recommended as a diagnostic

tool.

Large Array Surface Electromyography: Not Recommended

Surface EMG in combination with Range of Motion and/or Functional Capacity

Evaluation, and/or a Comprehensive Muscular Activity Profile: Not Recommended as a

diagnostic tool and cannot distinguish malingering from sub-maximal effort for other

reasons, such as fear/avoidance behavior.

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Specific Diagnostic Injections

General Notes for all Diagnostic Injections:

Diagnostic injections may be useful in localizing the source of pain:

• Indications: Since these procedures are invasive, less invasive or non-invasive

procedures should be considered first. All patients who undergo spinal diagnostic

injections should have had an MRI or CT scan at some point during treatment.

• Informed decision making should be documented.

• Special Requirements for Spinal Diagnostic Injections: Since multi-planar

fluoroscopy during procedures is required to document technique and needle

placement, an experienced physician should perform procedures.

• There should be pain relief of approximately 80% demonstrated by pre and post

Visual Analog Scale (VAS) scores. Documentation of functional changes is

required. Patient-completed pain diary must be part of the medical record.

Indications for Epidural Spinal Injections:

Needle Placement: Multi-planar fluoroscopic imaging is required for all epidural steroid

injections. Injection of contrast dye to assure correct needle placement is required to

verify the flow of medication. Permanent images are required to verify needle

placement.

1. When a patient with radicular findings due to herniated disc meets all of the

indications for surgery at approximately 6-8 weeks post active therapy, one

epidural may be attempted at the patient’s discretion.

2. For rare, acute ruptured (herniated) disc with clear objective radiculopathy if,

after one to two weeks of initial oral analgesic and conservative treatment; the

patient:

• has continued pain interfering with most ADL function; and

• is unable to tolerate the required movements to participate in therapy; and

• has pain greater in the leg than in the back, generally of 7 or greater on a

VAS scale of 10; and

• has pain following a correlated radicular dermatome; and

• there is a herniated disc on the MRI at the level of subjective and objective

findings;

• and has either:

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 dural tension signs of straight leg raising or slump test resulting in

radicular symptoms correlating with imaging pathology; and/or

 one of the following documented, reproducible findings, which correlates

with the suspected nerve root impingement:

 Decreased reflexes, or

 Radicular sensation deficits, or

 Motor weakness on testing.

3. Patients with Spinal Stenosis:

Patients with radicular findings: If patient has documented spinal stenosis,

has completed 6-8 weeks of active therapy, has persistent radicular findings

and difficulty with some activities, thus meeting criteria for surgical

intervention, patient may have one diagnostic injection. Early surgical

consultation is encouraged whenever the patient remains symptomatic after

conservative therapy. If patient does not wish to have a surgical intervention

two additional injections may be provided if original diagnostic intervention

was successful per guideline standards.

Patients with claudication: Patient has documented spinal stenosis,

completed 6-8 weeks of active therapy, has persistent claudication symptoms

and difficulty with some activities, thus meeting criteria for surgical

intervention, patient may have one diagnostic injection. Patients who have

any objective neurologic findings should proceed as the above patient with

radicular findings for whom an early surgical consultation is recommended.

Those who have mild claudication, or moderate or severe claudication and

who do not desire surgery, may continue to receive up to 2 additional

injections if the original diagnostic intervention was successful per guideline

standards.

 Time to produce effect for all epidural injections: Less than 30 minutes for

local anesthetic.

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Medial Branch Blocks:

A separate comparative medial branch block on a different date should be performed to

confirm the level of involvement.

Needle Placement: Multi-planar fluoroscopic imaging is required for all medial branch

blocks injections. Injection of contrast dye to assure correct needle placement is

required to verify the flow of medication. Permanent images are required to verify

needle placement.

Indications: Individuals should have met all of the following indications:

• Physical exam findings consistent with facet origin pain, and

• At least 3 months of pain, unresponsive to 6-8 weeks of conservative therapies,

including manual therapy, and

• A psychosocial screening (e.g., thorough psychosocial history, screening

questionnaire) with treatment as appropriate.

 Frequency and Maximum Duration: May be repeated once for comparative

blocks. Limited to 2 anatomic facet levels or 3 medial branch levels.

Frequency and Maximum Duration: May be repeated once for comparative blocks.

Limited to 2 anatomic facet levels or 3 medial branch levels.

Sacroiliac Joint Injection:

Needle Placement: Multi-planar fluoroscopic imaging is required for all steroid

injections. Injection of contrast dye to assure correct needle placement is required to

verify the flow of medication. Permanent images are required to verify needle placement

Indications: Primarily diagnostic to rule out sacroiliac joint dysfunction versus other

pain generators. Intra-articular injection can be of value in diagnosing the pain

generator. To qualify for an injection the patient must have at least 3 positive physical

exam maneuvers (e.g. Patrick’s sign, Faber’s test, Ganslen, distraction or gapping, or

compression test).

 Time to Produce Effect: Up to 30 minutes for local anesthetic.

 Frequency and Maximum Duration: 1 injection. It is recommended that morning

cortisol levels are checked prior to the 3rd or 4th steroid injection..

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Zygapophyseal (Facet) Blocks:

Needle Placement: Injection of a contrast dye to assure correct needle placement is

required to verify flow of medication. Permanent images required to verify correct

needle placement.

Indications: Patients with pain 1) suspected to be facet in origin based on exam

findings and 2) affecting activity; OR patients who have refused a rhizotomy and appear

clinically to have facet pain; OR patients who have facet findings with a thoracic

component. Due to the lack of proof that these injections improve outcome, prior

authorization is required. All injections should be preceded by an MRI or a CT scan.

 Time to produce effect: Up to 30 minutes for local anesthetic.

Frequency and Maximum Duration: Once per suspected level, limited to two levels

unilaterally or bilaterally. If radiofrequency neurotomy is being considered, refer to the

medial branch block section. It is recommended that morning cortisol levels are checked

prior to the 3rd or 4th steroid injection..

Personality/Psychological/Psychosocial Evaluation: Psychosocial evaluation should

be performed on patients not making expected progress within 6–12 weeks following

injury.

 Frequency: One time visit for evaluation. If psychometric testing is indicated as a

portion of the initial evaluation, time for such testing should not exceed an

additional two hours of professional time.

Provocation Discography:

Discography is accepted, but rarely indicated. It remains extremely controversial as an

invasive diagnostic procedure to identify or refute a discogenic source of pain for

patients who are surgical candidates for fusion or disc replacement.

Important points related to provocation discography:

• Discograms have a significant false positive rate.

• It is essential that all indications, pre-conditions, special considerations,

procedures, reporting requirements, and results are carefully and specifically

followed.

• Results should be interpreted judiciously.

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• Discography should only be performed by physicians who are experienced and

have been proctored in the technique.

• Informed Decision Making should be documented.

