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 1101-3-17-01-5 - Return to Activity and Work Considerations
Introduction. Return to activity and/or work-related activities is a primary therapeutic component of low back pain management and rehabilitation. There are special tests performed as a part of a skilled assessment of the patient's capacity to return to work, their strength capacities, and/or physical work demand classifications and tolerance. Terminology relevant to the activity and return to work discussion includes the following:
* computer enhanced evaluations,
* immobility,
* functional capacity evaluation (FCE),
* jobsite evaluation or analysis, and
* work tolerance screenings.
Communication among the patient, treating provider, employer, and insurer is essential for successful return to work efforts. Refer to the Active Therapies section for work conditioning and work simulation.
Contraindications / Complications / Side Effects and Adverse Events.
Absolute and Relative Contraindications to Return to Work.
* Absolute and relative contraindications include performance of job activities that pose a medical risk to the recovering worker.
Side Effects and Adverse Events Related to Return to Work.
* Side effects and adverse events include a temporary increase in discomfort or muscle soreness when correcting deconditioning after time away from typical tasks.
Recommendations.
Core Requirements.
Recommendation 27. A job history interview should be completed at the time of the initial evaluation. A thorough job history generally includes:
* duties and demands of job held at time of injury;
* duties and demands of current job, if different;
* stressors; and
* cognitive and social issues, with treatment incorporated into the plan of care.
Recommendation 28. A formal job description for the injured worker is required to identify physical demands at work and to assist in the creation of modified duty.
Recommendation 29. Ergonomic or adaptive equipment, therapeutic breaks, and workplace interventions are recommended to maintain employment (table 9).
Recommendation 30. Nurse case management is recommended in medically complex cases to facilitate communication between the primary provider, referral providers, insurer, employer, and employee. The patient may decline nurse case management services.
Workplace Tests Requirements.
Recommendation 31. A jobsite evaluation is permitted to fully understand the physical demands of a working day; this information can be used when determining medical causation, the need for ergonomic changes, and/or ability to return to work.
Recommendation 32. A work tolerance screening is recommended to determine a patient's tolerance for performing a specific job activity or task from a cardiovascular, postural tolerance, and physical fitness perspective.
Recommendation 33. An FCE may be used to determine an individual's capacity to work. A formal job description and jobsite evaluation, if performed, should be made available to the FCE evaluator prior to having the FCE performed.
Recommendation 34. Follow-up evaluation with the treating therapist and/or the treating physician is required between 1 to 3 days after the FCE to assess the patient's status.
Recommendation 35. FCEs are not recommended as the sole tool for the development of temporary or permanent work restrictions (table 10).
Recommendation 36. Performance during FCEs cannot be used as the sole criteria in diagnosing malingering.
Recommendation 37. Computer-enhanced strength evaluations or performance on FCEs cannot be used alone to determine return to work restrictions.
Return to Work Requirements.
Recommendation 38. It is strongly recommended that the patient return to work in a modified capacity as soon as it is medically appropriate.
Recommendation 39. Interdisciplinary services are permitted to assist the injured worker in return to work efforts (e.g., behavioral and/or psychological support, active therapy).
Recommendation 40. A graduated return to work strategy should be incorporated into a successful medical treatment plan and rehabilitation after injury with a goal of return to full duty, if medically feasible (e.g., nature and frequency of activities, and hours worked).
Recommendation 41. Permanent work restrictions should be developed based on objective information available, including:
* history;
* findings on physical examination and diagnostic testing; and
* functional response to active therapy, work conditioning, and/or modified duty.
Timing of Tests.
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Timing of Tests and Maximum Allowed |
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FCE |
1 time to determine baseline status, and 1 time to determine permanent work restrictions at case closure if it is clear that the patient cannot return to the position held at the time of injury. |
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Jobsite evaluations |
1 time for initial evaluation, 1 for mid-treatment assessment, and 1 at final evaluation. |
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Computer enhanced evaluations |
1 time for initial evaluation, 1 for mid-treatment assessment, and 1 at final evaluation. |
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Work tolerance screening |
1 time for the initial screen. May monitor improvements in strength every 3 to 4 weeks up to a total of 6 visits. |
Evidence Tables.
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Table 9. Evidence Table: Return to Work and Spine Pain |
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Summary: For workers with musculoskeletal conditions, including low back pain, workplace interventions reduce the recurrence of further injury and reduce time away from work. Such interventions involve the worker, employer, and an occupational physician, and they include ergonomic adjustments and work modification, as needed. |
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Evidence statement |
Design |
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Strong evidence |
For workers who have been absent from work due to musculoskeletal conditions, the cumulative time away from work in the first 12 months is likely to be reduced if there is a workplace intervention in which several stakeholders, including the workers, the employer, and an occupational physician, formulate a plan to reduce the recurrence of further injury; this generally will involve an ergonomic evaluation of the worksite and plans for work modification as needed. |
Systematic review |
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Good evidence |
Evidence statement |
Design |
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Workplace interventions in which several stakeholders, including the workers, the employer, and an occupational physician formulate a plan to reduce the recurrence of further injury are also likely to shorten the time needed for a first return to work, and are likely to be beneficial in reducing the risk of a recurrence of sickness absence due to the underlying musculoskeletal condition. |
Systematic review |
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Some evidence |
Evidence statement |
Design |
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An integrated care program, consisting of workplace interventions and graded activity teaching that pain need not limit activity, is effective in returning patients with chronic low back pain to work, even with minimal reported reduction of pain. |
RCT |
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Table 10. Evidence Table: FCE |
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Summary: FCEs are poor predictors of return to work, and there is no evidence that they predict re-injury. A short form FCE, designed for completion in 1 day, may have similar predictive value to standard FCEs. |
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Good evidence |
Evidence statement |
Design |
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Performance-based measures, such as those assessed in an FCE, are weakly predictive of return to work variables. Most of the variation in time for return to work is explained by factors other than the physical ability to perform specific tasks. |
Systematic review |
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Some evidence |
Evidence statement |
Design |
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Time off work and gender are important predictors for return to work, and floor-to-waist lifting may also help predict return to work; however, the strength of that relationship has not been determined. |
Cohort study |
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In chronic low back pain patients, (1) FCE task performance is weakly related to time on disability and time for claim closure and (2) even claimants who fail on numerous physical performance FCE tasks may be able to return to work. |
Cohort study |
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Some evidence cont. |
An FCE fails to predict which injured workers with chronic low back pain will have sustained return to work. |
Cohort study |
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A short form FCE reduced to a few tests produces a similar predictive quality compared to the longer 2-day version of the FCE regarding length of disability and recurrence of a claim after return to work. |
RCT |
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Lack of evidence |
Lack of evidence statement |
Design |
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There is a lack of evidence supporting the validity of FCE for prediction of re-injury following return to work. |
Systematic review |
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