Mid and Low Back Injury - DRAFT Revised December 2020 - For Review Effective: TBD - Workers' Compensation Board
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Mid and Low Back Injury DRAFT Revised December 2020 – For Review Effective: TBD Adapted by NYS Workers’ Compensation Board (“WCB”) from MDGuidelines® with permission of Reed Group, Ltd. (“ReedGroup”), which is not responsible for WCB’s modifications. MDGuidelines® are Copyright 2019 Reed Group, Ltd. All Rights Reserved. No part of this publication may be reproduced, displayed, disseminated, modified, or incorporated in any form without prior written permission from ReedGroup and WCB. Notwithstanding the foregoing, this publication may be viewed and printed solely for internal use as a reference, including to assist in compliance with WCL Sec. 13-0 and 12 NYCRR Part 44[0], provided that (i) users shall not sell or distribute, display, or otherwise provide such copies to others or otherwise commercially exploit the material. Commercial licenses, which provide access to the online text-searchable version of MDGuidelines®, are available from ReedGroup at www.mdguidelines.com.
Contributors The NYS Workers’ Compensation Board would like to thank the members of the New York Workers’ Compensation Board Medical Advisory Committee (MAC). The MAC served as the Board’s advisory body to adapt the American College of Occupational and Environmental Medicine (ACOEM) Practice Guidelines to a New York version of the Medical Treatment Guidelines (MTG). In this capacity, the MAC provided valuable input and made recommendations to help guide the final version of these Guidelines. With full consensus reached on many topics, and a careful review of any dissenting opinions on others, the Board established the final product. New York State Workers’ Compensation Board Medical Advisory Committee Joseph Canovas, Esq. Special Counsel New York State AFL-CIO Kenneth B. Chapman, MD Director Pain Medicine, SIUH Northwell Health Systems Assistant Clinical Professor, NYU Langone Medical Center Adjunct Assistant Professor, Hofstra Medical School Robert Goldberg, DO Attending Physician, Department of Rehabilitation, Beth Israel Hospital and Medical Center of NYC Professor of Physical Medicine and Rehabilitation and Health Policy Clinical Associate Professor of Rehabilitation Medicine, New York Medical College Clinical Professor of Rehabilitation Medicine, Philadelphia College of Osteopathic Medicine Member Council on Medical Education of the American Medical Association Frank Kerbein, SPHR Director, Center for Human Resources The Business Council of New York State, Inc. Joseph Pachman, MD, PhD, MBA, MPH Licensed Psychologist and Physician Board Certified in Occupational Medicine Fellow in ACOEM Vice President and National Medical Director, Liberty Mutual James A. Tacci, MD, JD, MPH (FACOEM, FACPM) NYS Workers’ Compensation Board Executive Medical Policy Director Edward C. Tanner, MD Chair, Department of Orthopaedics at Rochester General Hospital Past President, New York State Society of Orthopaedic Surgeons (NYSSOS) Member, American Academy of Orthopaedic Surgeons (AAOS) Member, American Association of Hip and Knee Surgeons (AAHKS)
This guideline is based upon Chapter 12, Low Back Disorders (Revised 2007) of the Occupational Medicine Practice Guidelines, 2nd Edition published and copyrighted by the American College of Occupational and Environmental Medicine. Copyright 2008, 2007, 2004, 1997 by the American College of Occupational and Environmental Medicine (ACOEM). Commercial reproduction or other use beyond fair use prohibited without explicit 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 Occupational Medicine 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 and educational purposes. 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. Revised January 2021
Table of Contents
A. General Guideline Principles................................................................................... 3
A.1 Medical Care .................................................................................................. 3
A.2 Rendering Of Medical Services ...................................................................... 3
A.3 Positive Patient Response .............................................................................. 3
A.4 Re-Evaluate Treatment................................................................................... 3
A.5 Education........................................................................................................ 3
A.6 Acuity .............................................................................................................. 4
A.7 Initial Evaluation ............................................................................................. 4
A.8 Diagnostic Time Frames ................................................................................. 4
A.9 Treatment Time Frames ................................................................................. 4
A.10 Delayed Recovery .......................................................................................... 4
A.11 Active Interventions ........................................................................................ 5
A.12 Active Therapeutic Exercise Program............................................................. 5
A.13 Diagnostic Imaging And Testing Procedures .................................................. 5
A.14 Surgical Interventions ..................................................................................... 6
A.15 Pre-Authorization ............................................................................................ 6
A.16 Psychological/Psychiatric Evaluations ............................................................ 6
A.17 Personality/Psychological/Psychosocial Intervention ..................................... 7
A.18 Functional Capacity Evaluation (FCE) ............................................................ 7
A.19 Return To Work .............................................................................................. 8
A.20 Job Site Evaluation ......................................................................................... 8
A.21 Guideline Recommendations And Medical Evidence ..................................... 9
A.22 Experimental/Investigational Treatment.......................................................... 9
A.23 Injured Workers As Patients ........................................................................... 9
A.24 Scope Of Practice ........................................................................................... 9
B. Introduction to Mid and Lower Back Injury .......................................................... 10
B.1 History Taking and Physical Examination ..................................................... 10
B.2 Imaging / Anatomical Tests .......................................................................... 13
NYS WCB MTG - Mid and Low Back Injury 1B.3 Laboratory Testing ........................................................................................ 14
B.4 Follow-Up Diagnostic Imaging and Testing Procedures ............................... 14
C. Diagnostic Studies ................................................................................................. 15
C.1 Imaging Studies ............................................................................................ 15
C.2 Other Tests / Procedures.............................................................................. 19
D. Therapeutic Procedures: Non-Operative ............................................................ 21
D.1 Acupuncture ................................................................................................. 22
D.2 Appliances .................................................................................................... 22
D.3 Bed Rest ....................................................................................................... 23
D.4 Biofeedback .................................................................................................. 24
D.5 Electrical Therapies ...................................................................................... 24
D.6 Injections: Therapeutic Spinal...................................................................... 25
D.7 Medications .................................................................................................. 36
D.8 Rehabilitation ................................................................................................ 43
D.9 Therapy – Ongoing Maintenance Care ......................................................... 51
D.10 Radiofrequency Ablation, Neurotomy, Facet Rhizotomy .............................. 52
E. Therapeutic Procedures: Operative..................................................................... 53
E.1 Discectomy, Microdiscectomy, Suquestrectomy, Endoscopic Decompression
53
E.2 Adhesiolysis.................................................................................................. 54
E.3 Decompressive Surgery (Laminotomy / Facetectomy Laminectomy ............ 54
E.4 Spinal Fusion ................................................................................................ 55
E.5 Electrical Bone Growth Stimulators .............................................................. 56
E.6 Disc Replacement ........................................................................................ 56
E.7 Vertebroplasty and Kyphoplasty ................................................................... 57
E.8 Sacroiliac Surgery ........................................................................................ 58
E.9 Intraoperative Monitoring / Image Guidance / Robotic Surgery .................... 59
E.10 Implantable Spinal cord Stimulators (SCS)................................................... 60
NYS WCB MTG - Mid and Low Back Injury 2A. General Guideline Principles
The principles summarized in this section are key to the intended application of the New
York State Medical Treatment Guidelines (MTG) and are applicable to all Workers’
Compensation Medical Treatment Guidelines.
