Code of Colorado Regulations
1100 - Department of Labor and Employment
1101 - Division of Labor Standards and Statistics (Includes 1103 Series)
7 CCR 1101-3 R17 Ex 01 - Rule 17, Exhibit 1 - LOW BACK PAIN MEDICAL TREATMENT GUIDELINES
Section 7 CCR 1101-3-17-01-4 - Diagnosis
Introduction. Initial and follow-up evaluation of low back pain may include a clinical history, physical examination, laboratory studies, imaging studies, and electrodiagnostic studies. Please see specific sections for diagnostic injections.
Recommendations.
Initial Diagnostic Studies Requirements.
Recommendation 11. A detailed history of pain onset, past medical history, and a detailed neurologic examination are required at the initial low back pain evaluation (tables 2, 3).
Recommendation 12. Medical causation must establish that low back pain is a result of a specific injury, an aggravation of an underlying condition, or a previously asymptomatic condition made symptomatic by a work-related exposure (tables 4, 5).
Recommendation 13. Initial functional assessment is strongly recommended. See the Appendix Functional Screens.
Recommendation 14. A psychological screen is encouraged as a routine part of clinical care and is required as soon as any of the following barriers to functional recovery are identified (Appendix Psychological Screens):
* limited patient engagement in recovery,
* activity avoidance or catastrophization due to pain,
* avoidance of essential recovery activities,
* inappropriate expression of a sense of injustice,
* exaggeration of symptoms/situation,
* low expectations of recovery,
* ineffective coping skills, or
* loss of vocational connection.
Individuals with barriers to functional recovery may benefit from an interdisciplinary approach to care (table 6, 7).
Recommendation 15. Imaging studies before 6 weeks are not recommended for patients with uncomplicated low back pain (table 8).
Recommendation 16. Imaging studies are recommended if the patient is 55 years or older, if there is a history of significant trauma, if there is persistent or unexplained pain after 6 weeks, or if there is concern for any of the following:
* fracture,
* instability,
* occult cancer,
* weakness,
* pain worse at rest,
* cauda equina syndrome,
* epidural abscess, or
* myelopathy.
Documentation shall include the specific findings under investigation and how the imaging test will influence treatment.
Recommendation 17. When clinically indicated, early laboratory studies may be ordered to evaluate for systemic illness, infection, neoplasia, underlying rheumatologic, or connective tissue disorder.
Follow-Up Diagnostic Studies Requirements.
Recommendation 18. A formal psychological or psychosocial evaluation is required for patients not making expected progress within 6 weeks of injury and whose subjective symptoms do not correlate with objective signs and tests. See the Behavioral and Psychological Interventions section.
Recommendation 19. Magnetic resonance imaging (MRI) is indicated when there is concern for myelopathy, masses, infection, metastatic disease, or cord contusion. MRI is recommended for patients who have responded poorly to initial care and there is clinical suspicion for disc herniation, nerve root compression, or annular tear. Contrast MRI can be used when there is a history of lumbar surgery or if there is possible infection, malignancy, or tumor (table 8).
Recommendation 20. Computed tomography (CT) scan is permitted to better visualize bone and to further evaluate masses and suspected fractures not clearly identified on radiographic evaluation.
Recommendation 21. Myelography is a diagnostic option when:
* CT or MRI are contraindicated or not available, and
* when other tests have proven non-diagnostic in the surgical candidate.
Recommendation 22. Radioisotope bone scanning is permitted when there is clinical suspicion for metastatic or primary bone tumors, occult or stress fractures, osteomyelitis, infection, or other inflammatory lesions.
Recommendation 23. Discography is not generally recommended, but it is permitted when confirmatory information is necessary prior to proceeding with lumbar fusion or total disc replacement (TDR). See the Spinal Fusion or Total Disc Replacement sections.
Recommendation 24. Electromyography and nerve conduction studies are recommended for patients with suspected neural involvement and persistent symptoms that are unresponsive to initial conservative treatment.
Recommendation 25. Somat osensory evoked potentials may be used to evaluate myelopathy, neurogenic bladder, and sexual dysfunction, but it is not recommended to identify radiculopathy.
Recommendation 26. Surface electromyography and current perception threshold evaluation are not recommended.
Evidence Tables.
