DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
7 CCR 1101-3
Workers’ compensation rules of procedure
Rule 17	MEDICAL TREATMENT GUIDELINES

17-5.	PROCEDURE FOR QUESTIONING CARE
(A)	In cases where treatment falls within the purview of a medical treatment guideline, prior authorization for payment is unnecessary unless the guideline specifies otherwise, or Rule 16-9 (A)(I)-(4) apply.
(B) (1)	If prior authorization is required by the Medical Treatment Guidelines or a provider requests prior authorization then the procedure for contesting a request for prior authorization for payment is under Rule 16-10.
(C)	The treatment guidelines set forth care that is generally considered reasonable for most injured workers.  However, the Division recognizes that reasonable medical practice may include deviations from these guidelines, as individual cases dictate.  For cases in which the provider requests care outside the guidelines the provider should follow the procedure for prior authorization in Rule 16-9.

RULE 17, EXHIBIT 1

Low Back Pain
Medical Treatment Guidelines
Revised:  April 26,  2007
Effective:  July 1, 2007
Adopted:   March 24, 1993	Effective:  April 30, 1993	
Revised:  March 11, 1994	Effective:  April 30, 1994	
Revised:  January  9, 1995	Effective: March 2, 1995	
Revised:  January 18, 1998	Effective: March 15, 1998	
Revised:  October 4, 2001	Effective:  December 1, 2001	
Revised:  September 29, 2005	Effective:  January 1, 2006	

Presented by:
State of Colorado
Department of Labor and Employment
DIVISION OF WORKERS' COMPENSATION

TABLE OF CONTENTS
SECTION	DESCRIPTION	PAGE
A.	INTRODUCTION	x
B.	GENERAL GUIDELINES PRINCIPLES	x
1.APPLICATION OF GUIDELINES	x
2.EDUCATION	x
3.TREATMENT PARAMETER DURATION	x
4.ACTIVE INTERVENTIONS	x
5.ACTIVE THERAPEUTIC EXERCISE PROGRAM	x
6.POSITIVE PATIENT RESPONSE	x
7.RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS	x
8.SURGICAL INTERVENTIONS	x
9.SIX-MONTH TIME FRAME	x
10 RETURN-TO-WORK	x
11.DELAYED RECOVERY	x
12.GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE	x
13.CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI)	x
C.	INITIAL DIAGNOSTIC PROCEDURES	x
1.HisTORY-TAKING AND PHYSICAL EXAMINATION (Hx & PE)	x
	a.	History of Present Injury	x
	b.	Past History	x
	c.	Physical Examination	x
	d.	Relationship to Work	x
2. RADIOGRAPHIC IMAGING	x
3. LABORATORY TESTING	x
D.	FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES	xx
1. IMAGING STUDIES	xx
	a.	Magnetic Resonance Imaging (MRI)	xx
	b.	Computed Axial Tomography (CT)	xx
	e.c.	Myelography	xx
	f.d.	CT Myelogram	xx
	c.e.	Lineal Tomography	xx
	d.f.	Bone Scan (Radioisotope Bone Scanning)	xx
	g.	Electrodiagnostic Studies/Nerve Conduction Velocities (EMG/NCV) 	..
	h.g.	Other Radionuclideisotope Scanning	xx
	h	Dynamic (Digital) Fluoroscopy............................................................................................xx
2. OTHER TESTS	xx
	b.a.	Electrodiagnostic Testing	xx
	c.b.	Injections – Diagnostic	xx
	a.c.	Personality/Psychological/Psychosocial Evaluation	xx
	d.	Provocation Discography	xx
	e.	Thermography	xx
3.     SPECIAL TESTS	xx
	a.	Computer-Enhanced Evaluations	xx
	b.	Functional Capacity Evaluation (FCE)	xx
	c.	Jobsite Evaluation	xx
	d.	Vocational Assessment	xx
	e.	Work Tolerance Screening	xx

E.	THERAPEUTIC PROCEDURES – NON-OPERATIVE	xx
1.ACUPUNCTURE	xx
	a.	Acupuncture	xx
	b.	Acupuncture with Electrical Stimulation	xx
	c. 	Total Time Frames For Acupuncture and Acupuncture with Electrical Stimulation	xx
	cd.	Other Acupuncture Modalities	xx
2.BIOFEEDBACK	xx
3.INJECTIONS – THERAPEUTIC	xx
	a.	Therapeutic Spinal Injections	xx
		i.  Epidural Steroid Injection (ESI)	xx
		ii.  Zygapophyseal (Facet) Injection	xx
		iii.  Sacroiliac Joint Injection	xx
		iv.  Intradiscal Steroid Therapy	xx
	b.	Facet Rhizotomy (Radio Frequency Medial Branch Neurotomy) /Facet Rhizotomy	xx
	c.	Sacro-Iliac (SI) Joint Radiofrequency Denervation	xx
	c.	Sacroiliac Joint Injection	
	d.	Trigger Point Injections and Dry Needling Treatment	xx
	e.	Prolotherapy	xx
	f.	Epiduroscopy and Epidural Lysis of Adhesions	xx
	f.	Sympathetic Injections 	
4.MEDICATIONS	xx
	a.	Acetaminophen	xx
	b.	Minor Tranquilizer/Muscle Relaxants	xx
	c.	Narcotics	xx
	d.	Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)	xx
	e.	Oral Steroids	xx
	f.	Intravenous Steroids...........................................................................................................xx
	fg.	Psychotropic/Anti-anxiety/Hypnotic Agents	xx
	gh.	Tramadol	xx
	h.	Topical Drug Delivery	
5.OCCUPATIONAL REHABILITATION PROGRAMS	xx
	a.	Non-Interdisciplinary	xx
	b.	Interdisciplinary	xx
6.ORTHOTICS	xx
	a.	Foot Orthoses and inserts	xx
	b.	Lumbar Support Devices	xx
	c.	Lumbar Corsets and Back Belts	xx
	b.d.	Lumbosacral Bracing	xx
7.PATIENT EDUCATION	xx
8.PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION	xx
9.RESTRICTION OF ACTIVITIES	xx
10Return-to-work	xx
	a.	Establishment of a Return-To-Work Status	xx
	b.	Establishment of Activity Level Restrictions	xx
	c.	Compliance with Activity Restrictions	xx
11.THERAPY – ACTIVE	xx
	a.	Activities of Daily Living (ADL)	xx
	b.	Aquatic Therapy	xx
	c.	Functional Activities	xx
	d.	Functional Electrical Stimulation	xx
	f.e.	Neuromuscular Re-education	xx
	ef.	Lumbar Spinal Stabilization	xx
	g.	Therapeutic Exercise 	xx
12.THERAPY – PASSIVE	xx
	a.	Electrical Stimulation (Unattended)	xx
	b.	Infrared Therapy	
	c.b.	Iontophoresis	xx
	d.c.	Manipulation	xx

	d.	Manipulation Under General Anesthesia (MUA)	xx
	e.	Manipulation Under Joint Anesthesia (MUJA)	xx
	ef.	Massage – Manual or Mechanical	xx
	f.g.	Mobilization (Joint)	xx
	gh.	Mobilization (Soft Tissue)	xx
	i.	Short-Wave Diathermy	xx
	h.j.	Superficial Heat and Cold Therapy	xx
	j.k.	Traction – Manual	xx
	k.l.	Traction – Mechanical	xx
	l.m.	Transcutaneous Electrical Nerve Stimulation (TENS)	xx
	mn.	Ultrasound (Including Phonophoresis)	xx
	n.o.	Vertebral Axial Decompression (VAX-D)/DRX, 9000	xx
	o.p.	Whirlpool/Hubbard Tank	xx
13.  vocational rehabilitation	xx
F.	THERAPEUTIC PROCEDURES – OPERATIVE	xx
1.DISCECTOMY	xx
2.CHEMONUCLEOLYSIS	
3.2PERCUTANEOUS DISCECTOMY (NUCLECTOMY) OR LASER DISCECTOMY	xx
4.3LAMINOTOMY/LAMINECTOMY/FORAMENOTOMY/FACETECTOMY	xx
5.4SPINAL FUSION	xx
6.5SACROILIAC JOINT FUSION	xx
7.6IMPLANTABLE SPINAL CORD STIMULATORS	xx
8.7INTRADISCAL ELECTROTHERMAL ANNULOPLASTY (IDEA)	xx
8.Laser Discectomy	xx
9.Artificial Lumbar Disc Replacement	xx
10.Kyphoplasty	xx
11.Vertebroplasty	xx
12.Percutaneous Radiofrequency Disc Decompression	xx
13.Nucleus Pulposus Replacement	xx
14.Epiduroscopy and Epidural Lysis of Adhesions	xx
15.Intraoperative Monitoring	xx

DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
CCR 1101-3
Rule 17, EXHIBIT 1

LOW BACK PAIN MEDICAL TREATMENT GUIDELINES

A.	INTRODUCTION
	This document has been prepared by the Colorado Department of Labor and Employment, Division of Workers’ Compensation (Division) and should be interpreted within the context of guidelines for physicians/providers treating individuals qualifying under Colorado’s Workers’ Compensation Act as injured workers with low back pain.
	Although the primary purpose of this document is advisory and educational, these guidelines are enforceable under the Workers’ Compensation Rules of Procedure, 7 CCR 1101-3.  The Division recognizes that acceptable medical practice may include deviations from these guidelines, as individual cases dictate.  Therefore, these guidelines are not relevant as evidence of a provider’s legal standard of professional care.
	To properly utilize this document, the reader should not skip nor overlook any sections.

B.	GENERAL GUIDELINES PRINCIPLES
	The principles summarized in this section are key to the intended implementation of all Division of Workers’ Compensation guidelines and critical to the reader’s application of the guidelines in this document.
1.	APPLICATION OF GUIDELINES The Division provides procedures to implement medical treatment guidelines and to foster communication to resolve disputes among the provider, payer, and patient through the Worker’s Compensation Rules of Procedure.  In lieu of more costly litigation, parties may wish to seek administrative dispute resolution services through the Division or the office of administrative courts.
2.	EDUCATION of the patient and family, 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 develop and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers, and the community as a whole.  An education-based paradigm should always start with inexpensive communication providing reassuring information to the patient.  More in-depth education currently exists within a treatment regime employing functional restorative and innovative programs of prevention and rehabilitation.  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.
3.	TREATMENT PARAMETER DURATION Time frames for specific interventions commence once treatments have been initiated, not on the date of injury.  Obviously, duration will be impacted by 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.
4.	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 interventions are viewed as a means to facilitate progress in an active rehabilitation program with concomitant attainment of objective functional gains.
5.	ACTIVE THERAPEUTIC EXERCISE PROGRAM goals should incorporate patient strength, endurance, flexibility, coordination, and education.  This includes functional application in vocational or community settings.
6.	POSITIVE PATIENT RESPONSE 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, cognition, 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.
7.	RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS If a given treatment or modality is not producing positive results within 3 to 4 weeks, the treatment should be either modified or discontinued.  Reconsideration of diagnosis should also occur in the event of poor response to a seemingly rational intervention.
8.	SURGICAL INTERVENTIONS 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.
9.	SIX-MONTH TIME FRAME The prognosis drops precipitously for returning an injured worker to work once he/she has been temporarily totally disabled for more than six months.  The emphasis within these guidelines is to move patients along a continuum of care and return to work within a six-month time frame, whenever possible.  It is important to note that time frames may not be pertinent to injuries that do not involve work-time loss or are not occupationally related.
10.	RETURN-TO-WORK is therapeutic, assuming the work is not likely to aggravate the basic problem or increase long-term pain.  The practitioner must provide specific physical limitations and the patient should never be released to “sedentary” or “light duty.”  The following physical limitations should be considered and modified as recommended:  lifting, pushing, pulling, crouching, walking, using stairs, bending at the waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors.  Even if there is residual chronic pain, return-to-work is not necessarily 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.
11.	DELAYED RECOVERY Strongly consider a psychological evaluation, if not previously provided, as well as initiating interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to make expected progress 6 to 12 weeks after an injury.  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 limits discussed within this document, but such treatment will require clear documentation by the authorized treating practitioner focusing on objective functional gains afforded by further treatment and impact upon prognosis.
12.	GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE are recommendations based on available evidence and/or consensus recommendations.  When possible, guideline recommendations will note the level of evidence supporting the treatment recommendation.  When interpreting medical evidence statements in the guideline, the following apply: 
	Consensus means the opinion of experienced professionals based on general medical principles.  Consensus recommendations are designated in the guideline as “generally well accepted,” “generally accepted,” “acceptable/accepted,” or “well-established.”
“Some” means the recommendation considered at least one adequate scientific study, which reported that a treatment was effective.
“Good” means the recommendation considered the availability of multiple adequate scientific studies or at least one relevant high-quality scientific study, which reported that a treatment was effective. 
	“Strong” means the recommendation considered the availability of multiple relevant and high quality scientific studies, which arrived at similar conclusions about the effectiveness of a treatment.
All recommendations in the guideline are considered to represent reasonable care in appropriately selected cases, regardless of the level of evidence or consensus statement attached to it.  Those procedures considered inappropriate, unreasonable, or unnecessary are designated in the guideline as being “not recommended.”
13.	CARE BEYOND 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 this guideline are for pre-MMI care and are not intended to limit post-MMI treatment.
The remainder of this document should be interpreted within the parameters of these guideline principles that may lead to more optimal medical and functional outcomes for injured workers.

