New York Mid And Low Back Injury Medical Treatment .

New YorkMid and Low Back InjuryMedical Treatment Guidelines Second EditionJanuary 14, 2013Corrected February 22, 2013Effective March 1, 2013 This guideline is based upon Chapter 12, Low Back Disorders (Revised 2007) of theOccupational Medicine Practice Guidelines, 2nd Edition published and copyrighted by theAmerican College of Occupational and Environmental Medicine.Copyright 2008, 2007, 2004, 1997 by the American College of Occupational and EnvironmentalMedicine (ACOEM). Commercial reproduction or other use beyond fair use prohibited withoutexplicit ACOEM permission.The American College of Occupational and Environmental Medicine has granted the Workers’Compensation Board permission to publish the Low Back Disorders portion of the OccupationalMedicine Practice Guidelines, 2nd Edition in connection with the adoption of this guideline,including making this guideline available in print and on its website for informational andeducational purposes. Use of the ACOEM portions of this guideline beyond fair use or forcommercial purpose, or both may only occur upon receipt of explicit permission from ACOEM.

New York State Workers’ Compensation BoardNew York Mid and Low Back Injury Medical Treatment GuidelinesTABLE OF CONTENTSAGENERAL GUIDELINE PRINCIPLES . 1A.1MEDICAL CARE . 1A.2RENDERING OF MEDICAL SERVICES . 1A.3POSITIVE PATIENT RESPONSE . 1A.4RE-EVALUATE TREATMENT . 1A.5EDUCATION . 1A.6DIAGNOSTIC TIME FRAMES . 2A.7TREATMENT TIME FRAMES . 2A.8SIX-MONTH TIME FRAME . 2A.9DELAYED RECOVERY . 2A.10 ACTIVE INTERVENTIONS. 2A.11 ACTIVE THERAPEUTIC EXERCISE PROGRAM . 3A.12 DIAGNOSTIC IMAGING AND TESTING PROCEDURES . 3A.13 SURGICAL INTERVENTIONS . 3A.14 PRE-AUTHORIZATION. 4A.15 PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL EVALUATIONS . 4A.16 PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION . 5A.17 FUNCTIONAL CAPACITY EVALUATION (FCE) (14) . 5A.18 RETURN TO WORK . 6A.19 JOB SITE EVALUATION . 6A.20 GUIDELINE RECOMMENDATIONS AND MEDICAL EVIDENCE . 7A.21 EXPERIMENTAL TREATMENT . 7A.22 INJURED WORKERS AS PATIENTS . 7A.23 SCOPE OF PRACTICE . 7Second Edition, January 14, 2013i

New York State Workers’ Compensation BoardNew York Mid and Low Back Injury Medical Treatment GuidelinesBINTRODUCTION . 7B.1B.1.aHistory of Present Illness . 7B.1.bPast History . 8B.1.cPhysical Examination . 9B.1.dSpinal Cord Evaluation . 9B.1.eRelationship to Work . 10B.1.fRed Flags . 10B.2IMAGING/ANATOMICAL TESTS . 11B.3LABORATORY TESTING . 11B.3.aComplete Blood Count (CBC) . 11B.3.bRheumatalogic, Infection or Connective Tissue Disorder . 11B.3.cMetabolic Bone Disease . 11B.3.dLiver and Kidney Function. 12B.4CHISTORY TAKING AND PHYSICAL EXAMINATION . 7FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES . 12DIAGNOSTIC STUDIES . 13C.1IMAGING STUDIES . 13C.1.aRoentgenograms (X-Rays) . 13C.1.bMagnetic Resonance Imaging (MRI) . 14C.1.cComputerized Tomography (CT) . 15C.1.dMyelography (Including CT Myelography and MRI Myelography) . 16C.1.eBone Scans . 16C.1.fFluoroscopy .17C.1.gSingle Proton Emission Computed Tomography (SPECT) .17C.1.hUltrasound (Diagnostic) .17Second Edition, January 14, 2013ii