• Should not be performed on those with somatoform disorders.

• Discography should never be the sole indication for surgery.

Indications: Discography may be indicated when a patient has a history of functionally

limiting, unremitting low back pain of greater than four months duration, with or without

leg pain, which has been unresponsive to all conservative interventions and meets all of

the criteria for spinal fusion. Those diagnostic and pre-operative indications for spinal

fusion are:

Diagnostic:

• Neural Arch Defect usually with stenosis or instability: Spondylolytic

spondylolisthesis, congenital unilateral neural arch hypoplasia. It should

be noted that the highest level of success for spinal fusions is when

spondylolisthesis grade 2 or higher is present.

• Segmental Instability: Excessive motion, as in degenerative

spondylolisthesis 4mm or greater, surgically induced segmental instability.

• Primary Mechanical Back Pain/Functional Spinal Unit Failure: Multiple

pain generators objectively involving two or more of the following: (a)

internal disc disruption (poor success rate if more than one disc involved),

(b) painful motion segment, as in annular tears, (c) disc resorption, (d)

facet syndrome, and/or (e) ligamentous tear. Because surgical outcomes

are less successful when there is neither stenosis nor instability, the

requirements for pre-operative indications must be strictly adhered to for

this category of patients.

• Revision surgery for failed previous operation(s) if significant functional

gains are anticipated.

• Other diagnoses: Infection, tumor, or deformity of the lumbosacral spine

that cause intractable pain, neurological deficit, and/or functional disability.

Pre-surgical:

• All pain generators are adequately defined and treated; and

• All physical medicine and manual therapy interventions are completed;

and

• X-ray, MRI, or CT myelography demonstrate spinal stenosis with instability

or disc pathology, requiring decompression that may surgically induce

segmental instability or a positive discogram; and

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• Spine pathology is limited to two levels; and

• Psychosocial evaluation with confounding issues addressed; (required for

all cases except those with degenerative spondylolisthesis with persistent

claudication or radicular leg pain with neurologic signs); and

• For any potential fusion surgery, it is recommended that the injured worker

refrain from smoking for at least six weeks prior to surgery and during the

period of fusion healing. Because smokers have a higher risk of non-union

and higher post-operative costs, it is recommended that insurers cover a

smoking cessation program peri-operatively.

Pre-conditions for provocation discography include all of the following:

1. A patient with functionally limiting, unremitting back and/or leg pain of greater

than four months duration in whom conservative treatment has been

unsuccessful and in whom the specific diagnosis of the pain generator has not

been made apparent on the basis of other non-invasive imaging studies (e.g.,

MRI, CT, plain films, etc.). , the patient should undergo other diagnostic testing

as appropriate in an effort to define the etiology.

2. Prior to consideration of discography, the patient should undergo other diagnostic

testing as appropriate in an effort to define the etiology of the patient's complaint

including psychological evaluation, myelography, CT, and MRI.

3. Psychosocial evaluation has been completed.

4. Patients are considered surgical candidates (e.g., symptoms are of sufficient

magnitude and the patient has been informed of the possible surgical and non-

surgical options that may be available based upon the results of discography).

5. Informed consent regarding the risks and potential diagnostic benefits of

discography has been obtained.

Special Considerations:

• Discography should not be performed by the physician expected to perform the

therapeutic procedure nor by physicians in the same practice. The procedure

should be carried out by an experienced individual who has received specialized

training in the technique of provocation discography.

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• Discography should be performed in a blinded format that avoids leading the

patient with anticipated responses. The procedure should always include one or

more disc levels thought to be normal or non-painful in order to serve as an

internal control.

Reporting of Discography:

All results should be clearly separated in the report from the narrative portion.

 Frequency: One time only.

 Maximum Duration: Repeat discography rarely indicated.

Thermography: no use as diagnostic test for low back pain.

SPECIAL TESTS:

Computer-Enhanced Evaluations: Should not be used alone to determine work

restrictions.

 Frequency: One time for evaluation, one for mid-treatment assessment, and one

at final evaluation.

Functional Capacity Evaluation:

 Frequency: Can be used: (1) initially to determine baseline status; and (2) for

case closure when patient is unable to return to the pre-injury position and further

information is desired to determine permanent work restrictions. Prior

Authorization for FCEs during treatment.

Jobsite Evaluation: Job descriptions provided by employer helpful but do not substitute

for direct observation.

 Frequency: One time with 1-2 additional visits as needed for follow-up per

jobsite.

Vocational Assessment: if the injury is such that the practitioner can easily determine

that the worker will be unable to return to his/her previous occupation, then vocational

assessment at that time may aid in the overall medical management and rehabilitation

of the patient.

 Frequency: One time with additional visits as needed for follow-up.

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Work Tolerance Screening: A determination of an individual's tolerance for performing

a specific job as based on a job activity or task and is generally preferable to a full FCE.

 Frequency: One time for initial screen. May monitor improvements in strength

every 3 to 4 weeks up to a total of 6 visits.

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THERAPEUTIC PROCEDURES – NON-OPERATIVE

For Physical and Occupational Therapy, please see Specific Intervention.

Acupuncture: Credentialed practitioners with experience in evaluation and treatment of

chronic pain must perform acupuncture evaluations. Must be performed by practitioners

with the appropriate credentials in accordance with state and other applicable

regulations. Therefore if not otherwise within professional scope of practice and

licensure, those performing acupuncture must have the appropriate credentials, such as

L.A.c., R.A.c, or Dipl.Ac.

Indications:

Joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical

pain relief, muscle spasm, and scar tissue pain.

Treatment beyond 15 treatments must be documented with respect to need and the

ability to facilitate positive symptomatic and functional gains.

Acupuncture with Electrical Stimulation:

It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway,

muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.

Other Acupuncture Modalities: Acupuncture treatment is based on individual patient

needs and therefore treatment may include a combination of procedures to enhance

treatment effect. Other procedures may include the use of heat, soft tissue

manipulation/massage, and exercise.

Total Time Frames for Acupuncture and Acupuncture with Electrical Stimulation:

Time frames are not meant to be applied to each section separately. The time frames

are to be applied to all acupuncture treatments regardless of the type or combination of

therapies being provided.

Total Time Frames for Acupuncture and Acupuncture with Electrical Stimulation:

 Time to Produce Effect: 3 to 6 treatments.

 Frequency: 1 to 3 times per week.

 Optimum Duration: 1 to 2 months.

 Maximum Duration: 15 treatments.

Treatment beyond 15 treatments must be documented with respect to need and the

ability to facilitate positive symptomatic and functional gains. All treatments should be

accompanied by active therapy.

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Biofeedback: a form of behavioral medicine that helps patients learn self-awareness

and self-regulation skills for the purpose of gaining greater control of their physiology,

such as muscle activity, brain waves, and measures of autonomic nervous system

activity Other applications: 1) training to improve self-management of pain, 2) anxiety, 3)

panic, 4) anger or emotional distress, 5) opioid withdrawal, 6) insomnia/sleep

disturbance, and 7) other central and autonomic nervous system imbalances.