C.	INITIAL DIAGNOSTIC PROCEDURES
	The Division recommends the following diagnostic procedures be considered, at least initially, the responsibility of the workers’ compensation carrier to ensure that an accurate diagnosis and treatment plan can be established.  Standard procedures, that should be utilized when initially diagnosing a work-related low back pain complaint, are listed below.
1.	HISTORY-TAKING AND PHYSICAL EXAMINATION (Hx & PE) are generally accepted, well-established and widely used procedures that establish the foundation/basis for and dictates subsequent stages of diagnostic and therapeutic procedures.  When findings of clinical evaluations and those of other diagnostic procedures are not complementing each other, the objective clinical findings should have preference.  The medical records should reasonably document the following.
a.	History of Present Injury:  A detailed history, taken in temporal proximity to the time of injury should primarily guide evaluation and treatment.  The history should include: 
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 normal work body postures, frequency during the workday, and lifting/push/pull requirements should be included in the absence of a known specific incident.
ii.	Relationship to work.  This includes a statement of the probability that the illness or injury is work-related; 
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 low back pain, secondary hip, groin).  The use of a patient completed pain drawing, Visual Analog Scale (VAS), is highly recommended, especially during the first two weeks following injury to assure that all work related symptoms are addressed;
iii. iv.	Presence and distribution of lower extremity numbness, paresthesias, or weakness, especially if precipitated by coughing or sneezing;
iv. v.	Alteration in bowel, bladder, or sexual function; and for female patients, alteration in their menstrual cycle;
v. vi.	Prior occupational and non-occupational injuries to the same area including specific prior treatment, chronic or recurrent symptoms, and any functional limitations; and Specific history regarding prior motor vehicle accidents may be helpful; and
vi. vii.	Ability to perform job duties and activities of daily living. 
b.	Past History:
i.	Past medical includes neoplasm, gout, arthritis, hypertension, kidney stones, and diabetes;
ii.	Review of systems includes symptoms of rheumatologic, neurologic, endocrine, neoplastic, infectious, and other systemic diseases;
iii.	Smoking history; and
iv.	Vocational and recreational pursuits.; and
v.	History of depression, anxiety, or other psychiatric illness.
c.	Physical Examination: should include accepted tests and exam techniques applicable to the area being examined, including:
i.	General inspection, including stance and gait;
ii.	Visual inspection;
iii.	Palpation;
iv.	Lumbar range of motion, quality of motion, and presence of muscle spasm.  Motion evaluation of specific joints may be indicated;
v.	Examination of thoracic spine and pelvis;
vi.	Nerve tension testing;
vii.	Sensory and motor examination of the lower extremities with specific nerve root focus;
viii.	Deep tendon reflexes with or without Babinski’s;
viii ix.	If applicable to injury, anal sphincter tone and/or perianal sensation; and 
ix.	If applicable, abdominal examination, vascular examination, circumferential lower extremity measurements, or evaluation of hip or other lower extremity abnormalities.;
xi. 	if applicable, Waddell Signs, which include 5 categories of clinical signs (1) tenderness- superficial and non-anatomic, (2) pain with simulation: axial loading and rotation, (3) regional findings: sensory and motor, inconsistent with nerve root patterns (4) distraction/inconsistency in straight leg raising findings, and (5) over-reaction to physical examination maneuvers.  Significance may be attached to positive findings in 3 out of 5 of these categories, but not to isolated findings.  Waddell advocates considering Waddell’s signs prior to recommending a surgical procedure.  these signs should be measured routinely to identify patients requiring further assessment (i.e., biopsychosocial) prior to undergoing back surgery.
	It is generally agreed that Waddell Signs are associated with decreased functional performance and greater subjective pain levels, though they provide no information on the etiology of pain.  Waddell Signs cannot be used to predict or diagnose malingering.  Their presence of 3 out of 5 signs may most appropriately be viewed as a “yellow flag”, or screening test, alerting clinicians to those patients who require a more comprehensive approach to their assessment and care plan.  Therefore, if 3 out of 5 Waddell Signs are positive in a patient with subacute or chronic back pain, a psychosocial evaluation should be part of the total evaluation of the patient.  Refer to Section D.2.c. Personality/Psychological/Psychosocial Evaluation.
d.	Relationship To Work:  This includes a statement of the probability that the illness or injury is work-related.  If further information is necessary to determine work relatedness, the physician should clearly state what additional diagnostic studies or job information is required.
2.	RADIOGRAPHIC IMAGING of the lumbosacral spine is a generally accepted, well-established and widely used diagnostic procedure when specific indications based on history and/or physical examination are present.  There is some evidence that early radiographic imaging without clear indications is associated with prolonged care, but no difference in functional outcomes.  Therefore, it should not be routinely performed without indications.  The mechanism of injury and specific indications for the radiograph should be listed on the request form to aid the radiologist and x-ray technician.  Suggested indications include:
a.	History of significant trauma, especially blunt trauma or fall from a height;
b.	Age over 55 years;
c.	Unexplained or persistent low back pain for at least 6 weeks or pain that is worse with rest;
d.	Localized pain, fever, constitutional symptoms, or history or exam suggestive of intravenous drug abuse, prolonged steroid use, or osteomyelitis;
e.	Suspected lesion in the lumbosacral spine as a part of a due to systemic illness such as a rheumatic/rheumatoid disorder or endocrinopathy.  Suspected lesions may require special views;
f.	Past medical history suggestive of pre-existing spinal disease, osteoporosis, spinal instrumentation, or cancer tumor; and
g.	Roentgenographic evaluation may be appropriate prior to before high-velocity/low amplitude manipulation or Grade IV to V mobilization.
3.	LABORATORY TESTING Laboratory tests are generally accepted, well-established and widely used procedures. They are, however, rarely indicated at the time of initial evaluation, unless there is suspicion of systemic illness, infection, neoplasia, or underlying rheumatologic disorder, connective tissue disorder, or based on history and/or physical examination. Laboratory tests can provide useful diagnostic information.  Tests include, but are not limited to:
a.	Complete blood count (CBC) with differential can detect infection, blood dyscrasias, and medication side effects;
b.	Erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), antinuclear antigen (ANA), human leukocyte antigen (HLA), and C-reactive protein (CRP), can be used to detect evidence of a rheumatologic, infectionus, or connective tissue disorder;
c.	Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease;
d.	Urinalysis for bacteria (usually with culture and sensitivity), calcium, phosphorus, hydroxyproline, or hematuria; and
e.	Liver and kidney function may be performed for prolonged anti-inflammatory use or other medications requiring monitoring.

D.	FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES
One diagnostic imaging procedure may provide the same or distinctive information as obtained by does another other procedures.  Therefore, the prudent choice of procedure(s) for a single diagnostic procedure, a complementary complement of procedures in combination with other procedures(s), or a sequence of proper sequential order in multiple procedures will ensure maximum optimize diagnostic accuracy; minimize adverse effect to patients and maximize cost effectiveness (by avoiding duplication or redundancy), and minimize potential adverse effects to patients.
All diagnostic imaging procedures have a significant percentage of specificity and sensitivity for various diagnoses.  All imaging procedures have a degree of specificity and sensitivity for various diagnoses.  None is specifically characteristic of a certain diagnosis no isolated imaging test can assure a correct diagnosis.  Clinical information obtained by history taking and physical examination should be form the basis for selection and interpretation of imaging procedure selecting an imaging procedure and interpreting its results. 
Magnetic resonance imaging (MRI), myelography, or Computed Axial Tomography (CT) scanning following myelography may provide useful information for many spinal disorders.  When a diagnostic procedure, in conjunction with clinical information, can provide sufficient information to establish an accurate diagnosis, the second diagnostic procedure will become a redundant procedure.  At the same time, a subsequent diagnostic procedure can be a complementary diagnostic procedure if the first or preceding procedures, in conjunction with clinical information, cannot provide an accurate diagnosis.  Usually, preference of a procedure over others depends upon availability, a patient’s tolerance, and/or the treating practitioner’s familiarity with the procedure.
1.	IMAGING STUDIES are generally accepted, well-established and widely used diagnostic procedures.  In the absence of myelopathy, or progressive neurological changes, or history of cancer, imaging usually is not appropriate until conservative therapy has been tried and failed.  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 indicated, imaging studies can be utilized for further evaluation of the low back, based upon the mechanism of injury, symptoms, and patient history.  Prudent choice of a single diagnostic procedure, a complementary combination of procedures, or a proper sequential order of complementary procedures will help ensure maximum diagnostic accuracy and minimize adverse effect to the patient. When the findings of the diagnostic imaging and testing procedures are not consistent with the clinical examination, the clinical findings should have preference.  There is good evidence that in the asymptomatic population, disc bulges, annular tears, or 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.  Therefore, the existence of these anatomic findings should not be considered relevant without physiologic and clinical correlation in an individual patient.
	The studies below are listed in frequency of use, not importance:
a.	Magnetic Resonance Imaging (MRI): is rarely indicated in patients with non-traumatic acute low back pain with no neuropathic signs or symptoms.  It is generally the first follow-up imaging study in individuals who respond poorly to proper initial conservative care.  MRI is useful in suspected nerve root compression, myelopathy, masses, infections, metastatic disease, disc herniation, annular tear, and cord contusion.  It MRI is contraindicated in patients with certain implants.
	In general, the high field, conventional, MRI provides better resolution.  A lower field scan may be indicated when a patient cannot fit into a high field scanner or who is too claustrophobic despite sedation.  Inadequate resolution on the first scan may require a second MRI using a different technique.  All questions in this regard should be discussed with the MRI center and/or radiologist.
Specialized MRI Scans
i.	MRI with 3-dimensional reconstruction

On rare occasions, MRI with 3-dimensional reconstruction views may be used as a pre-surgical diagnostic procedure to obtain accurate information of characteristics, location, and spatial relationships among soft tissue and bony structures.
ii.  	Dynamic-kinetic MRI of the spine