New York State Workers’ Compensation BoardNew York Mid and Low Back Injury Medical Treatment GuidelinesC.1.iC.2DVideofluoroscopy .17OTHER TESTS/PROCEDURES:. 18C.2.aElectrodiagnostic Studies (EDS)-includes Needle EMG’s(Electromyogram) . 18C.2.bSurface Electromyography (Surface EMG). 19C.2.cDiagnostic Facet Blocks . 19C.2.dLumbar Discography . 19C.2.eCT/MRI Discography . 19C.2.fMyeloscopy . 19C.2.gThermography . 20THERAPEUTIC PROCEDURES-NON-OPERATIVE . 20D.1ACUPUNTURE . 20D.2APPLIANCES . 22D.2.aShoe Insoles and Shoe Lifts . 22D.2.bKinesiotaping, Taping or Strapping . 22D.2.cLumbar Supports . 22D.2.dMagnets . 22D.2.eMattresses, Water Beds, and Sleeping Surfaces (None with Sciatica) . 23D.3BED REST . 23D.4BIOFEEDBACK . 24D.5ELECTRICAL THERAPIES . 24D.5.aInterferential Therapy . 24D.5.bTranscutaneous Electrical Neurostimulation (TENS). 25D.5.cPercutaneous Electrical Nerve Stimulation (PENS) . 25D.5.dMicrocurrent Electrical Stimulation . 26D.5.eElectrical Nerve Block . 26Second Edition, January 14, 2013iii

New York State Workers’ Compensation BoardNew York Mid and Low Back Injury Medical Treatment GuidelinesD.5.fElectrical Stimulation (Unattended). 26D.5.gTranscutaneous Neurostimulator (TCNS) . 26D.5.hH-Wave Stimulation. 26D.5.iHigh-Voltage Galvanic . 26D.5.jIontophoresis. 27D.6INJECTION THERAPIES . 27D.6.aLumbar/Transforaminal/Epidural Injections . 27D.6.bIntradiscal Steroids . 30D.6.cChemonucleolysis (Chymopapain and Collagenase) . 30D.6.dTender and Trigger Point Injections . 30D.6.eDiagnostic Facet Joint Injections (Intra-articular and Nerve Blocks) . 31D.6.fTherapeutic Facet Joint Injections . 31D.6.gFacet Joint Hyaluronic Acid Injections . 32D.6.hSacroiliac Joint Injections . 32D.6.iProlotherapy Injections . 33D.6.jPlatelet Rich Plasma (PRP) . 33D.7MEDICATIONS . 33D.7.aAcetaminophen . 33D.7.bAnti-Depressants . 34D.7.cAnti-Seizure Drugs . 35D.7.dColchicine (Oral and IV Colchicine) . 36D.7.eComplementary and Alternative Methods. 36D.7.fOther creams and ointments. 38D.7.gVitamins . 38D.7.hNon-Steroidal Anti-Inflammatory Drugs (NSAIDs) . 38Second Edition, January 14, 2013iv

New York State Workers’ Compensation BoardNew York Mid and Low Back Injury Medical Treatment GuidelinesD.7.iOpioids – Oral, Transdermal, and Parenteral . 40D.7.jSkeletal Muscle Relaxants . 42D.7.kSystemic Glucocorticosteroids (aka “Steroids”) . 44D.7.lTramadol . 44D.7.mTumor Necrosis Factor-Α Inhibitors . 45D.8SLEEP POSTURE . 45D.9THERAPY: ACTIVE . 46D.9.aTherapeutic Exercise . 46D.9.bAerobic Exercises . 46D.9.cStrengthening and Stabilization Exercises . 48D.9.dAquatic Therapy (Including Swimming) . 49D.9.eMEDX Machine . 49D.9.fYoga . 50D.10 THERAPY: PASSIVE . 50D.10.aManipulation . 50D.10.bManipulation under Anesthesia (MUA) and Medication-AssistedSpinal Manipulation (MASM) . 51D.10.cMassage (Manual or Mechanical) . 51D.10.dMobilization (Joint) . 53D.10.eMobilization (Soft Tissue) . 53D.10.fSuperficial Heat and Cold . 54D.10.gDiathermy . 54D.10.hInfrared Therapy . 54D.10.iUltrasound . 55D.10.jLow Level Laser Therapy . 55D.10.kMyofascial Release . 55Second Edition, January 14, 2013v