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Table 2. Evidence Table: Self-reported Body Pain Diagrams in Describing Low Back Pain |
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Summary: Pain diagrams, either manual or computerized, reliably identify pain location. |
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Some evidence |
Evidence statement |
Design |
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Using a computer program (electronic body surface estimation method) to measure pain distribution was found to have both high intra- and inter-examiner reliability in patients with chronic nonmalignant pain. |
Systematic review |
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Using either segmental classification or Quebec Task-Force classification to measure pain location was found to have both adequate intra- and inter-examiner reliability in patients with low back pain or lumbar radiculopathy. |
Systematic review |
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A body diagram, in which the patients use a pencil to shade in painful areas of the body, has acceptable reliability for designating the regions in which their pain is felt. |
Systematic review |
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Table 3. Evidence Table: Physical Examination Findings and Low Back Pain |
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Summary: A single neurologic test in isolation has limited diagnostic value. |
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Good evidence |
Evidence statement |
Design |
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In the setting of suspected herniated discs, a single neurologic test in isolation (such as sensory testing of specific dermatomes, weakness of specific muscles, or tendon reflexes) is of limited diagnostic value in identifying lumbar spinal disc herniation with radiculopathy. A single level disc herniation may not cause major sensory or motor deficits unless there is a large conduction block of the nerve root axons. |
Systematic review |
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Some evidence |
Evidence statement |
Design |
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In the initial clinical examination findings for adults with low back pain (who presented with radicular findings), the following prognostic factors were found to be consistent for evidence; symptom response classification (i.e., centralization) and non-organic signs. Specifically, centralization was the only factor with an association of less short-term pain. In addition, non-organic signs were the only factors associated with poor long-term outcome of return to work. |
Systematic review |
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Table 4. Evidence Table: Non-Occupational Risk Factors for Low Back Pain |
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Summary: Smoking is a risk factor for lumbar radicular pain. Severe obesity is associated with low back pain. |
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Evidence statement |
Design |
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Strong evidence |
Current and ever smoking are both moderate risk factors for patients experiencing lumbar radicular pain. |
Systematic review |
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Good evidence |
Evidence statement |
Design |
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Out of many modifiable lifestyle factors, severe obesity (defined as a body mass index [BMI] >= 35 kg/m2) was found to be most associated with lifetime chronic back pain, independent of genetic and familial factors. |
Cohort study |
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Table 5. Evidence Table: Occupational Risk Factors for Low Back Pain |
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Summary: Standing and walking in the workplace do not cause low back pain. Occupational sitting is unlikely to cause low back pain. Lifting or trunk rotation in combination with bending the trunk are risk factors for low back pain, with or without radiculopathy. There is good evidence that the combination of trunk flexion, rotation, and lifting in the workplace cumulatively is associated with low back pain. A combination of trunk flexion while repetitively lifting 50 pounds or more is a cumulative risk factor for low back pain (e.g., lifting a 50 pound box 3 feet more than 50 times per work week). Cumulative lifting (e.g., >= 7 hours per week for > 9.5 years), particularly when combined with other exposures, may result in low back pain. |
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Good evidence |
Evidence statement |
Design |
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Standing and walking do not cause low back pain. |
Systematic review |
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Trunk flexion, rotation, and lifting in the workplace cumulatively is associated with low back pain. |
Cohort study |
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Work-related factors, such as lifting and bending of the trunk or bending and twisting of the trunk, increase a worker's risk of developing lumbosacral radiculopathy. |
Systematic review |
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Some evidence |
Evidence statement |
Design |
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Whole body vibration has no important association with disc pathology in the lumbar spine in professional drivers. |
Case control study |
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Cumulative exposure to lifting in the workplace is associated with the development of low back pain. Exposures of 7 hours per week or greater, over more than 9.5 years, is associated with low back pain in an apparent dose-response relationship. The effects of lifting may only become apparent when considered in combination with other work exposures. |
Case control study |
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Sitting does not cause low back pain. |
Systematic review |
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Table 6. Evidence Table: Interdisciplinary Back Pain Care |
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Good evidence |
Evidence statement |
Design |
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Interdisciplinary programs that include screening for psychological issues, identification of fear-avoidance beliefs and treatment barriers, and establishment of individual functional and work goals will improve function and decrease disability. |
RCT |
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Good evidence cont. |
Interventions addressing fear-avoidance beliefs in populations with high baseline scores on Fear-Avoidance Behavior Questionnaire or Tampa Scale of Kinesiophobia are associated with reduction in pain (or disability) and improvements in return to work in patients with low back pain of less than 6 months duration (i.e., an acute or subacute population). |
Systematic review |