Dynamic-kinetic MRI of the spine uses an MRI unit configured with a top-front open design which enables upright, weight-bearing patient positioning in a variety of postures not obtainable with the recumbent images derived from conventional, closed unit MRI systems.  Imaging can be obtained in flexion, extension, and rotation of the spine, as well as in erect positioning.  There is a theoretical advantage to imaging sequences obtained under more physiologic conditions than in the supine position.  There is currently ongoing research to establish whether the theoretical advantages of positional and kinetic MRI result in improved sensitivity and specificity in detecting spine pathology.  Currently it remains investigational and is not recommended until the correlation with clinical syndromes and outcomes is firmly established.
b.	Computed Axial Tomography (CT): provides excellent visualization of bone and is used to further evaluate bony masses and suspected fractures not clearly identified on radiographic evaluation.  It may sometimes be done as a complement to MRI scanning to better delineate bony osteophyte formation in the neural foramen.  Instrument-scatter reduction software provides better resolution when metallic artifact is of concern.
c.e.	Myelography: is the injection of radiopaque material into the spinal subarachnoid space, with x-rays then taken to define anatomy.  It may be used as a pre-surgical diagnostic procedure to obtain accurate information of characteristics, location, and spatial relationships among soft tissue and bony structures.  Myelography is an invasive procedure with complications including nausea, vomiting, headache, convulsion, arachnoiditis, cerebral-spinal fluid (CSF) leakage, allergic reactions, bleeding, and infection.  Therefore, myelography should only be considered when CT and MRI are unavailable, for morbidly obese patients or those who have undergone multiple operations, multiple-operated patients, and when other tests prove non-diagnostic in the surgical candidate.  The use of small needles and a less toxic, water-soluble, nonionic contrast is preferred recommended.
d.f.	CT Myelogram: provides more detailed information about relationships between neural elements and surrounding anatomy and is appropriate in patients with multiple prior operations or tumorous conditions.
e.c.	Lineal Tomography: is infrequently used, yet may be helpful in the evaluation of bone surfaces, bony fusion, or pseudoarthrosis.
f. d.	Bone Scan (Radioisotope Bone Scanning): is generally accepted, well-established, and widely used.  Bone scanning is more sensitive but less specific than MRI.  99mTechneciumTechnetium diphosphonate uptake reflects osteoblastic activity and may be useful in diagnosing metastatic/primary bone tumors, stress fractures, osteomyelitis, and inflammatory lesions, but cannot distinguish between these entities.
g.	Electrodiagnostic Studies/Nerve Conduction Velocities (EMG/NCV):  include, but are not limited to, electromyography (EMG) and nerve conduction studies (NCS).  These are generally accepted, well-established, and widely used diagnostic procedures.  Electrodiagnostic studies may be useful in the evaluation of patients with suspected radiculopathy.
h. g.	Other Radionuclide Radioisotope Scanning: Indium and gallium scans are generally accepted, well-established, and widely used procedures usually to help diagnose lesions seen on other diagnostic imaging studies.  67Gallium citrate scans are used to localize tumor, infection, and abcesses abscesses.  111Indium-labeled leukocyte scanning is utilized for localizingation of infection or inflammation.
h. 	Dynamic [Digital] Fluoroscopy:  Dynamic [Digital] Fluoroscopy of the lumbar spine measures the motion of intervertebral segments using a videofluoroscopy unit to capture images as the subject performs lumbar flexion and extension, storing the anatomic motion of the spine in a computer.  Currently it is not recommended for use in the diagnosis of lumbar instability, since there is limited information on normal segmental motion for the age groups commonly presenting with low back pain, and diagnostic criteria for specific spinal conditions are not yet defined.  No studies have yet demonstrated predictive value in terms of standard operative and non-operative therapeutic outcomes.
2.	OTHER TESTS The following studies diagnostic procedures in this subsection are listed by frequency of use, in alphabetical order, not by importance:
b.a.	Electrodiagnostic Testing:  Electrodiagnostic tests include, but are not limited to: 
i.  	Electromyography (EMG), Nerve Conduction Studies (NCS):, and Somatosensory Evoked Potentials (SSEP).  These are generally accepted, well-established and widely used diagnostic procedures.  The SSEP study, although it is generally accepted, has limited use.   Electrodiagnostic studies EMG and NCS, when performed and interpreted by a trained physician/electrophysiologist, may be useful for patients with suspected neural involvement whose symptoms are persistent or unresponsive to initial conservative treatments.  They are used to differentiate peripheral neural deficits from radicular and spinal cord neural deficits and to rule out concomitant myopathy.  Current Perceptual Threshold Evaluation (CPT) may be useful as a screening tool, but its diagnostic efficacy in the evaluation of industrial low back pain has not been determined.  However, F-Wave Latencies are not diagnostic for radiculopathy. 
	In general, these diagnostic EMG and NCS procedures are complementary to imaging procedures such as CT, MRI, and/or myelography or diagnostic injection procedures.  Electrodiagnostic studies may provide useful, correlative neuropathophysiological information that would be otherwise unobtainable from the standard radiologic studies discussed above. 
ii.	Portable Automated Electrodiagnostic Device (also known as Surface EMG) is not a substitute for conventional diagnostic testing in clinical decision-making, and therefore, is not recommended. 
iii. 	Somatosensory Evoked Potential (ssep) is not recommended to identify radiculopathy.  It may be used to evaluate myelopathy and other rare neurological disorders such as neurogenic bladder and sexual dysfunction.
iv. 	Current Perception Threshold (CPT) Evaluation   may be useful as a screening tool, but its diagnostic efficacy in the evaluation of industrial low back pain has not been determined.  Therefore, CPT is not recommended as a diagnostic tool.
v.	Large Array Surface Electromyography measures low back muscle activity using a fixed array of 63 electrodes arranged in 9 rows and 7 columns between the seventh thoracic spinous process and the iliac crest.  The array simultaneously collects myoelectric data from multifidus, iliocostalis, quadratus lumborum, and other lumbar muscles, which is analyzed for patterns of activity in these muscle groups.  It is used in researching physiologic changes and adaptations to back pain, but is not recommended as a diagnostic procedure for individuals with back pain due to a lack of interpretive standards.
vi.	Surface EMG in combination with Range of Motion and/or Functional Capacity Evaluation 
This is designed to detect differences between persons with and without low back pain, measuring signals in lumbar flexion which show that painful paraspinal muscles fail to relax fully.  It may show aspects of the pathophysiology of muscle activity which advance the scientific understanding of low back pain.  The test also purports to determine the significance of disc pathology and the age of an injury.  It has not been evaluated in a setting which tests a spectrum of patients commonly seen in clinical practice, using an interpretation which is tested against a diagnostic reference standard.  Therefore, it is not suitable as a diagnostic test for low back pain and its use for this purpose is not recommended.
c.b.	Injections — Diagnostic:
i.	Description  Diagnostic spinal injections are generally accepted, well-established procedures.  These injections may be useful for localizing the source of pain, and may have added therapeutic value when combined with injection of therapeutic medication(s).  Each diagnostic injection has inherent risks, and risk versus benefit should always be evaluated when considering injection therapy.  
ii.	Indications - Since these procedures are invasive, less invasive or non-invasive procedures should be considered first.  Selection of patients, choice of procedure, and localization of the level for injection should be determined by clinical information indicating strong suspicion for pathologic condition(s) and the source of pain symptoms.  Because injections are invasive with an inherent risk, the number of diagnostic procedures should be limited in any individual patient to those most likely to be primary pain generators.  Patients should not receive all of the diagnostic blocks listed merely in an attempt to identify 100% of the pain generators.  
iii.	The interpretation of the test results are is primarily based upon on functional change, symptom report, and pain response (via a recognized pain scale), before and at an appropriate time period after the injection.  The diagnostic significance of the test result should be evaluated in conjunction with clinical information and the results of other diagnostic procedures.  Injections with local anesthetics of differing duration may be used to support a are required to confirm the diagnosis. of pain.  In some cases, injections at multiple levels may be required to accurately diagnose low back pain.  (Refer to Section E.3. “Injections – Therapeutic” for information on specific injections.)
It is obligatory that sufficient data be accumulated by the examiner performing this procedure such that the diagnostic value of the procedure be evident to other reviewers.  This entails, at a minimum, documentation of patient response immediately following the procedure with details of any symptoms with a response and the degree of response.  Additionally, a log must be recorded as part of the medical record which documents response, if any, on an hourly basis for, at a minimum, the expected duration of the local anesthetic phase of the procedure.  Responses must be identified as to specific body part (e.g., low back, leg pain).  The practitioner must identify the local anesthetic used and the expected duration of response for diagnostic purposes.
Multiple injections provided at the same session without staging may seriously dilute the diagnostic value of these procedures.  Practitioners must carefully weigh the diagnostic value of the procedure against the possible therapeutic value.
ii.iv.	Special Requirements for Diagnostic Injections  Since multi-planar fluoroscopicy arthrographic and/or CT guidance during procedures is required to document technique and needle placement, an experienced physician should perform the procedure.  Permanent images are required to verify needle placement.  The subspecialty disciplines of the physicians performing the injections may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry.  The practitioner should have experience in ongoing injection training workshops document hands-on training through workshops of the type provided offered by organizations such as the International Spinale Injection Intervention Society (ISIS) and/or completed a fellowship in pain medicine with interventional training.  They must also be knowledgeable in radiation safety.  In addition, practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments of Radiology, as applicable.
iii. v.	Complications- General complications of diagnostic injections may include transient neurapraxia, nerve injury, infection, headache, urinary retention, and vasovagal effects, as well as epidural hematoma, permanent neurologic damage, dural perforation, and CSF leakage, and spinal meningeal abscess.  Permanent paresis, anaphylaxis, and arachnoiditis have been rarely reported with the use of epidural steroids.
iv. vi.	Contraindications  Absolute contraindications of to diagnostic injections include: (a) bacterial infection – systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d) possible pregnancy.  
	Relative contraindications of to diagnostic injections may include:  (a) allergy to contrast, (b) poorly controlled Diabetes Mellitus or and hypertension., (c) aspirin/antiplatelet therapy (drug may be held for 3 days prior to injection), and (d) shellfish allergy, if contrast to be used.  Drugs affecting coagulation require restriction from use.  The following are suggested time period restrictions:

•	Aspirin-withhold for seven days;
•	NSAIDs-withhold for three days;
•	Clopidogrel-withhold for 3 days;
•	Other anti-platelet therapy and anti-coagulants should also be addressed individually by a knowledgeable specialist.
vii.	Specific Diagnostic Injections  In general, relief should last for at least the duration of the local anesthetic used and give should significantly relief of relieve pain and result in functional improvement.  Refer to “Injections – Therapeutic” for information on specific therapeutic injections.
A)	Medial Branch Blocks are primarily generally accepted diagnostic injections, used to determine whether a patient is a candidate for facet rhizotomy radiofrequency medial branch neurotomy (also known as facet rhizotomy).  ISIS suggests controlled blocks – using either placebo or anesthetics with varying lengths of activity (i.e., bupivacaine longer than lidocaine).  To be a positive diagnostic block, the patient should report a reduction of pain of 80% or greater relief from baseline for the length of time appropriate for the local anesthetic used.  In almost all cases, this will mean a reduction of pain to 1 or 2 on the Visual Analog Scale (VAS) 10-point scale correlated with functional improvement.  The patient should also identify activities of daily living (which may include measurements of range of motion) that are impeded by their pain and can be observed to document functional improvement in the clinical setting.  Ideally, these activities should be assessed throughout the observation period for function.  The observer should not be the physician who performed the procedure.  It is suggested that this be recorded on a form similar to ISIS recommendations.
	A separate comparative block on a different date should be performed to confirm the level of involvement.  A comparative block uses anesthetics of varying lengths of activity.  Medial Branch blocks are probably not helpful to determine the likelihood of success for spinal fusion. 
•	Frequency and Maximum Duration:  May be repeated once for comparative blocks.  Limited to 4 levels
B)	Transforaminal injections are generally accepted and useful in identifying spinal pathology. and can require repeat injections at multiple levels.  When used performed for diagnosis, small amounts of local anesthetic up to a total volume of 1.0  to 1.5 cc should be used to determine the level of nerve root irritation.  The relief should last for at least the duration of the local anesthetic used and give significant relief of pain. A positive diagnostic block should result in a positive diagnostic functional benefit and an 80% reduction in nerve-root generated pain appropriate for the anesthetic used as measured by accepted pain scales (such as a VAS).
•	Time to produce effect:  Less than 30 minutes for local anesthesia; corticosteroids up to 72 hours for most patients
•	Frequency and Maximum Duration:  Once per suspected level.  limited to two levels
C) 	Zygapophyseal (Facet) Blocks:
Facet blocks are generally accepted but should not be considered diagnostic blocks for the purposes of determining the need for a rhizotomy (radiofrequency medial branch neurotomy), nor should they be done with medial branch blocks.
These blocks should not be considered a definitive diagnostic tool.  They may be used diagnostically to direct functional rehabilitation programs.  A positive diagnostic block should result in a positive diagnostic functional benefit and an 80% reduction in pain appropriate for the anesthetic used as measured by accepted pain scales (such as a VAS).  They then may be repeated per the therapeutic guidelines when they are accompanied by a functional rehabilitation program.  (Refer to section E. 3. a. Therapeutic Spinal Injections).
•	Time to produce effect:  Less than 30 minutes for local anesthesia; corticosteroids up to 72 hours for most patients.
•	Frequency and maximum Duration:  Once per suspected level, limited to two levels.
c. D)	Sacroiliac Joint Injection:
	1)	Description  A generally accepted Injection of local anesthetic in an intra-articular fashion into the sacroiliac joint under fluoroscopic guidance.  Long-term therapeutic effect has not yet been established.
	2)	Indications  Primarily diagnostic to rule out sacroiliac joint dysfunction versus other pain generators.  Intra-articular injection can be of value in diagnosing the pain generator.  There should be documented relief from previously painful maneuvers (e.g., Patrick’s test) and at least 80% pain relief on post-injection physical exam (as measured by accepted pain scales such as a VAS) correlated with functional improvement.  Sacroiliac joint blocks should facilitate functionally directed rehabilitation programs.  