A.1 Medical Care
Medical care and treatment required as a result of a work-related injury should be
focused on restoring functional ability required to meet the patient’s daily and work
activities with a focus on a return to work, while striving to restore the patient’s
health to its pre-injury status in so far as is feasible.
A.2 Rendering Of Medical Services
Any medical provider rendering services to a workers’ compensation patient must
utilize the Treatment Guidelines as provided for with respect to all work-related
injuries and/or illnesses.
A.3 Positive Patient Response
Positive results are defined primarily as functional gains which can be objectively
measured. Objective functional gains include, but are not limited to, positional
tolerances, range of motion, strength, endurance, activities of daily living (ADL),
cognition, psychological behavior, and efficiency/velocity measures which can be
quantified. Subjective reports of pain and function may be considered and given
relative weight when the pain has anatomic and physiologic correlation in
proportion to the injury.
A.4 Re-Evaluate Treatment
If a given treatment or modality is not producing positive results within a well-
defined timeframe, the provider should either modify or discontinue the treatment
regime. The provider should evaluate the efficacy of the treatment or modality 2 to
3 weeks after the initial visit and 3 to 4 weeks thereafter. These timeframes may be
slightly longer in the context of conditions that are inherently mental health issues,
and shorter for other non-musculoskeletal medical conditions (e.g. pulmonary,
dermatologic etc.). Recognition that treatment failure is at times attributable to an
incorrect diagnosis a failure to respond should prompt the clinician to reconsider
the diagnosis in the event of an unexpected poor response to an otherwise rational
intervention.
A.5 Education
Education of the patient and family, as well as the employer, insurer, policy makers
and the community should be a primary emphasis in the treatment of work-related
injury or illness. Practitioners should develop and implement effective educational
strategies and skills. An education-based paradigm should always start with
communication providing reassuring information to the patient. No treatment plan is
complete without addressing issues of individual and/or group patient education as
a means of facilitating self-management of symptoms and prevention of future
injury.
NYS WCB MTG - Mid and Low Back Injury 3Time Frames
A.6 Acuity
Acute, Subacute and Chronic are generally defined as timeframes for disease
stages:
• Acute – Less than one month
• Subacute - One to three month, and
• Chronic - greater than three months.
•
A.7 Initial Evaluation
Initial evaluation refers to the acute timeframe following an injury and is not used to
define when a given physician first evaluates an injured worker (initial encounter) in
an office or clinical setting.
A.8 Diagnostic Time Frames
Diagnostic time frames for conducting diagnostic testing commence on the date of
injury. Clinical judgment may substantiate the need to accelerate or decelerate the
time frames discussed in this document.
A.9 Treatment Time Frames
Treatment time frames for specific interventions commence once treatments have
been initiated, not on the date of injury. It is recognized that treatment duration may
be impacted by disease process and severity, patient compliance, as well as
availability of services. Clinical judgment may substantiate the need to accelerate
or decelerate the time frames discussed in this document.
A.10 Delayed Recovery
For those patients who fail to make expected progress 6-12 weeks after an injury
and whose subjective symptoms do not correlate with objective signs and tests,
reexamination in order to confirm the accuracy of the diagnosis and re-evaluation of
the treatment program should be performed. When addressing a clinical issue that
is not inherently a mental health issue, assessment for potential barriers to
recovery (yellow flags/psychological issues) should be ongoing throughout the care
of the patient. At 6-12 weeks, alternate treatment programs, including formal
psychological or psychosocial evaluation should be considered. Clinicians must be
vigilant for any pre-existing mental health issues or subsequent, consequential
mental health issues that may be impacting recovery. For issues that are clearly
and inherently mental health issues from the outset (i.e. when it is evident that
there is an underlying, work-related, mental health disorder as part of the claim at
issue), referral to a mental health provider can and should occur much sooner.
Referrals to mental health providers for the evaluation and management of delayed
recovery do not indicate or require the establishment of a psychiatric or
psychological condition. The evaluation and management of delayed recovery does
not require the establishment of a psychiatric or psychological claim.
Treatment Approaches
NYS WCB MTG - Mid and Low Back Injury 4A.11 Active Interventions
Active interventions emphasizing patient responsibility, such as therapeutic
exercise and/or functional treatment, are generally emphasized over passive
modalities, especially as treatment progresses. Generally, passive and palliative
interventions are viewed as a means to facilitate progress in an active rehabilitation
program with concomitant attainment of objective functional gains.