If the patient has not been previously evaluated, a psychological evaluation should be

performed prior to beginning biofeedback treatment for chronic pain.

Psychologists or psychiatrists who provide psycho-physiological therapy, which

integrates biofeedback with psychotherapy, should be either Biofeedback Certification

International Alliance (BCIA) certified or practicing within the scope of their training. All

non-licensed health care providers of biofeedback for chronic pain patients must be

BCIA certified and shall have their biofeedback treatment plan approved by the

authorized treating psychologist or psychiatrist.

Biofeedback treatment must be done in conjunction with the patient’s psychosocial

intervention. Biofeedback may also be provided by health care providers who follow a

set treatment and educational protocol. Such treatment may utilize standardized

material or relaxation tapes.

Electromyogram (EMG): for self-management of pain and stress reactions involving

muscle tension.

Skin Temperature: for self-management of pain and stress reactions, especially

vascular headaches.

Respiration Feedback (RFB): For self-management of pain and stress reactions via

breathing control.

Respiratory Sinus Arrhythmia (RSA): for self-management of pain and stress

reactions via synchronous control of heart rate and respiration. RSA is a benign

phenomenon that consists of a small rise in heart rate during inhalation, and a

corresponding decrease during exhalation.

Heart Rate Variability (HRV): for self-management of stress via managing cardiac

reactivity.

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Electrodermal Response (EDR): for self-management of stress involving palmar

sweating or galvanic skin response.

Electroencephalograph (EEG, QEEG): for self-management of various psychological

states by controlling brainwaves.

Time Parameters for Biofeedback Sessions:

 Time to Produce Effect: 3 to 4 sessions.

 Frequency: 1 to 2 times per week.

 Optimum Duration: 6 to 8 sessions.

 Maximum Duration: 10 to 12 sessions. Treatment beyond 12 sessions must be

documented with respect to need, expectation, and ability to facilitate positive

symptomatic and functional gains.

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Specific Therapeutic Injections

For all therapeutic injections:

• Informed decision making should be documented.

• Morning cortisol measurements may be ordered prior to repeat steroid injections

or initial spinal steroid injection when the patient has received multiple previous

steroid joint injections.

• Documentation of functional results is required. •There should be pain relief of

approximately 80% demonstrated by pre and post Visual Analog Scale (VAS)

scores. Documentation of functional changes is required. Patient-completed pain

diary must be part of the medical record.

Spinal Therapeutic Injections:

These should only be used after diagnostic injections & imaging studies established

pathology which has not clinically improved after active engagement (6-8 weeks) of

physical therapy and in patients who otherwise qualify for more invasive procedures and

may need injections because they do not wish to proceed to surgery. The purpose of

spinal injections is to facilitate active therapy by providing short-term relief through

reduction of pain and inflammation. Patients must commit to continuing appropriate

exercise with functionally directed rehabilitation usually beginning within 7 days, at the

injectionist’s discretion. Active treatment, which patients should have had prior to

injections, frequently requires a repeat of sessions previously ordered.

Special Requirements for Spinal Injections: Since multi-planar fluoroscopy during

procedures required to document technique and needle placement, an experienced

physician should perform the procedure. Injection of contrast dye to assure correct

needle placement is required to verify the flow of medication. Permanent images

required to verify needle placement. Unnecessary fluoroscopy should be avoided due to

the radiation exposure contributing to cancer risk.

• Since these procedures are invasive, less invasive or non-invasive procedures

should be considered first. All patients who undergo spinal diagnostic injections

should have had an MRI or CT scan at some point during treatment.

• Informed decision making should be documented.

• Special Requirements for Spinal Diagnostic Injections: Since multi-planar

fluoroscopy during procedures is required to document technique and needle

placement, an experienced physician should perform procedures.

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• Documentation of functional results is required. There should be pain relief of

approximately 80% demonstrated by pre and post Visual Analog Scale (VAS)

scores. Documentation of functional changes is required. Patient-completed pain

diary must be part of the medical record.

Epidural Steroid Injection (ESI): may include caudal, transforaminal, or interlaminar

injections.

Needle Placement: Multi-planar fluoroscopic imaging is required for all epidural steroid

injections. Injection of contrast dye to assure correct needle placement is required to

verify the flow of medication. Permanent images are required to verify needle

placement.

Indications: The following sets of patients may have epidural injections.

1. When a patient: with radicular findings due to herniated disc meets all of the

indications for surgery at approximately 6-8 weeks post active therapy, one

epidural may be attempted at the patient’s discretion.

2. For rare, acute ruptured: (herniated) disc with clear objective radiculopathy if,

after one to two weeks of initial oral analgesic and conservative treatment; the

patient:

• has continued pain interfering with most ADL function; and

• is unable to tolerate the required movements to participate in therapy; and

• has pain greater in the leg than in the back, generally of 7 or greater on a

VAS scale of 10; and

• has pain following a correlated radicular dermatome; and

• there is a herniated disc on the MRI at the level of subjective and objective

findings;

• and has either:

 dural tension signs of straight leg raising or slump test resulting in

radicular symptoms correlating with imaging pathology; and/or

 one of the following documented, reproducible findings, which correlates

with the suspected nerve root impingement:

 Decreased reflexes, or

 Radicular sensation deficits, or

 Motor weakness on testing.

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3. Patients with Spinal Stenosis:

Patients with radicular findings: If patient has documented spinal stenosis,

has completed 6-8 weeks of active therapy, has persistent radicular

findings and difficulty with some activities, thus meeting criteria for surgical

intervention, patient may have one diagnostic injection. Early surgical

consultation is encouraged whenever the patient remains symptomatic

after conservative therapy. If patient does not wish to have a surgical

intervention two additional injections may be provided if original diagnostic

intervention was successful per guideline standards.

Patients with claudication: Patient has documented spinal stenosis,

completed 6-8 weeks of active therapy, has persistent claudication

symptoms and difficulty with some activities, thus meeting criteria for

surgical intervention, patient may have one diagnostic injection. Patients

who have any objective neurologic findings should proceed as the above

patient with radicular findings for whom an early surgical consultation is

recommended. Those who have mild claudication, or moderate or severe

claudication and who do not desire surgery, may continue to receive up to

2 additional injections if the original diagnostic intervention was successful

per guideline standards.

Time Parameters for Epidural Steroid Injections:

 Light sedation and pain relief may be needed for some patients requiring

therapeutic injection.

 Time to produce effect: Local anesthetic, less than 30 minutes.