•	Time to produce effect:  Up to 30 minutes for local anesthetic

•	Frequency and Maximum Duration: 1
a.c.	Personality/Psychological/Psychosocial/ Evaluation:  are generally accepted and well-established diagnostic procedures with selective use in the acute low back pain population, but have and more widespread use in sub-acute and chronic low back pain populations.
Diagnostic testing procedures may be useful for patients with symptoms of depression, delayed recovery, chronic pain, recurrent painful conditions, disability problems, and for pre-operative evaluation as well as a possible predictive value for post-operative response.  Psychological testing should provide differentiation between pre-existing depression versus injury-caused depression, as well as post-traumatic stress disorder.
Formal psychological or psychosocial evaluation should be performed on patients not making expected progress within 6-12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests.  In addition to the customary initial exam, the evaluation of the injured worker should specifically address the following areas:
i.	Employment history;
ii.	Interpersonal relationships — both social and work;
iii.	Leisure activities;
iv.	Current perception of the medical system;
v.	Results of current treatment;
vi.	Perceived locus of control; and
vii.	Childhood history, including abuse and family history of disability.
Results This information should provide clinicians with a better understanding of the patient, thus allowing for and enable a more effective rehabilitation.  The evaluation will determine the need for further psychosocial interventions, and in those cases, a Diagnostic Statistical Manual (DSM) of Mental Disorders  diagnosis should be determined and documented.  An individual with a PhD, PsyD, or Psychiatric MD/DO credentials may should perform initial evaluations, which are generally completed within one to two hours.  A professional fluent in the primary language of the patient is strongly preferred.  When such a provider is not available, services of a professional language interpreter must be provided.  When issues of chronic pain are identified, the evaluation should be more extensive and follow testing procedures as outlined in the Division’s Chronic Pain Disorder Medical Treatment Guidelines.
•	Frequency:  One time visit for evaluation.  If psychometric testing is indicated as a portion of the initial evaluation, time for such testing should not exceed an additional two hours of professional time.
d.	Provocation Discography:
i.	Description  Discography is an generally accepted, but rarely indicated, well-established   invasive diagnostic procedure to identify or refute a discogenic source of pain for patients who are surgical candidates.  Discography should only be performed by physicians who are experienced and have been proctored in the technique.  discograms have a significant false positive rate.  it is essential that all indications, pre-conditions, special considerations, procedures, reporting requirements, and results are carefully and specifically followed.  results should be interpreted judiciously.
ii.	Indications  Discography may be indicated when a patient has a history of functionally limiting, unremitting low back pain of greater than three four months duration, with or without leg pain, which has been unresponsive to all conservative interventions.  A patient who does not desire surgical operative therapeutic intervention is not a candidate for an invasive non-therapeutic intervention, such as provocativeon discography.  
Discography may prove useful for the evaluation of the pre-surgical spine, such as pseudoarthrosis, discogenic pain at levels above or below a prior spinal fusion, annular tear, or internal disc disruption.
Discography may show disc degeneration and annular disruption in the absence of low back pain.  Discography may also elicit concordant pain in patients with mild and functionally inconsequential back pain.  Because patients with mild back pain should not be considered for invasive treatment, discography should not be performed on these patients.  In symptomatic patients with annular tears on discography, the side of the tear does not necessarily correlate with the side on which the symptoms occur. The presence of an annular tear does not necessarily identify the tear as the pain generator.
Discography is not useful in previously operated discs., but may have a limited place in the work-up of pseudarthrosis.  In addition, d iscography Discography may prove useful in evaluationng of the number of lumbar spine levels that might require fusion.  It has also been utilized to differentiate organic from psychogenic factors.  CT-Discography provides further detailed information about morphological abnormalities of the disc and possible lateral disc herniations.
iii.	Pre-conditions for provocativeion discography include all of the following:
A)	A patient with functionally limiting, unremitting back and/or leg pain of greater than 3 four months duration in whom conservative treatment has been unsuccessful and in whom the specific diagnosis of the pain generator has not been made apparent on the basis of other noninvasive imaging studies (e.g., MRI, CT, plain films, etc.).  It is recommended that discography be reserved for use in patients with equivocal MRI findings, especially at levels adjacent to clearly pathological levels. and in whom a psychosocial evaluation has been considered. Discography may be more sensitive than MRI or CT in detecting radial annular tears.  However, radial tears must always be correlated with clinical presentation.
B)	Psychosocial Evaluation has been completed.  There is some evidence that false positives and complaints of long-term pain arising from the procedure itself occur more frequently in patients with somatoform disorders.  Therefore, discograms should not be performed on patients with somatoform disorders. 
B) C)	Patients who are considered surgical candidates (e.g., symptoms are of sufficient magnitude and the patient has been informed of the possible surgical options that may be available based upon the results of discography).  Discography should never be the sole indication for surgery.
C) D)	Informed consent regarding the risks and potential diagnostic benefits of discography has been obtained.
iv.	Complications  Complications iinclude, but are not limited to, discitis, nerve damage, chemical meningitis, pain exacerbation, and anaphylaxis may occur with discography.  Therefore, prior to consideration of discography, the patient should undergo other diagnostic modalities in an effort to define the etiology of the patient's complaint including psychological screening evaluation, myelography, CT and MRI.
v.	Contraindications  Contraindications for provocative discography may include: (a) active infection of any type or continuing antibiotic treatment for infection; and/or (b) bleeding diathesis or pharmaceutical anticoagulation with warfarin, etc.; and/or (c) significant spinal stenosis at the level being studied as visualized by MRI, myelography or CT scan; and/or (d) presence of clinical myelopathy; and/or (e) effacement of the cord, thecal sac or circumferential absence of epidural fat; and (f) known allergic reactions.
vi.	Special Considerations:
A)	Discography should not be done by the treating surgeon, should not be performed by the physician expected to perform the therapeutic procedure.  And  tThe procedure should be carried out by an experienced individual who has received specialized training in the technique of provocativeon discography.
B)	Discography should be performed in a blinded format that avoids leading the patient with anticipated responses.  The procedure should always include one or more disc levels thought to be normal or non-painful in order to serve as an internal control.  The patient should not know what level is being injected in order to avoid spurious results.  Abnormal disc levels may be repeated to confirm concordance. 
C)	Sterile technique should must be utilized.  
D)	Judicious use of light sedation during the procedure is acceptable, and represents the most common practice nationally at the current time, and is recommended by most experts in the field.  The patient must be awake and able to accurately report pain levels during the provocation portion of the procedure. 
E)	The discography should be performed using a manometer to record pressure.  Pressure should not exceed 50 pounds per square inch (psi) above opening pressure. 
E)  F)	CT or MRI must have established spinal dimensions and ruled out spinal stenosis.
F)	Intradiscal injection of local anesthetic should may be carried out after the provocativeon portion of the examination and the patient’s response.
G) 	It is recommended that a post-discogram CT be considered as it frequently provides additional useful information about disc morphology or other pathology.
vii.	Reporting of Discography  In addition to a narrative report, the discography report should contain a standardized classification of (a) disc morphology and (b) the pain response, and (c) maximum the pressure at which pain is produced.  Both All results should be clearly separated in the report from the narrative portion.  Asymptomatic annular tears are common and the concordant pain response is an essential finding for a positive discogram.  Alternative reporting techniques using pressure monitors are being investigated and may prove useful in identifying patients with discogenic pain.
When discography is performed to identify the source of a patient’s low-back pain, both a concordant pain response and morphological abnormalities must be present at the pathological level prior to initiating any treatment directed at that level.  The patient must be awake during the provocation phase of the procedure; therefore, sedative medication must be carefully titrated.
Caution should be used when interpreting results from discography.  In one study of patients without lumbar pathology, 10% of pain free patients experienced pain with discography and 83% of patients with somatization disorder experienced pain with lumbar discography. Several studies indicate that a false positive discogram for pain is likely above a pressure reading of 50 psi above opening pressure.  The false positive rate appears to drop to approximately 25% using a pressure of 20 psi above opening pressure in a population with low back pain.
A)	Reporting disc morphology as visualized by the post-injection CT scan (when available) should follow the Modified Dallas Discogram Scale where:
Grade 0 = Normal Nucleus
Grade 1 = Annular tear confined to inner one-third of annulus fibrosis.
Grade 2 = Annular tear extending to the middle third of the annulus fibrosis.
Grade 3 = Annular tear extending to the outer one-third of the annulus fibrosis.
Grade 4 = A grade 3 tear plus dissection within the outer annulus to involve more than 30 of the disc circumference.
Grade 5 = Full thickness tear with extra-annular leakage of contrast, either focal or diffuse.
B)	Reporting of pain response should be according to the modified Aprill Scheme.  In this scheme, codes are assigned a response during the initial injection (“P” provocative response) and the response to an injection of the local anesthetic (“R” response) where:
P0 = No Pain
P1 = Procedural pain, or pain that is non-concordant with the patient’s familiar pain 
P2 = Concordant pain
R0 = No pain relief with injection of local anesthetic
R1 = Partial relief
R2 = Complete relief
N = Nondiagnostic, nonphysiologic injection.  The final category of “N” is suggested when the discographer concludes that the provocative portion of the injection is nondiagnostic.  For example, a patient with a morphologically normal disc who responds when typical pain is reproduced is considered to have a non-diagnostic or nonphysiologic response.  Other circumstances may occur that cause the discographer to conclude that the provocative portion of the injection is invalid. The category “N” should be used for these situations.

•	Time to produce effect:  Immediate
•	Frequency:  One time only
•	Optimal duration:  One time
•	Maximum duration:  Repeat discography is rarely indicated.
B)	Reporting of pain response should be consistent with the operational criteria of the International Spine Intervention Society (ISIS) Guidelines.  The report must include the level of concordance for back pain and leg pain separately using a 10-point VAS, or similar quantitative assessment.  it should be noted that change in the VAS scale before and after provocation is more important than the number reported. 
1)  Unequivocal Discogenic Pain
•	stimulation of the target disc reproduces concordant pain
•	the pain is registered as at least 7 on a 10-point VAS.
•	the pain is reproduced at a pressure of less than 15 psi above opening pressure; and
•	stimulation of two adjacent discs does not produce pain at all
2)  Definite Discogenic Pain
•	stimulation of the target disc reproduces concordant pain
•	the pain is registered as at least 7 on a 10-point VAS.
•	the pain is reproduced at a pressure of less than 15 psi above opening pressure; and
•	stimulation of at least one adjacent disc does not produce pain at all
3)  Highly Probable Discogenic Pain
•	stimulation of the target disc reproduces concordant pain
•	that pain is registered as at least 7 on a 10-point VAS.
•	that the pain is reproduced at a pressure of less than 50 psi above opening pressure; and
•	stimulation of two adjacent discs does not produce pain at all
4)  Probable Discogenic Pain
•	stimulation of the target disc reproduces concordant pain
•	that pain is registered as at least 7 on a 10-point VAS.
•	the pain is reproduced at a pressure of less than 50 psi above opening pressure; and
•	stimulation of one adjacent disc does not produce pain at all, and stimulation of another adjacent disc at greater than 50 psi, produces pain, but the pain is not concordant.
multiple combinations of factors are possible.  however, if the patient does not qualify for at least a ‘Probable Discogenic Pain’ level, then the discogram should be considered negative.  The VAS score prior to the discogram should be taken into account when interpreting the VAS score reported by the patient during the discogram. 
Time Parameters for Provocation Discography are as follows:

•	Frequency: One time only

•	Maximum:  Repeat Discography is rarely indicated
e.	Thermography:  is an accepted and established procedure, but has limited no use as a diagnostic test for low back pain.  It may be used to diagnose regional pain disorders and in these cases, refer to the Division’s Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy Medical Treatment Guidelines.
3.	SPECIAL TESTS are generally well-accepted tests and are performed as part of a skilled assessment of the patients’ capacity to return to work, his/her strength capacities, and physical work demand classifications and tolerance. The procedures in this subsection are listed in alphabetical order, not by importance. 
a.	Computer-Enhanced Evaluations:  may include isotonic, isometric, isokinetic and/or isoinertial measurement of movement, range of motion, endurance, or strength.  Values obtained can include degrees of motion, torque forces, pressures, or resistance.  Indications include determining validity of effort, effectiveness of treatment and demonstrated motivation.  These evaluations should not be used alone to determine return to work restrictions.
•	Frequency:  One time for evaluation.  Can monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations.
b.	Functional Capacity Evaluation (FCE):  is a comprehensive or modified evaluation of the various aspects of function as they relate to the worker’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 and financial status, as well as psychosocial, cognitive, and sensory perceptual aspects of competitive employment 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; and (h) non-material and material handling activities;. 
	When an FCE is being used to determine return to a specific jobsite, the provider is responsible for fully understanding the job duties.  A jobsite evaluation is frequently necessary.  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.
	Full FCEs are rarely necessary.  in many cases, a work tolerance screening will identify the ability to perform the necessary job tasks.
•	Frequency:  Can be used initially to determine baseline status.  Additional evaluations can be performed to monitor and assess progress and aid in determining the endpoint for treatment.
c.	Jobsite Evaluation: is a comprehensive analysis of the physical, mental, and sensory components of a specific job.  These components may include, but are not limited to: (a) postural tolerance (static and dynamic); (b) aerobic requirements; (c) range of motion; (d) torque/force; (e) lifting/carrying; (f) cognitive demands; (g) social interactions; (h) visual perceptual; (i) sensation; (j) coordination; (k) environmental requirements of a job; (j) (l) repetitiveness; and (k)  (m) essential job functions of a job.  Job descriptions provided by the employer are helpful but should not be used as a substitute for direct observation.
	A jobsite evaluation may include observation and instruction of how work is done, what material changes (desk, chair) should be made, and determination of readiness to return to work. 
	Requests for a jobsite evaluation should describe the expected goals for the evaluation.  Goals may include, but are not limited to the following: 
	i. 	To determine if there are potential contributing factors to the person’s condition and/or for the physician to assess causality;
	ii. 	To make recommendations for, and to assess the potential for ergonomic changes;
	iii. 	To provide a detailed description of the physical and cognitive job requirements;
	iv. 	To assist the patient in their return to work by educating them on how they may be able to do their job more safely in a biomechanically appropriate manner;
	v. 	To give detailed work/activity restrictions. 
•	Frequency:  One time with additional visits as needed for follow-up per jobsite.
d.	Vocational Assessment:  Once an authorized practitioner has reasonably determined and objectively documented that a patient will not be able to return to his/her former employment and can reasonably prognosticate final restrictions, implementation of a timely vocational assessment can be performed.  If the injury is such that the practitioner can easily determine that the worker will be unable to return to his/her previous occupation, then vocational rehabilitation assistance at that time may aid in the overall medical management and rehabilitation of the patient.  The physician may decide that the patient is unable to return to the previous occupation prior to declaration of maximum medical improvement (MMI).
	The vocational assessment should provide valuable guidance in the determination of future rehabilitation program goals.  It should clarify rehabilitation goals, which optimize both patient motivation and utilization of rehabilitation resources.  The physician should have identified the expected permanent limitation(s) prior to the assessment.  If prognosis for return to former occupation is determined to be poor, except in the most extenuating circumstances, vocational assessment should be implemented within 3 to 12 months post-injury.  Declaration of Maximum Medical Improvement MMI should not be delayed solely due to lack of attainment of a vocational assessment.
•	Frequency:  One time with additional visits as needed for follow-up.
e.	Work Tolerance Screening:  is a determination of an individual's tolerance for performing a specific job as based on a job activity or task and may be used when a full Functional Capacity Evaluation is not indicated.  It may include a test or procedure to specifically identify and quantify work-relevant cardiovascular, physical fitness and postural tolerance.  It may also address ergonomic issues affecting the patient’s return-to-work potential.  May be used when a full Functional Capacity Evaluation is not indicated.
•	Frequency:  One time for  evaluation initial screen.  May monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations visits.
E.	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 injured worker.
First, patients undergoing therapeutic procedure(s) should be released or returned to modified or restricted duty during their rehabilitation at the earliest appropriate time.  Refer to “Return-to-Work” in this section for detailed information.
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, formal psychological or psychosocial screening evaluation should be performed on patients not making expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests.
In cases where a patient is unable to attend an outpatient center, home therapy may be necessary. 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.  Home therapy is usually of short duration and continues until the patient is able to tolerate coming to an outpatient center.
Non-operative treatment procedures for low back pain can be divided into two groups: conservative care and rehabilitation.  Conservative care is treatment applied to a problem in which spontaneous improvement is expected in 90% of the cases within three months.  It is usually provided during the tissue-healing phase and lasts no more than six months, and often considerably less.  Rehabilitation is treatment applied to a more chronic and complex problem in a patient with de-conditioning and disability.  It is provided during the period after tissue healing to obtain maximal medical recovery.  Treatment modalities may be utilized sequentially or concomitantly depending on chronicity and complexity of the problem, and treatment plans should always be based on a diagnosis utilizing appropriate diagnostic procedures.
	The following procedures are listed in alphabetical order.
1.	ACUPUNCTURE is an accepted and widely used procedure for the relief of pain and inflammation, and there is some scientific evidence to support its use.  The exact mode of action is only partially understood.  Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the brain, promotes deep relaxation, and affects the release of neurotransmitters.  Acupuncture is commonly used as an alternative or in addition to traditional Western pharmaceuticals.  While it is commonly used when pain medication is reduced or not tolerated, it may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten the return of functional activity.  Acupuncture should be performed by credentialed licensed practitioners.
a.	Acupuncture: is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points).  Needles may be inserted, manipulated, and retained for a period of time. Acupuncture can be used to reduce pain, reduce inflammation, increase blood flow, increase range of motion, decrease the side effect of medication-induced nausea, promote relaxation in an anxious patient, and reduce muscle spasm.
Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain.
•	Time to produce effect:  3 to 6 treatments
•	Frequency:  1 to 3 times per week
•	Optimum duration:  1 to 2 months
•	Maximum duration:  14 treatments
b.	Acupuncture with Electrical Stimulation:  is the use of electrical current (micro-amperage or milli-amperage) on the needles at the acupuncture site.  It is used to increase effectiveness of the needles by continuous stimulation of the acupoint. Physiological effects (depending on location and settings) can include endorphin release for pain relief, reduction of inflammation, increased blood circulation, analgesia through interruption of pain stimulus, and muscle relaxation. 
It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.
c.	Total Time Frames For Acupuncture and Acupuncture with Electrical Stimulation:  Time frames are not meant to be applied to each of the above sections separately.  The time frames are to be applied to all acupuncture treatments regardless of the type or combination of therapies being provided.
•	Time to produce effect:  3 to 6 treatments
•	Frequency:  1 to 3 times per week
•	Optimum duration:  1 to 2 months
•	Maximum duration:  14 treatments
Any of the above acupuncture treatments may extend longer if objective functional gains can be documented or when symptomatic benefits facilitate progression in the patient’s treatment program.  Treatment beyond 14 treatments must be documented with respect to need and ability to facilitate positive symptomatic or functional gains.  Such care should be re-evaluated and documented with each series of treatments.
d.c.	Other Acupuncture Modalities:  Acupuncture treatment is based on individual patient needs and therefore treatment may include a combination of procedures to enhance treatment effect.  Other procedures may include the use of heat, soft tissue manipulation/massage, and exercise.  Refer to Active Therapy (Therapeutic Exercise) and Passive Therapy sections (Massage and Superficial Heat and Cold Therapy) for a description of these adjunctive acupuncture modalities and time frames.
•	Time to produce effect:  3 to 6 treatments
•	Frequency:  1 to 3 times per week
•	Optimum duration:  1 to 2 months
•	Maximum duration:  14 treatments
2.	BIOFEEDBACK is a form of behavioral medicine that helps patients learn self-awareness and self-regulation skills for the purpose of gaining greater control of their physiology, such as muscle activity, brain waves, and measures of autonomic nervous system activity.  Electronic instrumentation is used to monitor the targeted physiology and then displayed or fed back to the patient visually, auditorially, or tactilely, with coaching by a biofeedback specialist.  Biofeedback is provided by clinicians certified in biofeedback and/or who have documented specialized education, advanced training, or direct or supervised experience qualifying them to provide the specialized treatment needed (e.g., surface EMG, EEG, or other). 
Treatment is individualized to the patient’s work-related diagnosis and needs.  Home practice of skills is required for mastery and may be facilitated by the use of home training tapes.  The ultimate goal in of biofeedback treatment is to normalizeing the physiology to the pre-injury status to the extent possible, and involves transfer of learned skills to the workplace and daily life.  Candidates for biofeedback therapy or training must be motivated to learn and practice biofeedback and self-regulation techniques.   
Indications for biofeedback include individuals who are suffering from musculoskeletal injury where in which muscle dysfunction or other physiological indicators of excessive or prolonged stress response affects and/or delays recovery.  Other applications include training to improve self-management of emotional stress/pain responses such as anxiety, depression, anger, sleep disturbance, and other central and autonomic nervous system imbalances.  Biofeedback is often utilized along used in conjunction with other treatment modalities.
•	Time to produce effect:  3 to 4 sessions 
•	Frequency:  1 to 2 times per week
•	Optimum duration:  5 to 6 sessions
•	Maximum duration:  10 to 12 sessions.  Treatment beyond 12 sessions must be documented with respect to need, expectation, and ability to facilitate positive symptomatic or functional gains.
3.	INJECTIONS-THERAPEUTIC
a.	Therapeutic Spinal Injections:  
i.	Description  Therapeutic spinal injections, which include epidural steroid and facet injections, are generally accepted and well-established procedures   They may be used after initial conservative treatments, such as physical and occupational therapy, medication, manual therapy, exercise, acupuncture, etc., hasve been undertaken.  Therapeutic injections should be used only after imaging studies and diagnostic injections have established pathology.  has been demonstrated.  Injections are invasive procedures that can cause serious complications; thus clinical indications and contraindications should be closely adhered to. The purpose of spinal injections is to facilitate active therapy by providing short-term relief through reduction of pain and inflammation.  All patients should continue appropriate exercise with functionally directed rehabilitation.  Active treatment, which patients should have had prior to injections, will frequently require a repeat of the sessions previously ordered (Refer to section E. 11, Active Therapy).  Injections, by themselves, are not likely to provide long-term relief.  Rather, active rehabilitation with modified work acheives long-term relief by increasing active ROM, strength, and stability.  If the first injection does not provide a diagnostic response with temporary and sustained pain relief substantiated by accepted pain scales, (i.e., 80% pain reduction on visual analog scale), and improvement in function, similar injections should not be repeated.  It is recommended that all patients have an appropriate exercise program that may include a functionally directed rehabilitation program.
 ii.	Special Considerations  For all injections (excluding trigger point), multi-planar fluoroscopic, arthrographic and/or CT guidance during procedures is recommended required to document technique and needle placement, and should be performed by a physician experienced in the procedure.  Permanent images are required to verify needle replacement. The subspecialty disciplines of the physicians performing injections may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry.  The practitioner should participate in ongoing injection training workshops such as    document hands-on training through workshops of the type such as those sponsored offered by organizations such as the International Society for Injection Studies Spine Intervention Society (ISIS) and/or completed a fellowship in pain medicine with interventional training.   and They must also be knowledgeable in radiation safety.  In addition, practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments of Radiology, as applicable.
iii.	Complications  General complications of spinal injections may include (a) transient neurapraxia, local pain, nerve injury, infection, headache, urinary retention and vasovagal effects.; (b) Eepidural hematoma, permanent neuroalogic damage, dural perforation and CSF leakage;, and/or spinal meningeal abscess may also occur.; and or (c) s Suppression of the hypothalamic pituitary adrenal axis,  which may be steroid dose dependent.  Permanent paresis, anaphylaxis, and arachnoiditis have been rarely reported with the use of epidural steroids.  With steroid injections, there may be a dose-dependent suppression of the hypothalamic-pituitary-adrenal axis lasting between one and three months.
iv.	Contraindications  Absolute contraindications to of diagnostic  therapeutic injections include: (a) bacterial infection–systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d) possible pregnancy. 
Relative contraindications of to diagnostic injections may include:  (a) allergy to contrast, (b) poorly controlled Diabetes Mellitus, or and hypertension. aspirin/antiplatelet therapy (drug may be held for 3 days prior to injection), (d) shellfish allergy, if contrast to be used.  Drugs affecting coagulation require restriction from use.  the following are suggested time period restrictions:

•	Aspirin-withhold for seven days
•	NSAIDs-withhold for three days
•	Clopidogrel-withhold for 3 days
•	Other anti-platelet therapy and anti-coagulants should also be addressed individually by a knowledgeable specialist
v.i.	Epidural Steroid Injection (ESI)
A)	Description  Epidural steroid injections are injections of corticosteroid into the epidural space.  The purpose of ESI is to reduce pain and inflammation in the acute or sub-acute phases of injury, restoring range of motion and, thereby, facilitating progress in more active treatment programs.  ESI uses three approaches: transforaminal, inter trans laminar (midline), and caudal.  There is good evidence to support a preference for a The transforaminal approach is the preferred method for unilateral, single-level pathology and for post-surgical patients.  The evidence also suggests  There is good evidence that the transforaminal approach can deliver medication to the target tissue with few complications and is therefore can be used to identify the specific site of pathology.  This is also the preferred approach for post-surgical patients.  The interlaminar approach is the preferred approach for multi-level pathology or spinal stenosis.  Caudal therapeutic injections may be used, but it is difficult to target the exact treatment area, due to diffuse distribution.
B)	Needle Placement  Multi-planar fluoroscopic Spinal imaging is required for all transforaminal epidural steroid injections.  Since injections performed without radiographic guidance result in an increased risk of incorrect needle placement, spinal imaging is recommended for caudal and translaminar injections if available within 30 miles of the patient’s home.    Contrast epidurograms allow one to verify the flow of medication into the epidural space. Permanent images are required to verify needle replacement.
C) 	Indications  There is some evidence that epidural steroid injections are effective for patients with radicular pain or radiculopathy (sensory or motor loss in a specific dermatome or myotome).  Up to 80% of patients with radicular pain may have initial relief.  however, only 25-57%, are likely to have excellent long-term relief.  Although there is no evidence regarding the effectiveness of ESI for non-radicular pain disc herniation, it is a generally an accepted intervention.  Only patients who have 1) pain affected by activity and 2) annular tears verified by appropriate imaging may have injections for axial pain.  Selected cases of vertebral compression fracture may be helped by ESI.  
There is some evidence that ESI injections are not effective for spinal stenosis without radicular findings.  Additionally, there is some evidence that patients who smoke or who have pain unaffected by rest or activity are less likely to have a successful outcome from ESIs. 
•	Time to produce effect:  Local anesthetic, approximately less than 30 minutes; corticosteroid, 48 to 72 hours for 80% of patients and 72 hours to 2 weeks for 20% of patients.  
•	Frequency:  One or more divided levels can be injected in one session.  Whether injections are repeated depends upon the patient’s response to the previous injection. session.  Subsequent injections sessions may occur after 1 to 2 weeks if patient response has been favorable.  Injections can be repeated after a hiatus of three six months if the patient has demonstrated functional gain and pain returns or worsens.  If ESIs are repeated in the future, there should be increasing duration of relief and continued functional gain. If the first injection does not provide a diagnostic response of temporary and sustained pain relief (lasting between 2 and 6 weeks) substantiated by accepted pain scales, (i.e., 80% pain reduction as measured by tools such as visual analog scale (VAS), and improvement in function, similar injections should not be repeated.
•	Optimum duration:  Usually 1 to 3 sessions of injection(s) over a period of six months depending upon each patient’s response and functional gain.
•	Maximum duration:  Up to 3 to 4 Two sessions (consisting of up to three injections each) of injections may be done in one year, as per the patient’s response to pain and function. Patients should be reassessed after each injection session. for an 80% improvement in pain (as measured by accepted pain scales) and evidence of functional improvement.
vi.ii.	Zygoapophyseal (Facet) Injection
A)	Description  A generally accepted iIntra-articular or pericapsular injection of local anesthetic and corticosteroid.  Medial branch nerve blocks are diagnostic only.  There is conflicting evidence to support a long-term therapeutic effect using facet injections.  There is no justification for a combined facet and medial branch block.
B)	Indications- Patients with pain 1) suspected to be facet in origin based on exam findings and 2) affecting activity; OR patients who have refused a rhizotomy; OR patients who have facet findings with a thoracic component.  In these patients, facet injections may be occasionally useful in facilitating a functionally-directed rehabilitation program and to aid in identifying pain generators.  Patients with recurrent pain should be evaluated with more definitive diagnostic injections, such as medial nerve branch injections, to determine the need for a rhizotomy.  Because facet injections are not likely to produce long-term benefit by themselves and are not the most accurate diagnostic tool, they should not be performed at more than two levels.
Facet injections may be repeated if they result in increased documented functional benefit for at least 4 to 6 weeks and at least an 80% initial improvement in pain scales as measured by accepted pain scales (such as VAS).  
B)	Indications  Facet injections may be considered in those patients whose history and examination are suggestive of a facet pain generator.  The therapeutic value of facet injections provides short-term pain relief for patients to progress through a functionally directed rehabilitation program.  These injections are useful when used in conjunction with Manipulation Under Joint Anesthesia (MUJA).  Facet injections determine level(s) of lumbar facet involvement and the degree of pain coming from the posterior elements.  Facet injections may help determine the best therapeutic exercise approach (i.e., lumbar stabilization vs. sacroiliac stabilization).
•	Time to produce effect:  Approximately Up to 30 minutes for local anesthetic; 48 to corticosteroid up to 72 hours for corticosteroid. 
•	Frequency: 1 injection per level with a diagnostic response.  1 to 3 sessions for each joint.  If the first injection does not provide a diagnostic response of temporary and sustained pain relief substantiated by accepted pain scales, (i.e., 80% pain reduction substantiated by tools such as VAS), and improvement in function, similar injections should not be repeated. At least 4 to 6 weeks of functional benefit should be obtained with each therapeutic injection.
•	Optimum duration:  1 to 3 sessions of 2 to 3 injections for each applicable joint per year. Not to exceed two joint levels. 
•	Maximum Duration:  4 per level per year.  Prior authorization must be obtained for injections beyond two levels.
•	Maximum duration:  3 intra-synovial or medial branch nerve injections per joint can be done for facilitating a therapeutic exercise program. 