A.12 Active Therapeutic Exercise Program
Active therapeutic exercise program goals should incorporate patient strength,
endurance, flexibility, range of motion, sensory integration, coordination, cognition
and behavior (when at issue) and education as clinically indicated. This includes
functional application in vocational or community settings.
A.13 Diagnostic Imaging And Testing Procedures
Clinical information obtained by history taking and physical examination should be
the basis for selection of imaging procedures and interpretation of results. All
diagnostic procedures have characteristic specificities and sensitivities for various
diagnoses. Usually, selection of one procedure over others depends upon various
factors, which may include: relative diagnostic value; risk/benefit profile of the
procedure; availability of technology; a patient’s tolerance; and/or the treating
practitioner’s familiarity with the procedure.
When a diagnostic procedure, in conjunction with clinical information, provides
sufficient information to establish an accurate diagnosis, a second diagnostic
procedure is not required. However, a subsequent diagnostic procedure including a
repeat of the original (same) procedure can be performed, when the specialty
physician (e.g. physiatrist, sports medicine physician or other appropriate
specialist) radiologist or surgeon documents that the initial study was of inadequate
quality to make a diagnosis. Therefore, in such circumstances, a repeat or
complementary diagnostic procedure is permissible under the MTG.
It is recognized that repeat imaging studies and other tests may be warranted by
the clinical course and/or to follow the progress of treatment in some cases. It may
be of value to repeat diagnostic procedures (e.g., imaging studies) during the
course of care to reassess or stage the pathology when there is progression of
symptoms or findings, prior to surgical interventions and/or therapeutic injections
when clinically indicated, and post-operatively to follow the healing process.
Regarding serial imaging, (including x-rays, but particularly CT scans), it must be
recognized that repeat procedures result in an increase in cumulative radiation
dose and associated risks.
A given diagnostic imaging procedure may provide the same or distinctive
information as obtained by other procedures. Therefore, prudent choice of
procedures(s) for a single diagnostic procedure, a complementary procedure in
combination with other procedures(s), or a proper sequential order in multiple
procedures will ensure maximum diagnostic accuracy, minimize the likelihood of
adverse effect on patients, and promote efficiency by avoiding duplication or
redundancy.
NYS WCB MTG - Mid and Low Back Injury 5A.14 Surgical Interventions
Consideration of surgery should be within the context of expected functional
outcome. The concept of "cure" with respect to surgical treatment by itself is
generally a misnomer. All operative interventions must be based upon positive
correlation of clinical findings, clinical course and imaging and other diagnostic
tests. A comprehensive assimilation of these factors must lead to a specific
diagnosis with positive identification of pathologic condition(s). For surgery to be
performed to treat pain, there must be clear correlation between the pain symptoms
and objective evidence of its cause. In all cases, shared decision making with the
patient is advised. The patient should be given the opportunity to understand the
pros and cons of surgery, potential for rehabilitation as an alternative where
applicable, evidence-based outcomes, and specific surgical experience.
A.15 Pre-Authorization
All diagnostic imaging, testing procedures, non-surgical and surgical therapeutic
procedures, and other therapeutics within the criteria of the Medical Treatment
Guidelines and based on a correct application of the Medical Treatment Guidelines
are considered authorized, with the exception of the following procedures: Lumbar
Fusion, Artificial Disc Replacements, Vertebroplasty, Kyphoplasty, Electrical Bone
Growth Stimulators, Spinal Cord Stimulators, Intrathecal Drug Delivery (Pain
Pumps), Osteochondral Autograft, Autologous Chondrocyte Implantation, Meniscal
Allograft Transplantation and Knee Arthroplasty (Total or Partial Knee Joint
Replacement). These are not included on the list of pre-authorized procedures.
Providers who want to perform one of these procedures must request pre-
authorization from the carrier before performing the procedure.
Second or subsequent procedures (the repeat performance of a surgical procedure
due to failure of, or incomplete success from the same surgical procedure
performed earlier, if the Medical Treatment Guidelines do not specifically address
multiple procedures) also require pre-authorization.
A.16 Psychological/Psychiatric Evaluations
In select patients, mental health evaluations are essential to make, secure or
confirm a diagnosis. Of course, the extent and duration of evaluations and/or
interventions by mental health professionals may vary, particularly based on
whether: the underlying clinical issue in the claim is inherently a mental health
issue; or there is a mental health issue that is secondary or consequential to the
medical injury or illness that is at issue in the claim in question; or there is a pre-
existing, unrelated mental health issue that has been made worse by, or is
impeding the recovery from (or both) the medical injury or illness that is at issue in
the claim in question.
Tests of psychological function or psychometric testing, when indicated, can be a
valuable component of the psychological evaluation in identifying associated
psychological, personality and psychosocial issues. Although these instruments
may suggest a diagnosis, neither screening nor psychometric tests are capable of
making a diagnosis. The diagnosis should only be made after careful analysis of all
available data, including from a thorough history and clinical interview.
A professional fluent in the primary language of the patient is strongly preferred.
NYS WCB MTG - Mid and Low Back Injury 6When such a provider is not available, services of a professional language
interpreter must be provided.
Frequency: When assessing for a pre-existing, unrelated mental health issue that
has been made worse by, or is impeding the recovery from (or both) a work-related,
medical injury or illness, then a one-time visit for initial psychiatric/psychological
encounter should be sufficient, as care would normally be continued by the prior
treating provider. If psychometric testing is indicated by findings in the initial
encounter, time for such testing should not exceed an additional three hours of
professional time. For conditions in which a mental health issue is a central part of
the initial claim, or in which there is a mental health issue that is secondary or
consequential to the work-related, medical injury or illness, that is part of the claim
in question, then more extensive diagnostic and therapeutic interventions may be
clinically indicated, and are discussed in detail in the Medical Treatment Guidelines
for such mental health conditions.