 Frequency: One or more divided levels can be injected in one session. Whether

injections are repeated depends upon the patient’s response to the previous

injection. There is no role for a “series” of 3 injections. Each injection should be

judged on the actual functional outcome. Patients with existing osteoporosis or

other risk factors for osteoporosis should rarely receive epidural steroid injections

(refer to complications section). Subsequent injections may occur after 1 to 2

weeks if patient response has been favorable. Injections can be repeated after a

hiatus of six months if the patient has demonstrated functional gain and pain

returns or worsens. If the first injection does not provide a diagnostic response of

temporary and sustained pain relief (approximately 80% lasting between 2 and 6

weeks) substantiated by accepted pain scales and improvement in function

documented preferably by a therapist or non-injectionist authorized physician,

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similar injections should not be repeated. Patients should complete a pain diary

over several days post injection.

 Optimum duration: Usually 1 to 3 injection(s) over a period of six months

depending upon each patient’s response and functional gain. Most patients will

not require 3 injections within 6 months and injections should not be repeated

without documented functional change.

 Maximum duration: Up to 4 per year. It is recommended that morning cortisol

levels are checked prior to the 3rd or 4th steroid injection. Patients should be

reassessed after each injection for evidence of functional improvement and an

80% improvement in pain (as measured by accepted pain scales).

Intradiscal Steroid Injections: Not Recommended.

Intradiscal injections of other substances such as bone marrow, stem cells, are Not

Recommended

Sacroiliac Joint Injection:

Indications:

Primarily diagnostic to rule out sacroiliac joint dysfunction versus other pain generators.

Intra-articular injection can be of value in diagnosing the pain generator. To qualify for

an injection the patient must have at least 3 positive physical exam maneuvers (e.g.

Patrick’s sign, Faber’s test, Ganslen, distraction or gapping, or compression test).

 Time to Produce Effect: Up to 30 minutes for local anesthetic.

 Frequency and Maximum Duration: 1 injection. It is recommended that morning

cortisol levels are checked prior to the 3rd or 4th steroid injection.

Transforaminal Injection with Etanercept: Not Recommended.

Zygaphophyseal (Facet) Injections:

Indications:

• Pain suspected to be facet in origin based on exam findings and 2) affecting

activity;

• OR patients who have refused a rhizotomy and appear clinically to have facet

pain;

• OR patients who have facet findings with a thoracic component.

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 Time to produce effect: Up to 30 minutes for local anesthetic; corticosteroid

up to 72 hours.

 Frequency: 1 injection per level with a diagnostic response. A well-controlled,

large retrospective cohort study found that individuals with the same risk

factors for osteoporotic fractures were 20% more likely to suffer such a

lumbar fracture if they had an epidural steroid injection. The risk increased

with multiple injections. Thus the risk must be carefully discussed with the

patient, particularly for patients over 60, and repeat injections should be

generally avoided unless the functional goals to be reached outweigh the risk

for future fracture. Patients with existing osteoporosis or other risk factors for

osteoporosis should rarely receive steroid injections. It is unknown whether

facet steroid injections contribute to increased vertebral fractures, however

appropriate caution should be taken for at risk patients as described above.

Facet injections may be repeated if they result in increased documented

functional benefit for at least 3 months and at least an 80% initial

improvement in pain scales as measured by accepted pain scales (such as

VAS).

 Optimum duration: 2 injections for each applicable joint per year. Not to

exceed two joint levels.

 Maximum Duration: 2 per level per year only when at least 3 months of

functional benefit is documented. Prior authorization must be obtained for

injections beyond two levels. Recommended that morning cortisol levels are

checked prior to the 3rd or 4th steroid injection.

Other Injections

Botulinum Toxin Injections: Used to temporarily weaken or paralyze muscles. Not

Recommended for use for low back pain or other myofascial trigger points. May be

indicated in cases of chronic piriformis syndrome established by 3 trigger point

injections and unrelieved by other therapy. Patients need to have a marked but

temporary improvement (80% or better), verified with demonstrated improvements in

functional activities, from the 3 separate trigger point injections.

Epiduroscopy and Epidural Lysis of Adhesions: Not Recommended.

Epiduroscopy-Directed Steroid Injections: Not Recommended

Prolotherapy: Also known as sclerotherapy. Not Generally Recommended for

patients with non-specific low back pain.

• Informed decision making must be documented.

• Patients must be willing to perform engage in active therapy and manual therapy

needed to recover.

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Indications for Prolotherapy:

• Insufficient functional progress after 6 months of an appropriate program that

includes a combination of active therapy, manual therapy and psychological

evaluation and treatment.

• Documented relief from previously painful maneuvers (e.g., Patrick’s or Faber’s

test, Gaenslen, distraction or gapping, and compression test).

• A positive result from SI joint diagnostic block including improvement in at least

three previously identified physical functions.

• At the minimum, manual therapy, performed weekly per guideline limits by

professional specializing in manual therapy (such as a doctor of osteopathy or

chiropractor)

Radio Frequency Ablation - Dorsal Nerve Root Ganglion: Not Recommended

Radio Frequency (RF) Denervation - Medial Branch Neurotomy/Facet Rhizotomy:

Several Notes:

• Cooled radiofrequency (A type of RF neurotomy) generally Not Recommended.

• This procedure is Not Recommended for patients with multiple pain generators

or involvement in more than 3 levels of medial branch nerves.

• Needle Placement: Multi-planar fluoroscopic imaging is required for all epidural

steroid injections. Injection of contrast dye to assure correct needle placement is

required to verify the flow of medication. Permanent images are required to verify

needle placement.

• All should continue appropriate exercise with functionally-directed rehabilitation.

• Informed Decision Making must be documented

• Post-procedure Active Therapy-patients unwilling to participate in active therapy

should not have the procedure.

Indications: All of the following:

• Physical exam findings consistent with facet origin pain, and

• Positive response to controlled medial branch blocks, and

• At least 3 months of pain, unresponsive to 6-8 weeks of conservative therapies,

including manual therapy, and

• A psychosocial screening (e.g., thorough psychosocial history, screening

questionnaire) with treatment as appropriate has been undergone.

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Time Parameters:

 Requirements for Repeat Radiofrequency Medial Branch Neurotomy: Successful

procedure usually provides from six to eighteen months of relief.

 Due to denervation of spinal musculature repeated rhizotomies should be limited.

Refer to the Division’s Chronic Pain Disorder Medical Treatment Guidelines.

 Before a repeat RF Neurotomy is done, a confirmatory medial branch injection

should be performed if the patient’s pain pattern presents differently than the

initial evaluation. In occasional patients, additional levels of RF neurotomy may

be necessary. The same indications and limitations apply.

Radio Frequency Denervation - Sacro-iliac (SI) Joint Cooled:

Needle Placement:

• Needle Placement: Multi-planar fluoroscopic imaging is required for all epidural

steroid injections. Injection of contrast dye to assure correct needle placement is

required to verify the flow of medication. Permanent images required to verify

needle placement.