c.iii. 	Sacroiliac Joint Injection:
i. A)	Description  A generally accepted i Injection of local anesthetic in an intra-articular fashion into the sacroiliac joint under radiographic guidance.  May include the use of corticosteroids.  Long-term therapeutic effect has not yet been established.  
ii. B)	Indications  Primarily diagnostic to rule out sacroiliac joint dysfunction vs. other pain generators.  Intra-articular injection can be of value in diagnosing the pain generator.  There should be documented relief from previously painful maneuvers (e.g., Patrick’s test) on post-injection physical exam.   These injections may be repeated if they result in increased documented functional benefit for at least 6 weeks and at least an 80% initial improvement in pain scales as measured by accepted pain scales (such as VAS).  Therapeutic response varies.  Sacroiliac joint blocks may should facilitate a functionally directed rehabilitation program.
•	Time to produce effect:  Approximately 30 minutes for local anesthetic; 48 to 72 hours for corticosteroid.
•	Frequency and optimum duration:  1 2 to 3 sessions of injections per year.  If the first injection does not provide a diagnostic response of temporary and sustained pain relief substantiated by accepted pain scales, (i.e., 80% pain reduction substantiated by tools such as VAS), and improvement in function, similar injections should not be repeated. At least 6 weeks of functional benefit should be obtained with each therapeutic injection.
•	Optimum Duration:  1 to 3 sesssions
•	Maximum duration: 4 injections per year.   3 sessions of injections.  Once diagnosis has been documented by intrajoint injection, posterior ligament block may be as effective as intra-joint injection for therapeutic value unless the primary pain is coming from an anterior capsular pain generator.
iv.	Intradiscal Steroid Therapy:  Intradiscal Steroid Therapy consists of injection of a steroid preparation into the intervertebral disc under fluoroscopic guidance at the time of discography.  There is good evidence that it is not effective in the treatment of suspected discogenic back pain and its use is not recommended.
b.	Facet Rhizotomy (Radio Frequency Medial Branch Neurotomy)/facet rhizotomy:
i.	Description  A procedure designed to denervate the facet joint by ablating the periarticular facet nerve corresponding sensory medial branches.  Continuous P percutaneous radiofrequency is the method generally used. 
There is good evidence to support this procedure Radio Frequency Medial Branch Neurotomy in the cervical spine but benefits beyond one year are not yet established.  Evidence in the lumbar spine is conflicting; however, the procedure is generally accepted.  In one study, 60% of patients maintained at least 90% pain relief at 12 months.  Radio-frequency rhizotomy Medial Branch Neurotomy is the procedure of choice over alcohol, phenol, or cryoablation.  Precise positioning of the probe using fluoroscopic guidance is recommended required since the maximum effective radius diameter of the device is a 5x8 2 millimeters oval. Permanent images should be recorded to verify placement of the device.
ii.	Indications  Those patients with proven, significant, facetogenic pain.  A minority of low back patients would be expected to qualify for this procedure.  This procedure is not recommended for patients with multiple pain generators or involvement of more than 3 levels of medial branch nerves.  
Individuals should have met all of the following indications:  Pain of well-documented facet origin, unresponsive to active and/or passive therapy, unresponsive to manual therapy, and in which a psychosocial screening evaluation has been performed (e.g., pain diagram, Waddell’s signs, thorough psychosocial history, screening questionnaire).  It is generally recommended that this procedure not be performed until three months of active therapy and manual therapy have been completed.  All patients should continue appropriate exercise with functionally directed rehabilitation.  Active treatment, which patients will have had prior to the procedure, will frequently require a repeat of the sessions previously ordered (Refer to section E. 11, Active Therapy.)  This procedure is commonly used to provide a window of pain relief allowing for participation in active therapy.  
All patients must should have a successful response to a diagnostic medial nerve branch blocks and a separate comparative block.  ISIS suggests controlled blocks using either placebo or anesthetics with varying lengths of activity (i.e., bupivacaine longer than lidocaine).  To be a positive diagnostic block the patient should report a reduction of pain of 80% or greater from baseline for the length of time appropriate for the local anesthetic used.  A successful response is considered to be 90% or greater relief of pain for the length of time appropriate to the local anesthetic used (i.e., bupivacaine greater than lidocaine).   In almost all cases this will mean a reduction of pain to 1 or 2 on the VAS 10-point scale correlated with functional improvement.  The patient should also identify activities of daily living (which may include measurements of range of motion) that are impeded by their pain and can be observed to document functional improvement in the clinical setting.  Ideally, these activities should be assessed throughout the observation period for function.  The observer should not be the physician who performed the procedure.  It is suggested that this be recorded on a form similar to ISIS recommendations.
A separate comparative block on a different date should be performed to confirm the level of involvement.  A comparative block uses anesthetics with varying lengths of activity.
iii.	Complications  Bleeding, infection, or neural injury.  The clinician must be aware of the risk of developing a localized neuritis, or rarely, a deafferentation centralized pain syndrome as a complication of this and other neuroablative procedures.
iv.	Post-Procedure Therapy  Active and/or passive therapy.  Implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-procedure week, barring complications.  Instruction and participation in a long-term home-based program of ROM, core strengthening, postural or neuromuscular re-education, endurance and stability exercises should done 3 to 4 weeks be accomplished over a period of four to ten visits post-procedure.
v.  	Requirements for Repeat Radiofrequency Medial Branch Neurotomy (or additional-level RF Neurotomies):  In some cases pain may recur.  Successful RF Neurotomy usually provides from six to eighteen months of relief.  
Before a repeat RF Neurotomy is done, a confirmatory medial branch injection should be performed if the patient’s pain pattern presents differently than the initial evaluation. in occasional patients, additional levels of RF neurotomy may be necessary.  The same indications and limitations apply.
c. 	Sacro-iliac (SI) Joint Radiofrequency Denervation:  is a denervation of the SI joint.  This procedure is not recommended as there is no evidence to support its use. 
d.	Trigger Point Injections and Dry Needling Treatment:
i.	Description  Trigger point injections are a generally accepted treatment.  Trigger point treatment injection can consists of dry needling or injection of local anesthetic, with or without corticosteroid, into highly localized, extremely sensitive bands of skeletal muscle fibers that produce local and referred pain when activated.  Medication is injected in a four-quadrant manner in the area of maximum tenderness.  Injection efficacy can be enhanced if injections are immediately followed by myofascial therapeutic interventions, such as vapo-coolant spray and stretch, ischemic pressure massage (myotherapy), specific soft tissue mobilization and physical modalities.  The effectiveness of trigger point injection is uncertain, in part due to the difficulty of demonstrating advantages of active medication over injection of saline. There is conflicting evidence regarding the benefit of trigger point injections.  A truly blinded study comparing dry needle treatment of trigger points is not feasible.  There is no evidence that injection of medications improves the results of trigger-point injections. Needling alone may be responsible account for some of the therapeutic response.
There is no indication for conscious sedation for patients receiving trigger point injections.  The patient must be alert to help identify the site of the injection.  
ii.	Indications  Trigger point injections may be used to relieve myofascial pain and facilitate active therapy and stretching of the affected areas.  They are to be used as an adjunctive treatment in combination with other treatment modalities such as functional restoration programs.  Trigger point injections should be utilized primarily for the purpose of facilitating functional progress.  Patients should continue in an aggressive aerobic and stretching therapeutic exercise program as tolerated throughout the time period they are undergoing intensive myofascial interventions.  Myofascial pain is often associated with other underlying structural problems and any abnormalities need to be ruled out prior to injection.
Trigger point injections are indicated in those patients where well circumscribed trigger points have been consistently observed, demonstrating a local twitch response, characteristic radiation of pain pattern and local autonomic reaction, such as persistent hyperemia following palpation.  Generally, these injections are not necessary unless consistently observed trigger points are not responding to specific, noninvasive, myofascial interventions within approximately a 6-week time frame.  However, trigger point injections may be occasionally effective when utilized in the patient with immediate, acute onset of low back pain.
iii.	Complications  Potential but rare complications of trigger point injections include infection, pneumothorax, anaphylaxis, penetration of viscera, neurapraxia, and neuropathy.  If corticosteroids are injected in addition to local anesthetic, there is a risk of local myopathy developing.  Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be immediately repositioned. 
•	Time to produce effect:  Local anesthetic 30 minutes; 24 to 48 hours for no anesthesia.
•	Frequency:  Weekly.  Suggest no more than 4 injection sites per session per week to avoid significant post-injection soreness.
•	Optimum duration:  4 Weeks.
•	Maximum duration:  8 weeks.  Occasional patients may require 2 to 4 repetitions of trigger point injection series over a 1 to 2 year period.
e.	Prolotherapy: also known as sclerotherapy consists of a series of injections of hypertonic dextrose, with or without glycerine and phenol, into the ligamentous structures of the low back.  Its proponents claim that the inflammatory response to the injections will recruit cytokine growth factors involved in the proliferation of connective tissue, stabilizing the ligaments of the low back when these structures have been damaged by mechanical insults.
There are conflicting studies concerning the effectiveness of Prolotherapy in the low back.  Lasting functional improvement has not been shown.  The injections are invasive, may be painful to the patient, and are not generally accepted or widely used.  Therefore, the use of Prolotherapy for low back pain is not recommended.
f.	Epiduroscopy and Epidural Lysis of Adhesions: is an investigational treatment of low back pain.  It involves the introduction of a fiberoptic endoscope into the epidural space via the sacral hiatus.  With cephalad advancement of the endoscope under direct visualization, the epidural space is irrigated with saline.  Adhesiolysis may be done mechanically with a fiberoptic endoscope.  The saline irrigation is performed with or without epiduroscopy and is intended to distend the epidural space in order to obtain an adequate visual field.  It is designed to produce lysis of adhesions, which are conjectured to produce symptoms due to traction on painful nerve roots.  Saline irrigation is associated with risks of elevated pressures which may impede blood flow and venous return, possibly causing ischemia of the cauda equina and retinal hemorrhage. 
	Other complications associated with instrumented lysis include catheter shearing, need for catheter surgical removal, infection (including meningitis), hematoma, and possible severe hemodynamic instability during application.  Although epidural adhesions have been postulated to cause chronic low back pain, studies have failed to find a significant correlation between the level of fibrosis and pain or difficulty functioning.  Studies of epidural lysis demonstrate no transient pain relief from the procedure.  Given the low likelihood of a positive response, the additional costs and time requirement, and the possible complications from the procedure, epidural injection, or mechanical lysis, is not recommended.
Epiduroscopy-directed steroid injections are also not recommended as there is no evidence to support an advantage for using an epiduroscope with steroid injections.
f.	Sympathetic Injections:  Refer to Division’s Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy Medical Treatment Guidelines for specific information regarding the use of these injections.
4.	MEDICATIONS use in the treatment of low back injuries is appropriate for controlling acute and chronic pain and inflammation.  Use of medications will vary widely due to the spectrum of injuries from simple strains to post-surgical healing.  All drugs should be used according to patient needs.  A thorough medication history, including use of alternative and over the counter medications, should be performed at the time of the initial visit and updated periodically.  Treatment for pain control is initially accomplished with acetaminophen and/or NSAIDs.  The patient should be educated regarding the interaction with prescription and over-the-counter medications as well as the contents of over-the-counter herbal products.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are useful in the treatment of inflammation.  These same medications can be used for pain control. 
Narcotic medications should be prescribed with strict time, quantity, and duration guidelines, and with definitive cessation parameters. Pain is subjective in nature and should be evaluated using a scale to rate effectiveness of the narcotic prescribed. 
Other medications, including antidepressants, may be useful in selected patients with chronic pain.  Tramadol, a centrally acting non-narcotic, can be useful to provide pain relief. Other medications, including antidepressants, may be useful in selected patients with chronic pain.  
Topical agents may be beneficial in the management of localized low back pain.  
The following are listed in alphabetical order:
a.	Acetaminophen: is an effective analgesic with antipyretic but not anti-inflammatory activity.  Acetaminophen is generally well tolerated, causes little or no gastrointestinal irritation, and is not associated with ulcer formation.  Acetaminophen has been associated with liver toxicity in overdose situations or in chronic alcohol use.  Patients may not realize that many over-the-counter preparations may contain acetaminophen.   The total daily dose of acetaminophen is recommended not to exceed 4 grams per 24-hour period, from all sources, including narcotic-acetaminophen combination preparations.
•	Optimum duration:  7 to 10 days.
•	Maximum duration:  Chronic use as indicated on a case-by-case basis.  Use of this substance long-term for 3 days per week or greater may be associated with rebound pain upon cessation.
b.	Minor Tranquilizer/Muscle Relaxants:  are appropriate for muscle spasm, mild with pain. and sleep disorders.  There is strong evidence that muscle relaxants are more effective than placebo for providing short-term pain relief in acute low back pain.  When prescribing these agents, physicians must seriously consider side effects of drowsiness or dizziness and the fact that benzodiazepines may be habit-forming.
•	Optimum duration:  1 week.
•	Maximum duration:  4 weeks. 2 weeks (or longer if used only at night).
c.	Narcotics: should be primarily reserved for the treatment of severe low back pain.  There are circumstances where prolonged use of narcotics is justified based upon specific diagnosis, and in these cases, it should be documented and justified.  In mild to moderate cases of low back pain, narcotic medication should be used cautiously on a case-by-case basis.  Adverse effects include respiratory depression, the development of physical and psychological dependence, and impaired alertness.
	Narcotic medications should be prescribed with strict time, quantity, and duration guidelines, and with definitive cessation parameters.  Pain is subjective in nature and should be evaluated using a scale to rate effectiveness of the narcotic prescribed.  Any use beyond the maximum should be documented and justified based on the diagnosis and/or invasive procedures.
•	Optimum duration:  3 to 7 days.
•	Maximum duration:  2 weeks.  Use beyond two weeks is acceptable in appropriate cases.   Refer to Chronic Pain Guidelines which gives a detailed discussion regarding medication use in chronic pain management.
d.	Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): are useful for pain and inflammation.  In mild cases, they may be the only drugs required for analgesia.  There are several classes of NSAIDs, and the response of the individual injured worker to a specific medication is unpredictable.  For this reason, a range of NSAIDs may be tried in each case with the most effective preparation being continued.  Patients should be closely monitored for adverse reactions. The US Food and Drug Administration advises that many NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal.  Naproxen sodium does not appear to be associated with increased risk of vascular events.  Administration of proton pump inhibitors, Histamine 2 Blockers or prostaglandin analog misoprostol along with these NSAIDs may reduce the risk of duodenal and gastric ulceration but do not impact possible cardiovascular complications.  Due to the cross-reactivity between aspirin and NSAIDs, NSAIDs should not be used in aspirin-sensitive patients, and should be used with caution in all asthma patients.  NSAIDs are associated with abnormal renal function, including renal failure, as well as, abnormal liver function.  Certain NSAIDs may have interactions with various other medications.  Individuals may have adverse events not listed above.   Intervals for metabolic screening are dependent upon the patient's age, general health status and should be within parameters listed for each specific medication.  Complete Blood Count (CBC), and L liver and renal function should be monitored at least every six months in patients on chronic NSAIDs and initially when indicated. 
i.	Non- selective Nonsteroidal Anti-Inflammatory Drugs-
Includes NSAIDs and acetylsalicylic acid (aspirin).  Serious GI toxicity, such as bleeding, perforation, and ulceration can occur at any time, with or without warning symptoms in patients treated with traditional NSAIDs.  Physicians should inform patients about the signs and/or symptoms of serious gastrointestinal toxicity and what steps to take if they occur.  Anaphylactoid reactions may occur in patients taking NSAIDs.  NSAIDs may interfere with platelet function.  Fluid retention and edema have been observed in some patients taking NSAIDs.
Due to the cross-reactivity between aspirin and NSAIDs, NSAIDs should not be used in aspirin-sensitive patients, and should be used with caution in all asthma patients.  NSAIDs are associated with abnormal renal function, including renal failure, as well as abnormal liver function.  Certain NSAIDs may have interactions with various other medications.  Individuals may have adverse events not listed above.
•	Optimal duration:  1 week
•	Maximum duration:  1 year. Use of these substances long-term (3 days per week or greater) is associated with rebound pain upon cessation.
ii.	Selective Cyclo-oxygenase-2 (COX-2) Inhibitors
COX-2 inhibitors are more recent NSAIDs and differ in adverse side effect profiles from the traditional NSAIDs.  The major advantages of selective COX-2 inhibitors over traditional NSAIDs are that they have less gastrointestinal toxicity and no platelet effects.  COX-2 inhibitors can worsen renal function in patients with renal insufficiency, thus renal function may need monitoring.
COX-2 inhibitors should not be first-line for low risk patients who will be using an NSAID short term but are indicated in select patients for whom traditional NSAIDs are not tolerated or in certain high-risk patients. Patients most at risk of having a complication from traditional NSAIDs include patients with a prior history of peptic ulcer disease, gastrointestinal bleeding, gastrointestinal perforation, or hemophilia, as well as patients with thrombocytopenia or systemic anticoagulation.  Serious upper GI adverse events can occur even in asymptomatic patients.  Patients at high risk for GI bleed include those who use alcohol, smoke, are older than 65, take corticosteroids or anti-coagulants, or have a longer duration of therapy.  Celecoxib is FDA approved for osteoarthritis and rheumatoid arthritis.  Rofecoxib is FDA approved for acute pain and osteoarthritis.  Celecoxib is contraindicated in sulfonamide allergic patients.
•	Optimal duration:  7 to 10 days
•	Maximum duration:  Chronic use is appropriate in individual cases.   Use of these substances long-term (3 days per week or greater) is associated with rebound pain upon cessation.
e.	Oral Steroids: have limited use but are accepted in cases requiring potent anti-inflammatory drug effect.  They have no proven benefit there is no evidence supporting oral steroids for patients with low back pain with or without radiculopathy and are not recommended. unless spinal cord compression is suspected.  
f.	Intravenous Steroids: The risks of permanent neurological damage from acute spinal cord compression generally outweigh the risks of pharmacologic side effects of steroids in an emergent situation.
f.  g.	Psychotropic/Anti-anxiety/Hypnotic Agents: may be useful for treatment of mild and chronic pain, dysesthesias, sleep disorders, and depression.  Antidepressant medications, such as tricyclics and Selective Serotonin Reuptake Inhibitors (SSRIs), are useful for affective disorder and chronic pain management.  Tricyclic antidepressant agents, in low dose, are useful for chronic pain but have more frequent side effects. 
	Anti-anxiety medications should generally be limited to are best used for short-term use. treatment (i.e., less than 6 months).  Accompanying sleep disorders are best treated with sedating antidepressants prior to bedtime.  Frequently,  cCombinations of the above agents are may be useful. 
	As a general rule, physicians should access the patient’s prior history of substance abuse or depression prior to prescribing any of these agents. Due to the habit-forming potential of the benzodiazepines and other drugs found in this class, they are not routinely recommended.   Refer to the Chronic Pain Guidelines which give a detailed discussion regarding medication use in chronic pain management.
•	Optimum duration:  1 to 6 months.
•	Maximum duration:  6 to 12 months, with monitoring.