A.17 Personality/Psychological/Psychosocial Intervention
Following psychosocial evaluation, when intervention is recommended, such
intervention should be implemented as soon as possible. This can be used alone or
in conjunction with other treatment modalities. For all psychological/psychiatric
interventions, there must be an assessment and treatment plan with measurable
behavioral goals, time frames and specific interventions planned.
• Time to produce effect: two to eight weeks.
• Optimum duration: six weeks to three months.
• Maximum duration: three to six months.
• Counseling is not intended to delay but rather to enhance functional
recovery.
For PTSD Psychological Intervention:
• Optimum duration three to six months.
• Maximum duration: nine to twelve months.
For select patients, longer supervision and treatment may be required, and if further
treatment is indicated, documentation of the nature of the psychological factors, as
well as projecting a realistic functional prognosis, should be provided by the
authorized treating practitioner every four weeks during the first six months of
treatment. For treatment expected to last six to twelve months, such documentation
should be provided every four to eight weeks. For long-term treatment beyond
twelve months, such documentation should be provided every eight to twelve
weeks. All parties should strive for ongoing and continuous communications, in
order to facilitate seamless, continuous and uninterrupted treatment.
A.18 Functional Capacity Evaluation (FCE)
Functional capacity evaluation is a comprehensive or more restricted evaluation of
the various aspects of function as they relate to the patient’s ability to return to
work. Areas such as endurance, lifting (dynamic and static), postural tolerance,
specific range-of-motion, coordination and strength, worker habits, employability, as
well as psychosocial, cognitive, and sensory perceptual aspects of competitive
NYS WCB MTG - Mid and Low Back Injury 7employment may be evaluated. Components of this evaluation may include: (a)
musculoskeletal screen; (b) cardiovascular profile/aerobic capacity; (c)
coordination; (d) lift/carrying analysis; (e) job-specific activity tolerance; (f)
maximum voluntary effort; (g) pain assessment/psychological screening; (h) non-
material and material handling activities; (i) cognitive and behavioral; (j) visual; and
(k) sensory perceptual factors.
In most cases, the question of whether a patient can return to work can be
answered without an FCE.
An FCE may be considered at time of MMI, following reasonable prior attempts to
return to full duty throughout course of treatment, when the treating physician is
unable to make a clear determination on work status on case closure. An FCE is
not indicated early during a treatment regime for any reason including one to
support a therapeutic plan.
When an FCE is being used to determine return to a specific job site, the treating
physician is responsible for understanding and considering the job duties. FCEs
cannot be used in isolation to determine work restrictions. The authorized treating
physician must interpret the FCE in light of the individual patient's presentation and
medical and personal perceptions. FCEs should not be used as the sole criteria to
diagnose malingering.
A.19 Return To Work
For purposes of these guidelines, return to work is defined as any work or duty that
the patient is able to perform safely. It may not be the patient’s regular work.
Ascertaining a return to work status is part of medical care, and should be included
in the treatment and rehabilitation plan. It is normally addressed at every outpatient
visit. A description of the patient’s status and task limitations is part of any
treatment plan and should provide the basis for restriction of work activities when
warranted. Early return to work should be a prime goal in treating occupational
injuries. The emphasis within these guidelines is to move patients along a
continuum of care and return to work, since the prognosis of returning an injured
worker to work drops progressively the longer the worker has been out of work.
A.20 Job Site Evaluation
The treating physician may communicate with the employer or employer’s
designee, either in person, by video conference, or by telephone, to obtain
information regarding the individual or specific demands of the patient’s pre-injury
job. This may include a description of the exertional demands of the job, the need
for repetitive activities, load lifting, static or awkward postures, environmental
exposures, psychological stressors and other factors that would pose a barrier to
re-entry, risk of re-injury or disrupt convalescence. When returning to work at the
patient’s previous job tasks or setting is not feasible, given the clinically
determined restrictions on the patient’s activities, inquiry should be made about
modified duty work settings that align with, the patient’s condition in view of
proposed work activities/demands in modified duty jobs. It should be noted, that
under certain circumstances, more than one job site evaluation may be indicated.
Ideally, the physician would gain the most information from an on-site inspection of
NYS WCB MTG - Mid and Low Back Injury 8the job settings and activities; but it is recognized that this may not be feasible in
most cases. If job videos/CDs/DVDs are available from the employer, these can
contribute valuable information, as can video conferences, conducted from the
worksite and ideally workstation or work area.
Frequency: one or two calls
• 1st call: Patient is in a functional state where the patient can perform some
work.
• 2nd call: Patient has advanced to state where the patient is capable of
enhanced functional demands in a work environment.
The physician shall document the conversation.
Other
A.21 Guideline Recommendations And Medical Evidence
The Workers’ Compensation Board and its Medical Advisory Committee have not
independently evaluated or vetted the scientific medical literature used in support of
the guidelines but have relied on the methodology used by the developers of
various guidelines utilized and referenced in these Guidelines.
A.22 Experimental/Investigational Treatment
Medical treatment that is experimental/investigational and not approved for any
purpose, application or indication by the FDA is not permitted under these
Guidelines.
A.23 Injured Workers As Patients
In these Guidelines, injured workers are referred to as patients recognizing that in
certain circumstances there is no doctor-patient relationship.
A.24 Scope of Practice
These Guidelines do not address scope of practice or change the scope of
practice.
NYS WCB MTG - Mid and Low Back Injury 9Mid and Lower Back Injury
Effective: mm/dd/yyyy
B. Introduction to Mid and Lower Back Injury
B.1 History Taking and Physical Examination
History taking and physical examination establish the foundation/basis for and
dictate subsequent stages of diagnostic and therapeutic procedures.
When findings of clinical evaluations and those of other diagnostic procedures are
not consistent with each other, the objective clinical findings have greater weight.
The medical records should reasonably document the following:
B.1.a. History of Present Illness
A detailed history, taken in temporal proximity to the time of injury, should
primarily guide evaluation and treatment. The history should include:
B.1.a.i Mechanism of Injury: This includes details of symptom onset
and progression. The mechanism of injury should include a
detailed description of the incident and the position of the body
before, during, and at the end of the incident. Inclusion of work
body postures, frequency during the workday and
lifting/push/pull requirements should be included in the absence
of a known specific incident.