Indications:

• Physical exam findings of at least 3 positive physical exam maneuvers (e.g.

Patrick’s sign, Faber’s test, Ganslen distraction or gapping, or compression test).

Insufficient functional progress after 6 months of appropriate program that

includes combination of active therapy, manual therapy and psychological

evaluation and treatment.

• Two fluoroscopically guided comparative blocks of the appropriate branches with

differing anesthetics, 80% relief of pain for the appropriate time periods, and

functional improvement must be documented to meet standards for control

blocks.

• Informed decision making must be documented including a discussion of

possible complications and likelihood of success.

 Requirements for Repeat Radiofrequency SI Joint Neurotomy: In some cases

pain may recur. Successful RF Neurotomy usually provides from six to

eighteen months of relief. Repeat neurotomy should only be performed if the

initial procedure resulted in improved function for 6 months.

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Transdiscal Biacuplasty: Not Recommended.

Trigger Point Injections and Dry Needling Treatment: To relieve myofascial pain and

facilitate active therapy and stretching of affective areas. An adjunct to, combined other

treatments because of active therapy.

 Time to produce effect: Local anesthetic 30 minutes; 24 to 48 hours for no

anesthesia.

 Frequency: Weekly. Suggest no more than 4 injection sites per session per week

to avoid significant post-injection soreness.

 Optimum duration: 4 Weeks.

 Maximum duration: 8 weeks. Occasional patients may require 2 to 4 repetitions

of trigger point injection series over a 1 to 2 year period.

Interdisciplinary Rehabilitation Programs:

In general these programs evaluate and treat multiple and sometimes irreversible

conditions, including, but not limited to: painful musculoskeletal, neurological, and other

chronic pain conditions and psychological issues; drug dependence, abuse, or

addiction; high levels of stress and anxiety; failed surgery; and pre-existing or latent

psychopathology. The Division recommends consideration of referral to an

interdisciplinary program within six months post-injury in patients with delayed recovery,

unless successful surgical interventions or other medical and/or psychological treatment

complications intervene.

Formal Programs include the following:

1. Interdisciplinary Pain Rehabilitation

2. Occupational Rehabilitation

3. Spinal Cord Programs

Interdisciplinary Pain Rehabilitation:

 Time to Produce Effect: 3 to 4 weeks.

 Frequency: Full time programs – No less than 5 hours per day, 5 days per week;

part-time programs – 4 hours per day, 2–3 days per week.

 Optimum Duration: 3 to 12 weeks at least 2–3 times a week. Follow-up visits

weekly or every other week during the first 1 to 2 months after the initial program

is completed.

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 Maximum Duration: 4 months for full-time programs and up to 6 months for part-

time programs. Periodic review and monitoring thereafter for 1 year, AND

additional follow-up based on the documented maintenance of functional gains.

Interdisciplinary Occupational Rehabilitation:

 Time to Produce Effect: 2 weeks.

 Frequency: 2 to 5 visits per week, up to 8 hours per day.

 Optimum Duration: 2 to 4 weeks.

 Maximum Duration: 6 weeks. Participation in a program beyond 6 weeks must be

documented with respect to need and the ability to facilitate positive symptomatic

and functional gains.

Interdisciplinary Spinal Cord Programs:

 Timeframe durations for any spinal cord program should be determined based on

the extent of the patient’s injury and at the discretion of the rehabilitation

physician in charge.

Informal Interdisciplinary Team Programs: Different from a formal program in that it

involves lower frequency and intensity of services/treatment. Informal rehabilitation is

geared toward those patients who do not need the intensity of service offered in a

formal program or who cannot attend an all-day program due to employment, daycare,

language, or other barriers.

 Time to Produce Effect: 3 to 4 weeks.

 Frequency: Full-time programs – No less than 5 hours per day, 5 days per week;

 Part-time programs – 4 hours per day for 2–3 days per week.

 Optimum Duration: 3 to 12 weeks at least 2–3 times a week. Follow-up visits

weekly or every other week during the first 1 to 2 months after the initial program

is completed.

Maximum Duration: 4 months for full-time programs and up to 6 months for part-time

programs. Periodic review and monitoring thereafter for 1 year, and additional follow-up

based upon the documented maintenance of functional gains.

Use of medications will vary widely due to the spectrum of injuries, from simple strains

to post-surgical healing. A thorough medication history, including use of alternative and

over-the-counter medications, should be performed at the time of the initial visit and

updated periodically. Treatment for pain control is initially accomplished with

acetaminophen and/or NSAIDs.

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Acetaminophen:

 Optimum Duration: 7 to 10 days.

 Maximum Duration: Extended use as indicated on a case-by-case basis. Use of

this substance long-term (for 3 days per week or greater) may be associated with

rebound pain upon cessation.

Antibiotics for chronic pain secondary to disc herniation:

Indications:

• Modic type 1 changes at adjacent vertebra at the time of treatment initiation.

• 6 to 24 months of pain with an average of 6/10 (calculate average by using the

worst reported pain within the last 2 weeks, current pain, and usual pain in the

last 2 weeks)

• Pain interferes with function, e.g., not able to return to full duty

• Use of chronic opioids to control pain

• No contraindications to antibiotic use.

Intravenous Steroids: The benefits of preventing neurological damage from acute

spinal cord compression in an emergent situation generally outweigh the risks of

pharmacologic side effects from steroids.

Glucosamine: Not Recommended for chronic lumbar spinal or non-joint pain.

Muscle Relaxants:

Indications:

Appropriate for muscle spasm with pain.

Chronic use of benzodiazepines or any muscle relaxant is Not Recommended due to

their habit-forming potential, seizure risk following abrupt withdrawal, and documented

contribution to deaths of patients on opioids due to respiratory depression. A number of

muscle relaxants interact with other medications.

 Optimum Duration: 1 week.

 Maximum Duration: 2 weeks (or longer if used only at night).

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Useful for pain and inflammation.

 Optimal Duration: 1 week.

 Maximum duration: 1 year. Use of these substances long-term (3 days per week

or greater) is associated with rebound pain upon cessation.

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Non-Selective Non-Steroidal Anti-Inflammatory Drugs: Selective Cyclo-oxygenase-2

(COX-2) Inhibitors:

 Optimal Duration: 7 to 10 days.

 Maximum Duration: Chronic use is appropriate in individual cases. Use of these

substances long-term (3 days per week or greater) is associated with rebound

pain upon cessation.

Opioids:

 Optimum Duration: 3 to 7 days.

 Maximum Duration: 2 weeks. Use beyond 2 weeks is acceptable in appropriate

cases. Refer to the Division’s Chronic Pain Disorder Medical Treatment

Guidelines, which give a detailed discussion regarding medication use in chronic

pain management. Use beyond 30 days after non-traumatic injuries, or 6 weeks

post-surgery after the original injury or post operatively is Not Recommended. If

necessary the physician should access the Colorado Prescription Drug

Monitoring Program (PDMP) and follow recommendations in Chronic Pain

Guideline. This system allows the prescribing physician to see most of the

controlled substances prescribed by other physicians for an individual patient.