New York State Workers’ Compensation BoardNew York Mid and Low Back Injury Medical Treatment GuidelinesD.10.lNeuroflexotherapy. 55D.10.mReflexology . 55D.10.nTraction . 56D.10.oVertebral Axial Compression (VAX-D) and Other DecompressiveDevices . 56D.11 THERAPY: ONGOING MAINTENANCE CARE . 56D.12 RADIOFREQUENCY NEUROTOMY, NEUROTOMY, AND FACETRHIZOTOMY . 57ED.12.aRadiofrequency Neurotomy, Neurotomy, and Facet Rhizotomy . 57D.12.bDorsal Root Ganglia Radiofrequency Lesioning . 57D.12.cIntradiscal Electrothermal Therapy (IDET) . 58D.12.dPercutaneous Intradiscal Radiofrequency Thermocoagulation (PIRFT). 58THERAPEUTIC PROCEDURES: OPERATIVE . 58E.1Discectomy, Microdiscectomy, Sequestrectomy, Endoscopic Decompression. 58E.2ADHESIOLYSIS. 59E.3DECOMPRESSIVE SURGERY (LAMINOTOMY/FACETECTOMY,LAMINECTOMY) . 59E.4SPINAL FUSION . 60E.5ELECTRICAL BONE GROWTH STIMULATORS . 61E.6DISC REPLACEMENT . 62E.7VERTEBROPLASTY AND KYPHOPLASTY . 64E.8SACROILIAC SURGERY . 64E.9INTRAOPERATIVE MONITORING . 64E.10 IMPLANTABLE SPINAL CORD STIMULATORS . 65Second Edition, January 14, 2013vi

A GENERAL GUIDELINE PRINCIPLESThe principles summarized in this section are key to the intended application ofthe New York State Medical Treatment Guidelines.Medical CareA.1MEDICAL CAREMedical care and treatment required as a result of a work-related injuryshould be focused on restoring functional ability required to meet thepatient’s daily and work activities and return to work, while striving torestore the patient’s health to its pre-injury status in so far as is feasible.A.2RENDERING OF MEDICAL SERVICESAny medical provider rendering services to a workers compensationpatient must utilize the Treatment Guidelines as provided for with respectto all work-related injuries and or illnesses.A.3POSITIVE PATIENT RESPONSEPositive results are defined primarily as functional gains which can beobjectively measured. Objective functional gains include, but are notlimited to, positional tolerances, range of motion, strength, endurance,activities of daily living, cognition, psychological behavior, andefficiency/velocity measures which can be quantified. Subjective reportsof pain and function should be considered and given relative weight whenthe pain has anatomic and physiologic correlation.A.4RE-EVALUATE TREATMENTIf a given treatment or modality is not producing positive results, theprovider should either modify or discontinue the treatment regime. Theprovider should evaluate the efficacy of the treatment or modality 2 to 3weeks after the initial visit and 3 to 4 weeks thereafter. Reconsideration ofdiagnosis should also occur in the event of poor response to a n of the patient and family, as well as the employer, insurer,policy makers and the community should be a primary emphasis in thetreatment of work-related injury or illness. Practitioners must developSecond Edition, January 14, 20131

New York State Workers’ Compensation BoardNew York Mid and Low Back Injury Medical Treatment Guidelinesand implement effective educational strategies and skills. An educationbased paradigm should always start with communication providingreassuring information to the patient. No treatment plan is completewithout addressing issues of individual and/or group patient education asa means of facilitating self-management of symptoms and prevention offuture injury.Time FramesA.6DIAGNOSTIC TIME FRAMESDiagnostic time frames for conducting diagnostic testing commence on thedate of injury. Clinical judgment may substantiate the need to accelerateor decelerate the time frames discussed in this document.A.7TREATMENT TIME FRAMESTreatment time frames for specific interventions commence oncetreatments have been initiated, not on the date of injury. Obviously,duration may be impacted by disease process and severity, patientcompliance, as well as availability of services. Clinical judgment maysubstantiate the need to accelerate or decelerate the time frames discussedin this document.A.8SIX-MONTH TIME FRAMESince the prognosis drops precipitously for re

Use of the ACOEM portions of this guideline beyond fair use or for commercial purpose, or both may only occur upon receipt of explicit permission from ACOEM. . D.6.d Tender and Trigger Point Injections.30 D.6.e Diagnostic Facet Joint Injections (Intra-articular and Nerve Blocks). 31 .