B.1.a.ii Location of pain, nature of symptoms, and alleviating/
exacerbating factors (e.g. sitting tolerance). The history should
include both the primary and secondary complaints (e.g.,
primary back pain, secondary hip, groin pain).
B.1.a.iii The use of an accepted pain assessment tool, (e.g. the Visual
Analog Scale [VAS]) is highly recommended, especially during
the first two weeks following injury, to assure that all work-
related symptoms, including pain, are being addressed.
B.1.a.iv Presence and distribution of lower extremity numbness,
paresthesias, or weakness, especially if precipitated or
worsened by coughing or sneezing.
B.1.a.v Alteration in bowel, bladder or sexual function.
B.1.a.vi Prior occupational and non-occupational injuries to the same
area including specific prior treatment, history of specific prior
motor vehicle accidents, chronic or recurrent symptoms, and
any functional limitations. Review of any prior spinal imaging
studies.
NYS WCB MTG - Mid and Low Back Injury 10B.1.a.vii History of emotional and/or psychological reactions to the
current injury/illness.
B.1.a.viii Ability to perform job duties and activities of daily living.
B.1.b Past History
B.1.b.i Comprehensive past medical history.
B.1.b.ii A review of systems should be conducted, the elements of which
may include signs or symptoms related to the following systems:
constitutional symptoms; eyes; ear, nose, mouth, and throat;
cardiovascular; respiratory; gastrointestinal; genitourinary;
musculoskeletal; integumentary/breast; neurological; psychiatric;
endocrine; hematologic/lymphatic; allergic/immunologic. Based on
the underlying condition being addressed, and clinical judgement,
the breadth and focus of the review of systems can be tailored on
a case by case basis.
B.1.b.iii Smoking history.
B.1.b.iv Vocational and recreational pursuits.
B.1.b.v History of depression, anxiety, or other psychiatric illness.
B.1.c Physical Examination
Guided by the medical history, should include accepted tests and exam
techniques applicable to the area being examined, including:
B.1.c.i Vital signs;
B.1.c.ii General inspection, including posture, stance and gait;
B.1.c.iii Visual inspection;
B.1.c.iv Palpation;
B.1.c.v Lumbar range of motion, quality of motion, and presence of
muscle spasm. Motion evaluation of specific joints may be
indicated.
B.1.c.vi Examination of thoracic spine and pelvis;
B.1.c.vii Nerve tension testing. When the Lassegue Test (Straight Leg
Raise test) is performed, a result is generally not considered to
be positive at an elevation less than 25 or greater than 60
degrees (and degrees should always be reported).
B.1.c.viii Sensory and motor examination of the lower extremities with
NYS WCB MTG - Mid and Low Back Injury 11specific nerve root focus.
B.1.c.ix Deep tendon reflexes.
B.1.c.x If applicable, abdominal examination, , circumferential lower
extremity measurements, or evaluation other lower extremity
abnormalities.
B.1.c.xi Hip exam to include ROM, pain, deformity etc.
B.1.c.xii Lower extremity vascular exam to include palpation of distal
pulses.
B.1.d Spinal Cord Evaluation
In cases where the mechanism of injury, history, or clinical presentation
suggests a possible severe injury, additional evaluation is indicated. A full
neurological examination for possible spinal cord injury may include:
B.1.d.i Sharp and light touch, deep pressure, temperature and
proprioceptive sensory function;
B.1.d.ii Strength testing;
B.1.d.iii Anal sphincter tone and/or perianal sensation;
B.1.d.iv Presence of pathological reflexes.
B.1.d.v Spinal cord lesions should be classified according to the
American Spine Injury Association (ASIA) impairment scale.
ASA Impairment Scale
A Complete No motor or sensory function is preserved in the
sacral segments S4 – S5
B Incomplete Sensory but not motor function is preserved below
the neurological level and includes the sacral
segments S4 – S5.
C Incomplete Motor function is preserved below the neurological
level, and more than half of key muscles below the
neurological level have a muscle grade less than
three.
D Incomplete Motor function is preserved below the neurological
level, and at least half of key muscles below the
neurological level have a grade three or more.
E Normal Motor and sensory function are normal.
A worksheet which details dermatomes and muscle testing required is
available from ASIA.
NYS WCB MTG - Mid and Low Back Injury 12B.1.e Red Flags
Certain findings, “red flags,” raise suspicion of potentially serious and urgent
medical conditions. Assessment (history and physical examination) should
include evaluation for red flags. In the mid and low back, these findings or
indicators may include: acute fractures, dislocations, infection, tumor,
progressive neurologic deficit or cauda equina syndrome, and extraspinal
disorders. Further evaluation/consultation or urgent/emergent intervention
may be indicated, and the New York Mid and Low Back Injury Guidelines
incorporate changes in clinical management triggered by the presence of
“red flags.”
B.2 Imaging / Anatomical Tests
Imaging studies should not be routinely performed without indications.
Physicians should be aware that “abnormal” findings on x-rays, magnetic
resonance images, and other diagnostic tests are frequently seen by age 40 even
in asymptomatic individuals. Bulging discs continue to increase after that point
and by approximately age 60, will be encountered in a majority of patients. This
requires that a careful history and physical examination be conducted by a
physician in order to correlate historical, clinical, and imaging findings prior to
diagnosing and attributing a patient’s complaints to the finding on imaging. The
focus of treatment should be improving symptoms and function, and not the
correction of abnormalities on imaging studies.
NYS WCB MTG - Mid and Low Back Injury 13B.3 Laboratory Testing
Laboratory tests are rarely indicated at the time of initial evaluation, unless there is
a suspicion of systemic illness, infection, neoplasia or underlying rheumatologic
disorder, connective tissue disorder, or other findings based on history and/or
physical examination. Laboratory tests can provide useful diagnostic information.