Oral Steroids: Have Limited Use But Accepted In Cases Requiring A Potential

Inflammatory Effect. Not Generally Recommended.

Psychotropic/Anti-Anxiety/Hypnotic Agents:

Indications: May be useful for mild and chronic pain, dysesthesias, sleep disorders,

depression. However, Not Generally Recommended.

 Optimum Duration: 1 to 6 months.

 Maximum Duration: 6 to 12 months, with monitoring.

Tramadol: Not Generally Recommended for those with prior opioid addiction

Indications: May be useful in relief of mild low back pain

 Optimum Duration: 3 to 7 days.

 Maximum Duration: 2 weeks. Use beyond 2 weeks is acceptable in appropriate

cases.

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ORTHOTICS:

• Foot Orthoses and Inserts: Accepted for spinal disorders due to aggravated

mechanical abnormalities such as leg-length discrepancy, scoliosis, or lower

extremity misalignment. Shoe inserts may be effective. A trial of taping may be

performed prior to evaluate potential effectiveness.

• Lumbar Support Devices: Includes backrests for car seats and chairs. May

provide relief for and movement reduction in chronic back problems.

• Lumbar Corsets and Back Belts: Have limited application. Injured worker

should be advised of potential harm of using support for a period of time greater

than prescribed.

• Lumbosacral Bracing: Commonly used for post-fusion, scoliosis, vertebral

fractures. Sacroiliac belts may be indicated for short periods.

Education/INFORMED DECISION MAKING:

 Frequency: Should occur at every visit.

PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION:

Psychosocial treatment is recommended as an important component in the total

management of a patient with chronic low back pain and should be implemented as

soon as the problem is identified.

Cognitive-Behavioral Therapy (CBT) refers to a group of psychological therapies that

are sometimes referred to by more specific names, such as Rational Emotive Behavior

Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and

Dialectic Behavior Therapy. Variations of CBT methods can be used to treat a variety of

conditions, including chronic pain, depression, anxiety, phobias, and post-traumatic

stress disorder (PTSD).

Cognitive Behavioral Therapy (CBT) or Similar Treatment:

 Time to Produce Effect: 6 to 8 1–2 hour session, group or individual (1-hour

individual or 2-hour group).

 Maximum Duration: 16 sessions.

Before CBT is done, the patient must have a full psychological evaluation. The CBT

program must be done under the supervision of a PhD, PsyD, EdD, or Psychiatric

MD/DO.

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Other Psychological/Psychiatric Interventions:

 Time to Produce Effect: 6 to 8 weeks.

 Frequency: 1 to 2 times weekly for the first 2 weeks (excluding hospitalization, if

required), decreasing to 1 time per week for the second month. Thereafter, 2 to 4

times monthly with the exception of exacerbations, which may require increased

frequency of visits. Not to include visits for medication management

 Optimum Duration: 2 to 6 months.

 Maximum Duration: 6 months. Not to include visits for medication management.

For select patients, longer supervised psychological/psychiatric treatment may be

required, especially if there are ongoing medical procedures or complications. If

counseling beyond 6 months is indicated, the management of psychosocial risks

or functional progress must be documented. Treatment plan/progress must show

severity.

RESTRICTION OF ACTIVITIES: Patients should be educated regarding the detrimental

effects of immobility versus the efficacious use of limited rest periods. Adequate rest

allows patient to comply with active treatment and benefit from rehabilitation programs.

In addition, complete work cessation should be avoided, if possible, since it often further

aggravates the pain presentation and promotes disability. Modified return to work is

almost always more efficacious and rarely contraindicated in the vast majority of injured

workers with low back pain.

RETURN TO WORK: Returning to work and/or work-related activities whenever

possible is one of the major components in low back pain management and

rehabilitation. Return to work is a subject that should be addressed by each workers’

compensation provider at the first meeting with the injured employee and updated at

each additional visit. A return-to-work format should be part of a company’s health plan,

knowing that return to work can decrease anxiety, reduce the possibility of depression,

and reconnect the worker with society. Because a prolonged period of time off work will

decrease the likelihood of return to work, the first weeks of treatment are crucial in

preventing and/or reversing chronicity and disability mindset.

Job History Interview: The authorized treating physician should perform a job history

interview at the time of the initial evaluation and before any plan of treatment is

established.

Coordination of Care: Management of the case is a significant part of return to work

and may be the responsibility of the authorized treating physician, occupational health

nurse, risk manager, or others.

Communication: This is essential between the patient, authorized treating physician,

employer, and insurer.

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Establishment of Return-to-Work Status: Return to work for persons with chronic

pain should be considered therapeutic, assuming that work is not likely to aggravate the

basic problem or increase the discomfort. In most cases of chronic pain, the worker may

not be currently working or even employed.

Establishment of Activity Level Restrictions:

• A formal job description for the injured worker is necessary to identify physical

demands at work and assist in the creation of modified duty.

• A jobsite evaluation may be utilized to identify applicable tasks and the number of

hours that may be worked per day.

• Occupationally focused functional capacity evaluation may be necessary

• Between one and three days after the evaluation, there should be a follow-up

evaluation by the treating therapist and/or the authorized treating physician to

assess the patient’s status. Work restrictions assigned by the authorized treating

physician may be temporary or permanent.

• Case manager should continue to seek out modified work until restrictions

become less cumbersome or as the worker’s condition improves or deteriorates.

• Rehabilitation and Return to Work: As part of rehabilitation, every attempt should

be made to simulate work activities so that the authorized treating physician may

promote adequate job performance. The use of ergonomic or adaptive

equipment, therapeutic breaks, and interventional modalities at work may be

necessary to maintain employment.

THERAPY – ACTIVE: The following active therapies are listed in alphabetical order:

Activities of Daily Living (ADLs):

 Time to Produce Effect: 4 to 5 treatments.

 Frequency: 3 to 5 times per week.

 Optimum Duration: 4 to 6 weeks.

 Maximum Duration: 6 weeks.

Aquatic Therapy:

• Cannot tolerate active land-based or full-weight bearing therapeutic procedures;

• Require increased support in the presence of proprioceptive deficit (tendency to

fall or collapse);

• Are at risk of compression fracture due to decreased bone density;

• Have symptoms that are exacerbated in a dry environment;

• Would have a higher probability of meeting active therapeutic goals than in a dry

environment.

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The pool should be large enough to allow full extremity range of motion and fully erect

posture. Aquatic vests, belts and other devices can be used to provide stability,

balance, buoyancy, and resistance.

 Time to Produce Effect: 4 to 5 treatments.

 Frequency: 3 to 5 times per week.