h.g.	Tramadol: is useful in relief of low back pain and has been shown to provide pain relief equivalent to that of commonly prescribed NSAIDs.  Although Tramadol may cause impaired alertness, it is generally well tolerated, does not cause gastrointestinal ulceration, or exacerbate hypertension or congestive heart failure.  Tramadol should be used cautiously in patients who have a history of seizures or who are taking medication that may lower the seizure threshold, such as monoamine oxidase (MAO) inhibitors, SSRIs, and tricyclic antidepressants.  This medication has physically addictive properties and withdrawal may follow abrupt discontinuation and is not recommended for those with prior opioid addiction.
•	Optimum duration:  3 to 7 days.
•	Maximum duration:  2 weeks.  Use beyond 2 weeks is acceptable in appropriate cases.
h.	Topical Drug Delivery: may be an alternative treatment for localized musculoskeletal disorders and is an acceptable form of treatment in selected patients although there is no scientific evidence to support its use in low back pain.  It is necessary that all topical agents be used with strict instructions for application as well as maximum number of applications per day to obtain the desired benefit and avoid potential toxicity.  As with all medications, patient selection must be rigorous to select those patients with the highest probability of compliance.  Refer to “Iontophoresis” in the Passive Therapy section for information regarding topical iontophoretic agents. 
5.	OCCUPATIONAL REHABILITATION PROGRAMS 
a.	Non-Interdisciplinary:  These generally accepted programs are work-related, outcome-focused, individualized treatment programs.  Objectives of the program include, but are not limited to, improvement of cardiopulmonary and neuromusculoskeletal functions (strength, endurance, movement, flexibility, stability, and motor control functions), patient education, and symptom relief.  The goal is for patients to gain full or optimal function and return to work.  The service may include the time-limited use of passive modalities with progression to achieve active treatment and/or simulated/real work.
i.	Work Conditioning 
These programs are usually initiated once reconditioning has been completed but may be offered at any time throughout the recovery phase.  It Work conditioning should be initiated when imminent return of a patient to modified or full duty is not an option, but the prognosis for returning the patient to work at completion of the program is at least fair to good.
•	Length of visit:  1 to 2 hours per day.
•	Frequency:  2 to 5 visits per week
•	Optimum duration:  2 to 4 weeks
•	Maximum duration:  6 weeks.  Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.
ii.  	Work Simulation
Work simulation is a program where an individual completes specific work-related tasks for a particular job and return to work.  Use of this program is appropriate when modified duty can only be partially accommodated in the work place, when modified duty in the work place is unavailable, or when the patient requires more structured supervision.  The need for work place simulation should be based upon the results of a Functional Capacity Evaluation and/or Jobsite Analysis.
•	Length of visit:  2 to 6 hours per day
•	Frequency:  2 to 5 visits per week
•	Optimum duration:  2 to 4 weeks
•	Maximum duration:  6 weeks.  Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.
b.	Interdisciplinary: programs are well-established treatment for patients with sub-acute and functionally impairing low back pain.  They are characterized by a variety of disciplines that participate in the assessment, planning, and/or implementation of an injured worker’s program with the goal for patients to gain full or optimal function and return to work.  There should be close interaction and integration among the disciplines to ensure that all members of the team interact to achieve team goals.   Programs should include cognitive-behavioral therapy as there is good evidence for its effectiveness in patients with chronic low back pain.  These programs are for patients with greater levels of perceived disability, dysfunction, de-conditioning and psychological involvement.  For patients with chronic pain, refer to the Division’s Chronic Pain Disorder Medical Treatment Guidelines.
i.	Work Hardening
Work Hardening is an interdisciplinary program addressing a patient’s employability and return to work.  It includes a progressive increase in the number of hours per day that a patient completes work simulation tasks until the patient can tolerate a full workday.  This is accomplished by addressing the medical, psychological, behavioral, physical, functional, and vocational components of employability and return-to-work.
This can include a highly structured program involving a team approach or can involve any of the components thereof.  The interdisciplinary team should, at a minimum, be comprised of a qualified medical director who is board certified with documented training in occupational rehabilitation, ; team physicians having experience in occupational rehabilitation, ; occupational therapyist, ;physical therapyist, ;case manager, ;and psychologist.  As appropriate, the team may also include: chiropractor, RN, or vocational specialist or Certified Biofeedback Therapist.
•	Length of visit:  Up to 8 hours/day
•	Frequency:  2 to 5 visits per week
•	Optimum duration:  2 to 4 weeks
•	Maximum duration:  6 weeks.  Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.
ii. 	Spinal Cord Programs
Spinal Cord Systems of Care provide coordinated, case-managed, and integrated service for people with spinal cord dysfunction, whether due to trauma or disease.  The system includes an inpatient component in an organization licensed as a hospital and an outpatient component.  Each component endorses the active participation and choice of the persons served throughout the entire program.  The Spinal Cord System of Care also provides or formally links with key components of care that address the lifelong needs of the persons served.
This can include a highly structured program involving a team approach or can involve any of the components thereof.  The interdisciplinary team should, at a minimum, be comprised of a qualified medical director who is board certified and trained in rehabilitation, a case manager, occupational therapy, physical therapy, psychologist, rehabilitation RN and MD, and therapeutic recreation specialist.  As appropriate, the team may also include: rehabilitation counselor, respiratory therapist, social worker, or speech-language pathologist.
Timeframe durations for any spinal cord program should be determined based upon the extent of the patient’s injury and at the discretion of the rehabilitation physician in charge.
6.	ORTHOTICS
a.	Foot Orthoses and Inserts: are arecognized and accepted interventions for spinal disorders that are due to aggravated mechanical abnormalities, such as leg length discrepancy, scoliosis, or lower extremity misalignment.  Shoe insoles or inserts may be effective for patients with acute low back problems who stand for prolonged periods of time.
b.  	Lumbar Support Devices:  include backrests for chairs and car seats.  Lumbar supports may provide symptomatic relief of pain and movement reduction in cases of chronic low back problems.
c.  	Lumbar Corsets and Back Belts: There is insufficient evidence to support their use. They are an accepted treatment with limited application.  The injured worker should be advised of the potential harm from using a lumbar support for a period of time greater than that which is prescribed.  Harmful effects include de-conditioning of the trunk musculature, skin irritation, and general discomfort.
d.  b.  	Lumbosacral Bracing:  Rigid bracing devices are well accepted and commonly used for post-fusion, scoliosis, and vertebral fractures.
7.	PATIENT EDUCATION No treatment plan is complete without addressing issues of individual and/or group patient education as a means of prolonging the beneficial effects of treatment, as well as facilitating self-management of symptoms and injury prevention.  The patient should be encouraged to take an active role in the establishment of functional outcome goals.  They should be educated on their specific injury, assessment findings, and plan of treatment.  Instruction on proper body mechanics and posture, positions to avoid, self-care for exacerbation of symptoms, and home exercise should also be addressed.
•	Time to produce effect:  Varies with individual patient
•	Frequency:  Should occur at every visit.
8.	PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION Psychosocial treatment is generally accepted, widely used, and well-established intervention.  This group of therapeutic and diagnostic modalities includes, but is not limited to, individual counseling, group therapy, stress management, psychosocial crises intervention, hypnosis, and meditation.  Any screening evaluation or diagnostic workup should clarify and distinguish between pre-existing versus aggravated versus purely causative psychological conditions.  Psychosocial intervention is recommended as an important component in the total management program that should be implemented as soon as the problem is identified.  There is some evidence that early cognitive-behavioral treatment reduces health care use in comparison to written information alone. This can be used alone, or in conjunction with other treatment modalities.  Providers treating patients with chronic pain should refer to the Division’s Chronic Pain Disorder Medical Treatment Guidelines.
•	Time to produce effect:  2 to 4 weeks.
•	Frequency:  1 to 3 times weekly for the first 4 weeks (excluding hospitalization, if required), decreasing to 1 to 2 times per week for the second month.  Thereafter, 2 to 4 times monthly.
•	Optimum duration:  6 weeks to 3 months
•	Maximum duration:  3 to 12 months.  Counseling is not intended to delay but to enhance functional recovery.  For select patients, longer supervised treatment may be required and if further counseling beyond 3 months is indicated, extensive documentation addressing which pertinent issues are pre-existing versus aggravated versus causative, as well as projecting a realistic functional prognosis, should be provided by the authorized treating provider every 4 to 6 weeks during treatment.
9.	RESTRICTION OF ACTIVITIES Continuation of normal daily activities is the recommendation for acute and chronic low back pain without neurologic symptoms.  There is good evidence against the use of bed rest in cases without neurologic symptoms.  Bed rest may lead to de-conditioning and impair rehabilitation.  Complete work cessation should be avoided, if possible, since it often further aggravates the pain presentation.  Modified return-to-work is almost always more efficacious and rarely contraindicated in the vast majority of injured workers with low back pain.
10.	RETURN-TO-WORK Early return-to-work should be a prime goal in treating occupational injuries given the poor return-to-work prognosis for an injured worker who has been out of work for more than six months.  It is imperative that the patient be educated regarding the benefits of return-to-work, work restrictions, and follow-up if problems arise.  When attempting to return a patient to work after a specific injury, clear objective restrictions of activity level should be made.  An accurate job description may be with detailed physical duty restrictions is often necessary to assist the physician in making return-to-work recommendations.  This may require a jobsite evaluation. 
Employers should be prepared to offer transitional work.  This may consist of temporary work in a less demanding position, return to the regular job with restrictions, or gradual return to the regular job.  Company policies which encourage return-to-work with positive communication are most likely to have decreased worker disability.
Return-to-work is defined as any work or duty that the patient is able to perform safely., and Iit may not be the patient’s regular work.  Due to the large spectrum of injuries of varying severity and varying physical demands in the work place, it is not possible to make specific return-to-work guidelines for each injury.  Therefore, the Division recommends the following:
a.	Establishment of a Return-To-Work Status:  Ascertaining a return-to-work status is part of medical care, should be included in the treatment and rehabilitation plan, and addressed at every visit.  A description of daily activity limitations is part of any treatment plan and should be the basis for restriction of work activities.  In most non-surgical cases, the patient should be able to return-to-work in some capacity or in an alternate position consistent with medical treatment within several days unless there are extenuating circumstances. Injuries requiring more than two weeks off work should be thoroughly documented.
b.	Establishment of Activity Level Restrictions:  Communication is essential between the patient, employer, and provider to determine appropriate restrictions and return-to-work dates.  It is the responsibility of the physician to provide clear concise restrictions, and it is the employer’s responsibility to determine if temporary duties can be provided within the restrictions.  For low back pain injuries, the following should be addressed when describing the patient’s activity level:
•	Lifting limits with the maximum amount of weight to be lifted.  This may vary depending on the frequency of the lifting and/or the object height level.  Pushing, pulling, as well as bending and twisting at the waist should be considered as well.
•	Lower body postures such as squatting, kneeling, crawling, stooping, or climbing should include duration and frequency.
•	Ambulatory level for distance, frequency, and terrain should be specified.
•	Standing duration and frequency with regard to balance issues.  Duration and frequency of sitting, standing, and walking should be delineated.  Balance issues should also be considered in these determinations. 
•	Use of adaptive devices or equipment for proper office ergonomics to enhance capacities can be included.
c.	Compliance with Activity Restrictions:  In some cases, compliance with restriction of activity levels may require a complete jobsite evaluation, a functional capacity evaluation (FCE) or other special testing.  Refer to the “Special Tests” section of this guideline.
11.	THERAPY—ACTIVE The following active therapies have some evidence to support their use and are widely used and accepted methods of care for a variety of work-related injuries.  They are based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion, and can alleviate discomfort.  Active therapy requires an internal effort by the individual to complete a specific exercise or task.  This form of therapy requires supervision from a therapist or medical provider such as verbal, visual, and/or tactile instruction(s).  At times, the provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is predominately executed by the patient.
Patients should be instructed to continue active therapies at home as an extension of the treatment process in order to maintain improvement levels.  Follow-up visits to reinforce and monitor progress and proper technique are recommended.  Home exercise can include exercise with or without mechanical assistance or resistance and functional activities with assistive devices.
The following active therapies are listed in alphabetical order:
a.	Activities of Daily Living (ADL): is are well-established interventions which involve instruction, active-assisted training, and/or adaptation of activities or equipment to improve a person's capacity in normal daily activities such as self-care, work re-integration training, homemaking, and driving.
•	Time to produce effect:  4 to 5 treatments
•	Frequency:  3 to 5 times per week
•	Optimum duration:  4 to 6 weeks
•	Maximum duration:  6 weeks
b.	Aquatic Therapy:  is a well-accepted treatment which consists includes of the therapeutic use of aquatic immersion for therapeutic exercise to promote strengthening, core stabilization, endurance, range of motion, flexibility, body mechanics, and pain management.  Aquatic therapy includes is the implementation of active therapeutic procedures in a swimming or therapeutic pool.  The water provides a buoyancy force that lessens the amount of force gravity applies to the body.  The decreased gravity effect allows the patient to have a mechanical advantage and more likely have a successful trial of therapeutic exercise.  Aquatic vests or belts can be used to provide stability and balance in the water.  Indications are for individuals who The therapy may be indicated for individuals who: 
•	cannot tolerate active land-based or full-weight bearing therapeutic procedures;
•	require increased support in the presence of proprioceptive deficit;
•	are at risk of compression fracture due to decreased bone density;
•	have symptoms that are exacerbated in a dry environment;
•	have a preference for water.
•	would have a higher probability of meeting active therapeutic goals than in a dry environment.
	The pool should be large enough to allow full extremity range of motion and fully erect posture.  Aquatic vests, belts and other devices and can be used to provide stability, balance, buoyancy, and resistance.
•	Time to produce effect:  4 to 5 treatments
•	Frequency:  3 to 5 times per week
•	Optimum duration:  4 to 6 weeks
•	Maximum duration:  6  8 weeks
	A self-directed program is recommended after the supervised aquatics program has been established, or, alternatively a transition to a self-directed dry environment exercise program. 
c.	Functional Activities: are well-established interventions which involve the use of therapeutic activity to enhance mobility, body mechanics, employability, coordination, balance, and sensory motor integration.
•	Time to produce effect:  4 to 5 treatments
•	Frequency:  3 to 5 times per week
•	Optimum duration:  4 to 6 weeks
•	Maximum duration:  6 weeks
d.	Functional Electrical Stimulation:  is an accepted treatment in which the application of electrical current to elicit involuntary or assisted contractions of atrophied and/or impaired muscles.  Indications include It may be indicated for muscle atrophy due to radiculopathy,. weakness, and sluggish muscle contraction secondary to pain, injury, neuromuscular dysfunction, peripheral nerve lesion, or radicular symptoms.
•	Time to produce effect:  2 to 6 treatments
•	Frequency:  3 times per week
•	Optimum duration:  8 weeks.
•	Maximum duration:  8 weeks.  If beneficial, provide with home unit.
f.e.	Neuromuscular Re-education: is a generally accepted treatment.   It is the skilled application of exercise with manual, mechanical, or electrical facilitation to enhance strength;, movement patterns;, neuromuscular response;, proprioception, kinesthetic sense, and coordination;, education of movement, balance, and posture.  Indications include the need to promote neuromuscular responses through carefully timed proprioceptive stimuli, to elicit and improve motor activity in patterns similar to normal neurologically developed sequences, and improve neuromotor response with independent control.
•	Time to produce effect:  2 to 6 treatments
•	Frequency:  3 times per week
•	Optimum duration:  4 to 8 weeks
•	Maximum duration:  8 weeks
e.f.	Lumbar Spinal Stabilization: is a generally well-accepted treatment.  The goal of tThis a therapeutic program whose goal is to strengthen the spine in its neural and anatomic position.  The stabilization is dynamic which allows whole body movements while maintaining a stabilized spine.  It is the ability to move and function normally through postures and activities without creating undue vertebral stress.
•	Time to produce effect:  4 to 8 treatments
•	Frequency:  3 to 5 times per week
•	Optimum duration:  4 to 8 weeks
•	Maximum duration:  8 weeks
g.	Therapeutic Exercise:  is a generally well-accepted treatment.  Therapeutic exercise, with or without mechanical assistance or resistance, may include isoinertial, isotonic, isometric and isokinetic types of exercises.  Indications include the need for cardiovascular fitness, reduced edema, improved muscle strength, improved connective tissue strength and integrity, increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle recruitment, improved proprioception, and coordination, increased range of motion. and Therapeutic exercises are used to promote normal movement patterns., and cCan also include complementary/alternative exercise movement therapy (with oversight of a physician or appropriate healthcare professional).
	There is some evidence to support the effectiveness of yoga therapy in alleviating symptoms and decreasing medication use in uncomplicated low back pain.
•	Time to produce effect:  2 to 6 treatments
•	Frequency:  3 to 5 times per week
•	Optimum duration:  4 to 8 weeks
•	Maximum duration:  8 weeks
12.	THERAPY — PASSIVE Most of the following passive therapies and modalities are generally accepted methods of care for a variety of work-related injuries.  Passive therapy includes those treatment modalities that do not require energy expenditure on the part of the patient. They are principally effective during the early phases of treatment and are directed at controlling symptoms such as pain, inflammation and swelling and to improve the rate of healing soft tissue injuries.  They should be used adjunctively with active therapies such as postural stabilization and exercise programs to help control swelling, pain, and inflammation during the active rehabilitation process.  Please refer to Section B. 4., General Guideline Principles, Active Interventions.  They Passive therapies may be used intermittently as a therapist deems appropriate or regularly if there are specific goals with objectively measured functional improvements during treatment.  
	While protocols for On occasion, specific diagnoses and post-surgical conditions may warrant durations of treatment beyond those listed as "maximum.” ffactors such as exacerbation of symptoms, re-injury, interrupted continuity of care, and comorbidities may also extend durations of care.  Having sSpecific goals with objectively measured functional improvement during treatment can support must be cited to justify extended durations of care.  It is recommended that, if after  6 to 8 visits no functional gain treatment effect is observed, after the number of treatments under “time to produce effect” have been completed, alternative treatment interventions, further diagnostic studies, or further consultations should be pursued.
The following passive therapies are listed in alphabetical order:
a.	Electrical Stimulation (Unattended):  is an accepted treatment. Electrical Stimulation oOnce applied, unattended electrical stimulation requires minimal on-site supervision by the physical therapist, occupational therapist, or other nonphysical provider.  Indications include pain, inflammation, muscle spasm, atrophy, decreased circulation, and the need for osteogenic stimulation.  A home unit should be purchased if treatment is effective and frequent use is recommended. 
•	Time to produce effect:  2 to 4 treatments
•	Frequency:  Varies, depending upon indication, between 2 to 3 times/day to 1 time/week.  Provide home unit if frequent use. Home unit should be purchased if treatment is effective and frequent use is recommended.
•	Optimum/ duration:  1 to 3 months 4 treatments for clinic use 
•	Maximum duration:  3 months 8 treatments for clinic use
b.	Infrared Therapy:  is a radiant form of heat application.  Indications include the need to elevate the pain threshold before exercise and to alleviate muscle spasm to promote increased movement.