Tests include, but are not limited to:
B.3.i Complete blood count (CBC) with differential
Recommended - for patients with suspicion of infection, blood dyscrasias,
and medication side effects.
B.3.ii Erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), anti-
nuclear antigen (ANA), human leukocyte antigen (HLA), and C-
reactive protein (CRP)
Recommended - to detect evidence of a rheumatologic, infection, or
connective tissue disorder.
B.3.iii Serum calcium, phosphorous, uric acid, alkaline phosphatase, and
acid phosphatase
Recommended - in select patients with suspicion of metabolic bone
disease.
B.3.iv Liver and kidney function
Recommended - in select patients with prolonged anti-inflammatory use
or other medications requiring monitoring.
B.3.v Serum Protein Electrophoresis
Recommended - to evaluate for multiple myeloma.
B.4 Follow-Up Diagnostic Imaging and Testing Procedures
As outlined in detail in General Principles section A-13, the selection of diagnostic
imaging studies depends on the case-specific clinical presentation, as well as
clinical judgment. In addition, there may be instances where repeat or alternate
diagnostic imaging may be clinically indicated. Such instances include, but are not
necessarily limited to when: a prior test is of poor quality and/or nondiagnostic; the
clinical situation changes (e.g. new or worsening symptoms, preparing for surgery
or therapeutic injections, etc.); it is necessary to monitor clinical progress (e.g. post-
operatively) or deterioration over time.
Prudent choice of procedure(s) or a proper sequential order in multiple procedures
will ensure maximum diagnostic accuracy, minimize adverse effect to patients and
promote clinical efficiency. Repeat procedures result in an increase in cumulative
radiation dose and associated risks.
NYS WCB MTG - Mid and Low Back Injury 14Diagnostic imaging procedures have varying degrees of sensitivity and specificity
for any diagnosis. Clinical history, physical examination and clinical judgment
should be the basis for selection and interpretation of imaging studies.
Generally, plain X-rays are a useful starting point, but they are not always
sufficient. Magnetic resonance imaging (MRI), myelography, or computed axial
tomography (CT) scanning following myelography may provide useful information
for many spinal disorders. Regarding CT examinations, it must be recognized that
repeat procedures result in an increase in cumulative radiation dose and
associated risks. In certain circumstances as stated above, repeat or alternate
imaging may be warranted. Usually, selection of one procedure over others
depends upon multiple factors.
After initial imaging is performed, as may be indicated by clinical presentation,
history of significant trauma or other clinical “red flags” that raise suspicions for
serious underlying conditions, in the absence of a significant neurologic
deficit/abnormality, myelopathy or progressive neurological changes, imaging
usually is not clinically indicated until conservative therapy has been tried and
failed. A minimum of four weeks, but as long as six to eight weeks of treatment
are usually an adequate period of time before an imaging procedure is in order,
but the clinician should use judgment in this regard. When the findings of the
diagnostic imaging and testing procedures are not consistent with the clinical
examination, objective clinical findings should be given greater weight. There is
good evidence that in the over-40, asymptomatic population, the prevalence of
disc degeneration is greater than 50%. Disc degeneration, seen as loss of signal
intensity on MRI, may be due to age-related changes causing biochemical
changes and structural changes separate and distinct from traumatic injury and
may not have pathological significance. Disc bulging and posterior disc protrusion,
while not rare, is less commonly symptomatic in the lumbar spine than in the
cervical spine due to the smaller cervical spinal canal. Mild reduction in the cross-
sectional area of the spinal cord may be seen without myelopathy in patients older
than 40; therefore, clinical correlation is required.
When indicated, the following studies can be utilized for further evaluation of mid
and low back injuries, based upon the mechanism of injury, symptoms, and patient
history. The studies below are not listed in order of preference, clinical indication,
or clinical utility, as that may vary based on the clinical details of any given case.
C. Diagnostic Studies
C.1 Imaging Studies
C.1.a Roentgenograms (X-Rays)
C.1.a.i Routine x-rays for acute non-specific back pain.
Recommended - for acute back pain with red flags for fracture or
serious systemic illness, back pain that is not improving, or non-
NYS WCB MTG - Mid and Low Back Injury 15acute back pain, as an option to rule out other possible
conditions.
Frequency/Duration: Obtaining x-rays once is generally sufficient
except in patients with fractures where more frequent monitoring
may be required. For patients with non-acute back pain, it may be
reasonable to obtain a second set months or years subsequently
to re-evaluate the patient’s condition, particularly if symptoms
change.
Not Recommended - in the absence of red flags (indicators of
potentially serious disease, such as fever, weight loss, nocturnal
pain, night sweats, bowel or bladder incontinence or major
trauma), imaging tests are not recommended in the first four to
six weeks of back pain symptoms.
C.1.a.ii Flexion and Extension Views
Recommended - for evaluating symptomatic spondylolisthesis in
which there is consideration for surgery or other invasive
treatment or occasionally in the setting of trauma.
Frequency/Duration: Obtaining flexion and extension and lateral
flexion and extension views are generally needed no more
frequently than every few years, in the absence of a rapidly
changing clinical course.
C.1.b Magnetic Resonance Imaging (MRI)
MRI is considered the gold standard in diagnostic imaging for defining
anatomy because it offers excellent resolution without radiation exposure.
While CT remains an important analytical tool especially for evaluating
bony or calcified structures of the spine, due to the greater resolution of
MRI, particularly with respect to soft tissue of the spine (nerve root
compression, spinal cord and nerve root abnormality) , there is less need
for using CT at the current time. Ferrous material/metallic objects in tissue
may be a contraindication for the performance of an MRI.
Patients who have had prior thoracic or lumbar surgery, concerns for
malignancy or infection may require the use of Gadolinium enhancement for
the MRI study. This should be performed in consultation of the requesting
physician taking into account any underlying medical conditions that would
be a contraindication to an enhanced MRI.