 Optimum Duration: 4 to 6 weeks.

 Maximum Duration: 8 weeks.

A self-directed program is recommended after the supervised aquatics program has

been established.

Back Schools: When prescribed, back schools should be initiated in the early phases

of treatment.

Functional Activities: Therapeutic activity to enhance mobility, body mechanics,

employability, coordination, balance, and sensory motor integration.

 Time to Produce Effect: 4 to 5 treatments.

 Frequency: 3 to 5 times per week.

 Optimum Duration: 4 to 6 weeks.

 Maximum Duration: 6 weeks.

Functional Electrical Stimulation: It may be indicated for muscle atrophy in the limbs

due to a radiculopathy.

 Time to Produce Effect: 2 to 6 treatments.

 Frequency: 3 times per week.

 Optimum Duration: 8 weeks.

 Maximum Duration: 8 weeks. If beneficial, provide with home unit.

Neuromuscular Re-education:

Indications include the need to promote neuromuscular responses through carefully

timed proprioceptive stimuli, elicit and improve motor activity in patterns similar to

normal neurologically developed sequences, and improve neuromotor response with

independent control. There are multiple types of neuromuscular education. Two specific

types are described: Spinal Stabilization; Directional Preference:

Total Time Frames for all Neuromuscular re-education

 Time to Produce Effect: 4 to 8 treatments.

 Frequency: 3 to 5 times per week.

 Optimum Duration: 4 to 8 weeks.

 Maximum Duration: 8 weeks

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Therapeutic Exercise: Indications include the need for cardiovascular fitness, reduced

edema, improved muscle strength; improved connective tissue strength and integrity,

increased bone density, promotion of circulation to enhance soft tissue healing,

improvement of muscle recruitment, improved proprioception, and coordination, and

increased range of motion.

 Time to Produce Effect: 2 to 6 treatments.

 Frequency: 3 to 5 times per week.

 Optimum Duration: 4 to 8 weeks and concurrent with an active daily home

exercise program.

 Maximum Duration: 8 to 12 weeks of therapist oversight. Home exercise should

continue indefinitely.

Other movement therapy which may be included in therapeutic exercise includes yoga

and other alternative exercise therapy supervised by a physician or other appropriate

health care professional.

 Time to Produce Effect: 6 to 8 private or small group sessions.

 Frequency: 3 to 5 times per week with daily home practice.

 Optimum Duration: 6 to 8 weeks of classes and concurrent with an active daily

home exercise program.

 Maximum Duration: 8 to 10 weeks of therapist oversight. Home exercise should

continue indefinitely.

Work Conditioning: It should be initiated when imminent return of a patient to modified

or full duty is not an option, but the prognosis for returning the patient to work at

completion of the program is at least fair to good.

 Length of Visit: 1 to 2 hours per day.

 Frequency: 2 to 5 visits per week.

 Optimum Duration: 2 to 4 weeks.

 Maximum Duration: 6 weeks. Participation in a program beyond six weeks must

be documented with respect to need and the ability to facilitate positive

symptomatic or functional gains.

Work Simulation: Use of this program is appropriate when modified duty can only be

partially accommodated in the work place, when modified duty in the work place is

unavailable, or when the patient requires more structured supervision. The need for

work place simulation should be based upon the results of a functional capacity

evaluation (FCE) and/or jobsite analysis.

 Length of Visit: 2 to 6 hours per day.

 Frequency: 2 to 5 visits per week.

 Optimum Duration: 2 to 4 weeks.

 Maximum Duration: 6 weeks. Participation in a program beyond 6 weeks must be

documented with respect to need and the ability to facilitate positive symptomatic

or functional gains.

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THERAPY – PASSIVE: Principally effective during the early phases of treatment and

are directed at controlling symptoms such as pain, inflammation, and swelling and to

improve the rate of healing soft tissue injuries. Should be used adjunctively with active

therapies, such as postural stabilization and exercise programs to help control swelling,

pain, and inflammation during the active rehabilitation process. Passive therapies may

be used intermittently as a therapist deems appropriate or regularly if there are specific

goals with objectively measured functional improvements during treatment.

Electrical Stimulation (Unattended): Indications include muscle spasm, atrophy, and

the need for osteogenic stimulation. A home unit should be purchased if treatment is

effective, and frequent use is recommended.

 Time to Produce Effect: 2 to 4 treatments.

 Frequency: Varies, depending upon indication, between 2 to 3 times per day to 1

time per week.

Home unit should be purchased if treatment is effective, and frequent use is

recommended.

 Optimum Duration: 4 treatments for clinic use.

 Maximum Duration: 8 treatments for clinic use.

Iontophoresis: Not Recommended

Low Level Laser: Not Recommended

Manipulation:

Manipulation may be indicated in patients who have not had an evaluation for manual

medicine, or who have not progressed adequately in an exercise program.

 Time to Produce Effect: 4 to 6 treatments.

 Frequency: 1 to 2 times per week for the first 2 weeks as indicated by the

severity of the condition. Treatment may continue at 1 treatment per week for the

next 6 weeks.

 Optimum Duration: 8 weeks.

 Maximum Duration: 8 weeks. At week 8, patients should be re-evaluated. Care

beyond 8 weeks may be indicated for certain chronic pain patients in whom

manipulation is helpful in improving function, decreasing pain, and improving

quality of life. In these cases, treatment may be continued at one treatment every

other week until the patient has reached MMI and maintenance treatments have

been determined. Extended durations of care beyond what is considered

“maximum” may be necessary in cases of re-injury, interrupted continuity of care,

exacerbation of symptoms, and in those patients with co-morbidities. Such care

should be re-evaluated and documented on a monthly basis.

Manipulation under General Anesthesia (MUA): Not Recommended.

Manipulation under Joint Anesthesia (MUJA): Not Recommended.

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Massage – Manual or Mechanical: Indications include edema (peripheral or hard and

non-pliable edema), muscle spasm, adhesions, the need to improve peripheral

circulation and ROM, or the need to increase muscle relaxation and flexibility prior to

exercise.

 Time to Produce Effect: Immediate.

 Frequency: 1 to 2 times per week.

 Optimum Duration: 6 weeks.

 Maximum Duration: 2 months.

Mobilization (Joint): Indications include the need to improve joint play, segmental

alignment, and intracapsular arthrokinematics, or the need to reduce pain associated

with tissue impingement.

 Time to Produce Effect: 6 to 9 treatments.

 Frequency: Up to 3 times per week.

 Optimum Duration: 4 to 6 weeks.

 Maximum Duration: 6 weeks.

Mobilization (Soft Tissue): Indications include muscle spasm around a joint, trigger

points, adhesions, and neural compression. Best practice suggests that mobilization

should be accompanied by active therapy.

 Time to Produce Effect: 4 to 9 treatments.

 Frequency: Up to 3 times per week.