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Table 7. Evidence Table: Multidisciplinary Biopsychosocial Rehabilitation |
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Summary: Multidisciplinary interventions lead to greater improvements in function, pain, and return to work time compared to usual care or singular interventions for patients with subacute and chronic low back pain. Patients with psychosocial risk factors are more likely to benefit from a multidisciplinary approach. |
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Good evidence |
Evidence statement |
Design |
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Among people with subacute (6-12 weeks) low back pain, multidisciplinary biopsychosocial rehabilitation was significantly more effective than usual care for short (<= 3 months) and long-term ( >=12 months) pain and disability improvement, but it was no more effective than other types of treatment. For this systematic review, multidisciplinary biopsychosocial rehabilitation included a physical component (e.g., pharmacological, physical therapy, massage, manual therapy, etc.) in combination with either a psychological, social or occupational component (e.g., cognitive behavioral interventions, fear-avoidance treatment, motivational interviewing). |
Systematic review |
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Among people with subacute low back pain, multidisciplinary biopsychosocial rehabilitation was significantly more effective than usual care for return to work at the long term ( >= 12 months), but it was no more effective than other types of treatment in reducing sick leave periods at the long term. For this systematic review, multidisciplinary biopsychosocial rehabilitation included a physical component (e.g., pharmacological, physical therapy, massage, manual therapy, etc.) in combination with either a psychological, social or occupational component (e.g., cognitive behavioral interventions, fear-avoidance treatment, motivational interviewing). |
Systematic review |
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Multidisciplinary biopsychosocial rehabilitation shows small effects in reducing pain and improving disability compared to usual care, and that multidisciplinary biopsychosocial rehabilitation was more effective than physical treatment for return to work after 12 months of treatment in patients with chronic low back pain. Patients with a significant psychosocial impact are most likely to benefit. |
Meta analysis |
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Good evidence cont. |
Patients with chronic low back pain who received multidisciplinary rehabilitation had lower short-term pain intensity and greater improvement in function than those who received usual care, no rehab, and non-multidisciplinary physical therapy. |
Systematic review |
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Some evidence |
Evidence statement |
Design |
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In patients with symptomatic degenerative disc disease at L4-5 or at L5-S1 lasting more than 1 year, persisting after 6 months of physical therapy or chiropractic treatment, an initial treatment regimen consisting of rehabilitation with a multidisciplinary team of specialists may effectively improve function, defined as a 15 point improvement in the Oswestry Disability Index (ODI), in up to half of patients, making it a reasonable initial treatment option. |
RCT |
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However, a TDR is overall more effective than multidisciplinary rehabilitation for pain and function, and may improve function by the same amount in about 70% of patients. |
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Patients with persistent low back pain and subthreshold depression are at risk for developing a major depressive episode over the course of the next 12 months. A program of online self-help, based on cognitive-behavioral principles in which each participant completes weekly homework assignments and receives weekly guidance and feedback from a trained psychologist, may prevent the progression from subthreshold depression to a major depressive episode. |
RCT |
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Table 8. Evidence Table: Imaging Findings and Low Back Pain |
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Summary: Imaging findings occur frequently in asymptomatic patients and therefore are a poor indicator for clinically significant pathology. In addition, imaging may fail to detect problems identified by clinical predictors, such as physical exam findings, pain drawing, and depression. |
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Good evidence |
Evidence statement |
Design |
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In the asymptomatic population, disc bulges, disc protrusions, annular tears, high intensity zone areas, and disc height loss are prevalent 40-60% of the time, depending on the condition, study, and age of the patient. |
Cohort study |
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Some evidence |
Evidence statement |
Design |
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Extruded discs are uncommon in asymptomatic persons and are associated with low back pain. |
Cohort study |
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In patients with long-standing nerve root symptoms, MRI significantly underestimates the presence of nerve involvement otherwise detected by a combination of physical examination and simplified pain drawing. |
Diagnostic study |
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Asymptomatic subjects of all ages frequently show common degenerative changes in the cervical and lumbar spine as seen on MRI. These changes are more common with increasing age. The cervical and lumbar spine are equally affected, suggesting that disc degeneration occurs in tandem in the lumbar and cervical spine. |
Cohort study |
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The majority of workers over 60 show evidence of disc degeneration, and posterior disc protrusions are present in the majority of asymptomatic workers over 40 years of age. |
Cohort study |
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Type 1 Modic changes are at an increased risk for no improvement in pain or function and for unsuccessful return to work at 1 year. |
Cohort study |
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Depression is a more accurate predictor of the development of low back pain than many common MRI findings, such as disc bulges, disc protrusions, Modic endplate changes, disc height loss, annular tears, and facet degeneration, which are common in asymptomatic persons and are not associated with the development of low back pain. |
Cohort study |
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Early radiographic imaging without clear indications is associated with prolonged care, although it does not change functional outcomes. |
RCT |
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