Inadequate resolution on the first scan may require a second MRI using a
different technique. A subsequent diagnostic MRI may be a repeat of the
same procedure when the rehabilitation physician (e.g. physiatrist, sports
medicine physician etc.) radiologist or surgeon documents that the study
was of inadequate quality to make a diagnosis. All questions in this regard
should be discussed with the MRI center and/or radiologist.
NYS WCB MTG - Mid and Low Back Injury 16C.1.b.i Recommended - for patients with acute back pain during the first
6 weeks if they have demonstrated a significant neurological
deficit, progressive neurologic deficit, cauda equina syndrome,
significant trauma, a history of neoplasia (cancer), or atypical
presentation (e.g., clinical picture suggests multiple nerve root
involvement).
C.1.b.ii Recommended - for acute radicular pain syndromes in the first
six weeks if the symptoms are severe and not trending towards
improvement and both the patient and the physician are willing to
consider prompt surgical treatment, assuming the MRI confirms
ongoing nerve root compression.
Frequency/Duration: Repeat MRI imaging without significant
clinical deterioration in symptoms and/or signs is not
recommended.
C.1.b.iii Recommended - for patients with non-acute radicular pain
syndromes lasting at least six weeks, in whom the symptoms are
not trending towards improvement, if both the patient and
surgeon are considering prompt surgical treatment, assuming the
MRI confirms ongoing nerve root compression.
C.1.b.iv In cases where an epidural glucocorticosteroid injection is being
considered for temporary relief of acute or subacute
radiculopathy, MRI at three to four weeks (before the epidural
steroid injection) may be reasonable (see Section D.6, Injections:
Therapeutic Spinal).
C.1.b.v Recommended - as an option for the evaluation of select non-
acute back pain patients in order to rule out concurrent pathology
unrelated to injury. This should rarely be considered before three
months and failure of several treatment modalities (including
NSAIDs, aerobic exercise, other exercise, and considerations for
manipulation, and/or acupuncture).
C.1.b.vi Not Recommended - for acute back pain or acute radicular pain
syndromes in the first six weeks, in the absence of red flags.
C.1.b.vii Not Recommended - standing or weight-bearing MRI is not
indicated for any back or radicular pain syndrome or condition. In
the absence of studies demonstrating improved patient
outcomes, this technology is currently considered
experimental/investigational.
C.1.c Computerized Tomography (CT)
Due to the far greater resolution of MRIs, particularly with respect to the soft
tissue structures of the spine, there is much less need for CT. However, CT
NYS WCB MTG - Mid and Low Back Injury 17remains a good test to evaluate bony or calcified structures of the spine. CT
is most useful to evaluate the spine in patients with contraindications for
MRI (most typically an implanted metallic-ferrous device). CT is not invasive
(minimally invasive when contrast is needed), has low potential adverse
effects, but entails radiation exposure. In patients with radicular symptoms,
CT myelography should be considered given the greater sensitivity for
identification of nerve root compression. In select patients for whom the
benefits of the procedure outweigh the risks and for whom MRI is non-
diagnostic, not indicated or clinically contraindicated.
C.1.c.i Recommended - CT is recommended in select patients (MRI
preferred) for those with radicular pain syndrome that has failed
to improve within four to six weeks and there is consideration for
an epidural glucocorticoid injection or surgical discectomy (see
Section D.6, Injections: Therapeutic Spinal).
C.1.c.ii Recommended - in patients with an indication for MRI who
cannot undergo MRI examination due to contraindications such
as implanted metallic-ferrous device or significant claustrophobia.
Frequency/Duration: Obtaining serial CT exams is not
recommended, although if there has been a significant worsening
in the patient’s history of examination, repeat imaging may be
warranted.
C.1.c.iii Not Recommended - routine CT for acute or non-acute non-
specific back pain or for radicular pain syndromes.
C.1.d Myelography (Including CT Myelography and MRI Myelography)
May be useful only when MRI or other tests are contraindicated, are not
considered diagnostic or not available. This testing may be indicated in
select patients for whom the clinical benefits outweigh the risks, and for
whom MRI is either non-diagnostic, or not clinically indicated or clinically
contraindicated.
Note: Potential complications of this more invasive technique include pain,
infection, and allergic reactions.
C.1.d.i Recommended - Myelography, including CT myelography, is
recommended in select patients in uncommon specific situations
(e.g., implanted metal that precludes MRI, equivocal findings of
disc herniation on MRI suspected of being falsely positive, spinal
stenosis, and/or a post-surgical situation that requires
myelography).
C.1.d.ii Not Recommended - Myelography (as well as CT myelography
and MRI myelography) as the first diagnostic study for the
diagnosis of lumbar root compromise.
NYS WCB MTG - Mid and Low Back Injury 18Indications: This testing may be indicated in select patients for
whom the clinical benefits outweigh the risks, and for whom MRI
is either non-diagnostic, or not clinically indicated or clinically
contraindicated.
Note: Potential complications of this more invasive technique
include pain, infection, and allergic reactions.
C.1.e Bone Scans
C.1.e.i Recommended - in select patients as clinically indicated.
Indications: Bone scanning is a good diagnostic test for specific
situations which involve a minority of patients and may be useful
in diagnosing neoplasia, suspected metastases, infection (e.g.
osteomyelitis), inflammatory arthropathies and occult fractures.
C.1.e.ii Not Recommended - for routine use in back pain patients.
Note: This technology is generally not used for evaluation of most
occupational back pain situations.
C.1.f Fluoroscopy
C.1.f.i Not Recommended - for the evaluation of acute or non-acute
back pain.
C.1.g Single Proton Emission Computed Tomography (SPECT)
C.1.g.i Recommended - in select patients as clinically indicated.