 Optimum Duration: 4 to 6 weeks.

 Maximum Duration: 6 weeks.

Short-Wave Diathermy: Indications include enhanced collagen extensibility before

stretching, reduced muscle guarding, reduced inflammatory response, and enhanced

re-absorption of hemorrhage/hematoma or edema.

 Time to Produce Effect: 2 to 4 treatments.

 Frequency: 2 to 3 times per week up to 3 weeks.

 Optimum Duration: 3 to 5 weeks.

 Maximum Duration: 5 weeks.

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Superficial Heat and Cold Therapy (excluding Infrared Therapy): Indications include

acute pain, the need to increase pain threshold, the need to reduce muscle spasm, and

the need to promote stretching/flexibility. Cold and heat packs can be used at home as

an extension of therapy in the clinic setting.

 Time to Produce Effect: Immediate.

 Frequency: 2 to 5 times per week.

 Optimum Duration: 3 weeks as primary or intermittently as an adjunct to other

therapeutic procedures up to 2 months.

 Maximum Duration: 2 months.

Traction – Manual: Indications include decreased joint space, muscle spasm around

joints, and the need for increased synovial nutrition and response.

 Time to Produce Effect: 1 to 3 sessions.

 Frequency: 2 to 3 times per week.

 Optimum Duration: 30 days.

 Maximum Duration: 1 month.

Traction – Mechanical: Not Recommended.

Transcutaneous Electrical Nerve Stimulation (TENS): Indications include muscle

spasm, atrophy, and decreased circulation and pain control. Minimal TENS unit

parameters should include pulse rate, pulse width, and amplitude modulation.

 Time to Produce Effect: Immediate.

 Frequency: Variable.

 Optimum Duration: 3 sessions.

 Maximum Duration: 3 sessions. If beneficial, provide with home unit or purchase

if effective.

Ultrasound (including phonophoresis): Not recommended

Vertebral Axial Decompression (VAX-D)/DRX, 9000: Not Recommended.

VOCATIONAL REHABILITATION: Colorado limits its use as a result of Senate Bill 87-

79. Initiation of vocational rehabilitation requires adequate evaluation of patients for

quantification of highest functional level, motivation, and achievement of MMI.

Vocational rehabilitation may be as simple as returning to the original job or as

complicated as being retrained for a new occupation.

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THERAPEUTIC PROCEDURES – OPERATIVE

In order to justify operative interventions, clinical findings, clinical course, and diagnostic

tests must all be consistent resulting in a reasonable likelihood of at least a measurable

and meaningful functional and symptomatic improvement.

In general, if the program of non-operative treatment fails, operative treatment is

indicated when symptoms and findings suggest a surgically amenable problem and:

1. Improvement of the symptoms has plateaued and the residual symptoms of pain

and functional disability are unacceptable at the end of 6 to 12 weeks of active

therapy and manual treatment (mere passage of time with poorly guided

treatment is not considered an active treatment program). In cases of myelopathy

and some cases of severe nerve root compression, earlier intervention is

indicated; or

2. Frequent recurrences of symptoms cause serious functional limitations, even if a

non-operative active treatment program provides significant improvement of

symptoms, and restoration of function on each recurrence; and

3. The patient and treating physician have identified functional operative goals and

the likelihood of achieving improved ability to perform activities of daily living or

work activities. The patient should agree to comply with the pre- and post-

operative treatment plan including home exercise. The provider should be

especially careful to make sure the patient understands the amount of post-

operative treatment required and the length of partial- and full-disability expected

post-operatively. The patient should have committed to the recommended post-

operative treatment plan and fully completed the recommended active, manual

and pre-operative treatment plans.

Every post-operative patient should be involved in an active treatment program after

clearance by the surgeon. Interdisciplinary interventions should be strongly considered

post-operatively in any patient not making functional progress within expected time

frames (refer to F.5. Interdisciplinary Rehabilitation Programs).

Informed decision making should be documented for all invasive procedures. This must

include a thorough discussion of the pros and cons of the procedure and the possible

complications as well as the natural history of the identified diagnosis. Since most

patients with the most common conditions will improve significantly over time, without

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invasive interventions, patients must be able to make well-informed decisions regarding

their treatment.

Return to work restrictions should be specific. Return to Work. Most surgical patients

can return to a limited level of duty between three to six weeks. Full activity is generally

achieved between three months to one year, depending on the procedure, the type of

duties performed, and healing of the individual. Patient should be informed of expected

time off work.

DISCECTOMY (usually accompanied by partial laminectomy):

Surgical Indications: To include all of the following:

• specific diagnosis of nerve root compression proven by MRI or CT myelogram

and correlated to exam findings,

• primary radicular symptoms,

• radiculopathy on exam) and

• failure of 6 weeks of active therapy.

 In some cases, surgery may need to occur sooner due to an individual’s

inability to participate in active therapy.

 Although epidural injections have not been proven to have long-term benefit;

they may be trialed prior to surgery if the patient wishes to try to avoid surgery

or is unable to participate in therapy after the first 2 weeks.

Post-Operative Treatment: An individualized rehabilitation program based upon

communication between the surgeon and the therapist and using the therapies as

outlined in Section F. Therapeutic Procedures Non-Operative. In all cases,

communication between the physician and therapist is important to the timing of

exercise progressions. Post-operative active treatment will frequently require a repeat of

the therapy sessions previously ordered. The implementation of a gentle aerobic

reconditioning program (e.g., walking) and back education within the first post-operative

week is appropriate in uncomplicated post-surgical cases. Some patients may benefit

from several occupational therapy visits to improve performance of ADLs. Participation

in an active therapy program which includes restoration of ROM, core stabilization,

strengthening, and endurance is often recommended to be initiated three to twelve

weeks post-operatively. The goals of the therapy program should include instruction in a

long-term home based exercise program (refer to F.12. Therapy – Active). Medium or

heavy lifting should not be begun before 10 to 12 weeks in most cases.

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PERCUTANEOUS DISCECTOMY:

Surgical Indications: Percutaneous discectomy is indicated only in cases of suspected

septic discitis in order to obtain diagnostic tissue. The procedure is Not Recommended

for contained disc herniations or bulges with associated radiculopathy due to lack of

evidence to support long-term improvement.

LAMINOTOMY/LAMINECTOMY/FORAMENOTOMY/FACETECTOMY for central or

lateral spinal stenosis:

Surgical Indications: Include all of the following:

1. Radicular symptoms or symptoms of neurogenic claudication, often with clinical

evidence of radiculopathy that correlates with the patient’s pain and findings.

2. Evidence of nerve root compression generally proven by MRI or CT myelogram.

3. Failure of non-surgical care. For patients with stenosis non-surgical active

treatment should generally consist of 6 to 12 weeks for an adequate trial.

Patients with severe stenosis that correlates with symptoms often do not improve

with conservative care.