Code of Colorado Regulations
1100 - Department of Labor and Employment
1101 - Division of Workers' Compensation
7 CCR 1101-3 R17 Ex 01 - Rule 17, Exhibit 1 - LOW BACK PAIN MEDICAL TREATMENT GUIDELINES
Section 7 CCR 1101-3-17-01-2 - General Guidelines Principles

Section 2.a. Education

Education of the individual and family and/or support system, as well as the employer, insurer, policy makers, and the community, should be the primary emphasis in the treatment of low back pain and disability. Currently, practitioners often think of education last, after medications, manual therapy, and surgery. Practitioners must implement strategies to educate individuals with low back pain, employers, insurance systems, policy makers, and the community as a whole. An education-based paradigm should always start with inexpensive communication that provides recovery, function-focused, patient-centered, and evidence-based information to the individual with low back pain. More in-depth education is currently a component of treatment regimens that employ functional, restorative, preventive, and rehabilitative programs. 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. Facilitation through language interpretation, when necessary, is a priority and part of the medical care treatment protocol.

Section 2.b. Shared Decision Making

Providers should implement shared decision making as a crucial element of a successful treatment plan. Patients, with the assistance of their health care practitioner and support system, should identify their personal and professional functional goals of treatment at the first visit. Progress towards the individual's identified functional goals should be addressed by all members of the health care team at subsequent visits and throughout the established treatment plan. Nurse case managers, psychologists, physical therapists, and other members of the health care team play an integral role in shared decision making and achievement of functional goals. Patient education and shared decision making should facilitate self-management of symptoms and prevention of further injury.

Section 2.c. Return to Work

Return to work is therapeutic, assuming the work is not likely to aggravate the basic problem. The practitioner must provide specific written physical limitations, and the patient should never be released to work with non-specific and vague descriptions such as "sedentary" or "light duty." The following physical limitations should be considered and modified as recommended: lifting, pushing, pulling, crouching, carrying, walking, using stairs, bending at the waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, repetitive motion tasks, sustained grip, tool usage, and vibration factors. Even if there is residual chronic pain, return to work is not usually contraindicated.

The practitioner should understand all of the physical demands of the patient's job position before returning the patient to full duty and should request clarification of the patient's job duties. Clarification should be obtained from the employer or, if necessary, including, but not limited to, an occupational health nurse, occupational therapist, vocational rehabilitation specialist, or an industrial hygienist.

Section 2.d. Treatment Parameter Duration

Time frames for specific interventions commence once treatments have been initiated, not on the date of injury. Duration will be impacted by the individual's adherence, as well as availability of services. Clinical judgment may substantiate the need to accelerate or decelerate the time frames discussed in this document.

Section 2.e. Active Interventions

Active interventions emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment, are generally utilized over passive interventions, especially as treatment progresses. Generally, passive interventions are viewed as a means to facilitate progress in an active rehabilitation program with concomitant attainment of objective functional gains.

Section 2.f. Active Therapeutic Exercise Program

Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and education. This includes functional application in vocational or community settings.

Section 2.g. Positive Patient Response

Positive results are defined primarily as functional gains that can be objectively measured. Objective functional gains include, but are not limited to: positional tolerances, range of motion (ROM), strength, endurance, activities of daily living (ADLs), ability to function at work, cognition and communication, psychological behavior, and efficiency/velocity measures that can be quantified. Subjective reports of pain and function should be considered and given relative weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on objective findings. Patient completed functional questionnaires can provide useful additional confirmation, such as those recommended by the Colorado Division of Workers' Compensation (Division) Quality Performance and Outcomes Payments program (QPOP, see Rule 18), the Patient-Specific Functional Scale, or other validated function scales.

Section 2.h. Re-evaluation of Treatment Effectiveness

Re-evaluation should occur every 3 to 4 weeks or within the time to produce effect for a given treatment. Treatment should be modified or discontinued if there is no evidence of positive results. Before discontinuing the treatment, the provider should have a detailed discussion with the patient to determine the reason for failure to produce positive results. Reconsideration of diagnosis should also occur in the event of a poor response to a seemingly rational intervention.

Section 2.i. Surgical Interventions

Surgery should be contemplated within the context of expected functional outcome and not purely for the purpose of pain relief. 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 diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with positive identification of pathologic conditions.

Section 2.j. 6-month Time Frame

The prognosis drops precipitously for returning an injured worker to work once they have been temporarily totally disabled for more than 6 months. The emphasis within these guidelines is to move patients along a continuum of care and return to work within a 6-month time frame, whenever possible. It is important to note that time frames may be less pertinent for injuries that do not involve work-time loss or are not occupationally related.

Section 2.k. Delayed Recovery

For patients who are failing to make expected progress 6 to 12 weeks after initiation of treatment of an injury, strongly consider a psychological evaluation, if not previously provided, as well as initiating interdisciplinary rehabilitation treatment and vocational goal setting. The Division recognizes that 3 to 10% of all industrially injured patients will not recover within the timelines outlined in this document, despite optimal care. Such individuals may require treatments beyond the timelines discussed within this document, but such treatment requires clear documentation by the authorized treating practitioner focusing on objective functional gains afforded by further treatment and impact upon prognosis.

Section 2.l. Post Maximum Medical Improvement (MMI) Care

Maximum medical improvement (MMI) should be declared when a patient's condition has plateaued to the point where the authorized treating physician no longer believes further medical intervention is likely to result in improved function. However, some patients may require treatment after MMI has been declared in order to maintain their functional state. The recommendations in these guidelines are for pre-MMI care and are not intended to limit post-MMI treatment.