Indications: SPECT is not generally recommended, aside from
cases of suspected inflammatory arthropathies not diagnosed by
more common tests or to rule out possible acute spondylolysis;
SPECT has a very limited role in the evaluation of patients with
back pain
C.1.h Ultrasound (Diagnostic)
C.1.h.i Not Recommended - for patients with back pain.
C.1.i Videofluoroscopy
C.1.i.i Not Recommended - for the assessment of acute or non-acute
back pain.
C.2 Other Tests / Procedures
C.2.a Electrodiagnostic Studies (EDX)
NYS WCB MTG - Mid and Low Back Injury 19EDX include needle EMG, peripheral nerve conduction velocity studies
(NCV) and motor and sensory evoked potentials. Needle EMG is usually
what substantiates the diagnosis of radiculopathy or spinal stenosis in
patients with back pain and/or radiculopathy problems.
Needle EMG can help determine if radiculopathy is acute or chronic. NCV
are done in addition to needle EMG to rule out other potential causes for
the symptoms (co-morbidity or alternate diagnosis involving peripheral
nerves) and to confirm radiculopathy. It is recommended and preferred that
EDX in the out-patient setting be performed and interpreted by physicians
board-certified in Neurology or Physical Medicine and Rehabilitation.
C.2.a.i EDX (must include needle EMG and NCV)
Recommended - in select patients as clinically indicated.
Indications: Where a CT or MRI is equivocal and there are
ongoing complaints of pain, weakness, and/or
numbness/parasthesias that raise questions about whether there
may be a neurological compromise that may be identifiable. This
means leg symptoms consistent with radiculopathy, spinal
stenosis, peripheral neuropathy, etc.
Nerve conduction studies are done in addition to the needle EMG
both to rule out other potential causes for the symptoms (co-
morbidity or alternate diagnosis involving peripheral nerves, e.g.
compression neuropathies) and to confirm radiculopathy, but the
testing must include needle EMG.
Where there is failure of suspected radicular pain to resolve or
plateau after waiting four to six weeks (to provide for sufficient
time to develop EMG abnormalities as well as time for
conservative treatment to resolve the problems), equivocal
imaging findings, e.g. on CT or MRI studies, and suspicion by
history and physical examination that a neurologic condition other
than radiculopathy may be present instead of or in addition to
radiculopathy.
Not Recommended - for patients with acute or non- acute back
pain who do not have significant leg pain or numbness.
C.2.b Surface Electromyography (Surface EMG)
Not Recommended
C.2.c Diagnostic Facet Blocks
See Section D.6.f.
C.2.d Lumbar Discography
NYS WCB MTG - Mid and Low Back Injury 20Not Recommended - whether performed as a solitary test or when paired
with imaging (e.g., MRI), is not recommended for acute or non-acute back
pain or radicular pain syndromes.
Note: Improvement in surgical outcomes has not been shown to follow the
use of discography, and there is evidence that performing discography on
normal discs is associated with an enhanced risk of degenerative changes
in those discs in later years.
C.2.e CT/MRI Discography
Recommendations - See Lumbar Discography above.
C.2.f Myeloscopy
Not Recommended - for acute or non-acute back pain, spinal stenosis,
radicular pain syndromes or post-surgical back pain problems.
C.2.g Thermography
Not Recommended - for the assessment of acute or non-acute back pain,
or radicular pain patients.
D. Therapeutic Procedures: Non-Operative
Before initiation of any therapeutic procedure, the authorized treating provider, employer,
and insurer must consider these important issues in the care of the patient.
First, patients undergoing therapeutic procedure(s) should be released or returned to
modified or restricted duty during their rehabilitation at the earliest appropriate time.
Second, cessation and/or review of treatment modalities should be undertaken when no
further significant subjective or objective improvement in the patient’s condition is noted. If
patients are not responding within the recommended duration periods, alternative
treatment interventions, further diagnostic studies or consultations should be pursued.
Third, providers should provide and document education to the patient. No treatment plan
is complete without addressing issues of individual and/or group patient education as a
means of facilitating self-management of symptoms.
Lastly, for those patients who fail to make expected progress six to 12 weeks after an
injury and whose subjective symptoms do not correlate with objective signs and tests,
reexamination in order to confirm the accuracy of the diagnosis should be made. Formal
psychological or psychosocial evaluation may be considered.
Home therapy is an important component of therapy and may include active and passive
therapeutic procedures as well as other modalities to assist in alleviating pain, swelling,
and abnormal muscle tone.
NYS WCB MTG - Mid and Low Back Injury 21The following are listed in alphabetical order.
D.1 Acupuncture
Recommended - in select patients as clinically indicated.
Indications: For select use in non-acute back pain as an adjunct to more
efficacious treatments. Acupuncture may be recommended as treatment of
non- acute back pain as a limited course during which time there are clear
objective and functional goals that are to be achieved.
Not Recommended - routine use of acupuncture is not recommended for acute
back pain or radicular pain.
Not Recommended - for treatment of acute, subacute, radicular, or post-
operative low back pain.
Indications: Consideration for time-limited use in non-acute back pain patients
without underlying serious pathology is an adjunct to a conditioning program that
has both graded aerobic exercise and strengthening exercises. Acupuncture is
only recommended to assist in increasing functional activity levels more rapidly
and the primary attention should remain on the conditioning program.
This intervention is not recommended for patients not involved in a
conditioning program, or who are non- compliant with graded increases in
activity levels.
Frequency/Duration:
a) There are different patterns which are used in quality studies. These
range from weekly for a month to 20 appointments over 6 months;
however the norm is generally no more than eight to 12 sessions.
b) An initial trial of five to six appointments would appear reasonable in
combination with a conditioning program of aerobic and strengthening
exercises.
c) Future appointments should be tied to improvements in objective
measures and would justify an additional 6 sessions, for a total of 12
sessions.
Discontinuation: Resolution, intolerance, or non- compliance, including non-
compliance with aerobic and strengthening exercises.
D.2 Appliances
D.2.a Shoe Insoles and Shoe Lifts
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