New York State Workers' Comp Board. Mid and Lower Back Treatment Guidelines. Summary From 1st Edition, June 30, Effective December 1, 2010

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1 New York State Workers' Comp Board Mid and Lower Back Treatment Guidelines Summary From 1st Edition, June 30, 2010 Effective December 1, 2010 General Principles Treatment should be focused on restoring functional ability required to meet the patient's daily and work activities and return to work, while striving to restore the patient's health to it's preinjury status in so far as feasible. All treatments must be according to the Treatment Guidelines Positive response is defined as a functional gain which can be objectively measured. These include: o Positional tolerance o ROM o Strength o Endurance o ADL o Cognition o Psychological Behavior o Efficiency/Velocity measures Reevaluation should occur 2-3 weeks after initial visit and 3-4 weeks thereafter. Reconsideration of diagnosis should occur after poor response to rational intervention. Education should be a primary emphasis. Treatment time frames are effective from the time of the initial treatment, not the date of injury.

2 Return To Work Functional Capacity Evaluation In most cases, the question of whether or not a patient can return to work can be answered without an FCE. FCE 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 include: Endurance Lifting (dynamic and static) Postural tolerance Specific ROM Coordination and strength Worker Habits Employability Psychosocial, cognitive, sensory perception Components of FCE include: Musculoskeletal screen Cardiovascular profile/aerobic capacity Coordination Lift/carrying analysis Job-specific activity tolerance Maximum voluntary effort Pain assessment/psychological screening Non-material and material handling activities Cognitive Visual Sensory perception factors Return To Work Ascertaining a return to work status is part of medical care, should be included in the treatment and rehabilitation plan, and normally addressed at every outpatient visit. Early return to work should be a prime goal given the poor return to work prognosis for a patient who has been out of work for more than six months.

3 History Taking and Physical Examination HPI Should include: Mechanism of Injury: details of symptom onset and progression; detailed description of incident including body position before, during and at the end of the incident In the absence of a specific injury include a description of routine work body postures and frequency of lifting/push/pull requirements. Location of Pain: exacerbating and alleviating patterns Use of an acceptable pain assessment tool, Visual Analog Scale (VAS) recommended during first two weeks after injury. Presence and distribution of lower extremity numbness, paresthesias or weakness, especially if worsened or exacerbated with coughing/sneezing. Alteration in bowel/bladder/sexual symptoms. Prior history of dysfunction History of emotional or psychological reactions to current injury/illness Ability to perform job duties and ADL's Therapeutic Procedure Considerations Patients undergoing therapeutic procedure(s) should be returned to modified or restricted duty during their rehabilitation at the earliest appropriate time.

4 Appliances Shoe Insoles and Lifts YES: For treatment of acute, subacute or chronic back pain or radicular pain syndrome in the presence of significant leg length discrepancy NO: In the absence of significant leg length discrepancy Taping Not recommended Lumbar Supports Bed Rest ESTIM YES: for specific treatment of spondylolyis, documented instability or post operative treatment in the absence of significant LLD NO: for prevention or treatment of other back pain conditions YES: for unstable spinal fractures NO: any other spinal condition Interferential Not recommended TENS Iontophoresis YES: chronic back pain or chronic radiculopathy YES: as an adjunct to aerobic and strengthening exercise NO: for acute, subacute back pain and/or radiculopathy o If considering TENS purchase, must be tried 2-3 times in office with appropriate education. o Must be attended meaning therapist is physically present. Not recommend

5 Active Therapy Therapeutic Exercise Indications o need for cardiovascular fitness o reduced edema o improved muscle strength o improved connective tissue strength and integrity o increased bone density o promotion of circulation to enhance soft tissue healing o improvement of muscle recruitment o improved proprioception and coordination o increased range of motion o to promote normal movement patterns Time to produce effect: 2-6 treatments 3-5 times per week Optimum duration: 4-8 weeks Maximum duration: 8 weeks Aerobic Exercises (non surgical and surgical) Recommended for all patients with acute, subacute and chronic low back pain. o For most patients a structured walking program on the ground or non-incline treadmill recommended o Controversy exists over benefit of bicycling from a biomechanical perspective (lordosis) and the fact that back muscles are less active with bicycling. However, if preferred by patient over walking it is superior than no aerobic activity at all Chronic 4 times per week at 60% of max HR (220 - age) Week 1: 20 minutes Week 2: 30 minutes Week 3: 45 minutes Acute/Subacute Daily Week 1: minutes twice a day Increase min increments weekly until 30 minutes per day is achieved

6 Strength And Stabilization Exercises Recommended for all patients, surgical and non-surgical. Acute: 1-2 times a day Subacute and Chronic: 2-3 times a day Abdominal Exercises: No evidence that they are effective and some studies demonstrate that they are not effective. Massage YES: Recommended for subacute and chronic conditions and as an adjunct to more efficacious treatments consisting of aerobic and strengthening activities. YES: Acute back pain and chronic radicular symptoms in which back pain is a substantial symptom YES: Subacute and chronic back pain without underlying serious pathology such as fracture, tumor or infection. Time to produce effect: Immediate 1-2 times a week Optimum Duration: 6 weeks

7 Passive Therapy Joint Mobilization: Indications: the need to improve joint play or segmental alignment the need to improve intrascapular arthrokinematics to reduce pain associated with tissue impingement Mobilizations should be accompanied by active therapy Time to produce: Optimum duration: Maximum duration: 6-9 treatments Up to 3 times per week 4-6 weeks 6 weeks Soft Tissue Mobilization: muscle energy, strain/counterstrain, myofascial release, manual trigger point release and other manual techniques designed to improve or normalize movement patterns through the reduction of soft tissue pain and restrictions. Time to produce effect: 4-9 treatments up to 3 times a week Optimum Duration: 4-6 weeks Maximum duration: 6 weeks Superficial Heat and Cold YES: acute pain edema, hemorrhage, need to increase pain threshold reduce muscle spasm promote stretching/flexibility

8 Ultrasound Indicated for any condition where deeper heating is desired Time to produce effect: Immediate 2-5 times a week Optimum Duration: 3 weeks as primary or intermittently as adjunct Maximal Duration: 2 months Myofascial Release Not recommended Traction Not recommended

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