•	Time to produce effect:  2 to 4 treatments
•	Frequency:  3 to 5 times per week
•	Optimum duration:  3 weeks as primary, or intermittently as an adjunct to other therapeutic procedures up to 2 months.
•	Maximum duration:  2 months
c.b.	Iontophoresis: is an accepted treatment which consists of the transfer of medication, including, but not limited to, steroidal anti-inflammatories and anesthetics, through the use of electrical stimulation.  Indications include pain (Lidocaine), inflammation (hydrocortisone, salicylate), edema (mecholyl, hyaluronidase, salicylate), ischemia (magnesium, mecholyl, iodine), muscle spasm (magnesium, calcium), calcific deposits (acetate), scars, and keloids (chlorine,sodium chloride, iodine, acetate).  there is no proven benefit for this therapy in the low back.
•	Time to produce effect:  1 to 4 treatments
•	Frequency:  3 times per week with at least 48 hours between treatments
•	Optimum duration:  4 to 6 weeks
•	Maximum duration:  6 weeks
d.c.	Manipulation:  is generally accepted, well-established and widely used therapeutic intervention for low back pain. Manipulative Treatment (not therapy) is defined as the therapeutic application of manually guided forces by an operator to improve physiologic function and/or support homeostasis that has been altered by the injury or occupational disease, and has associated clinical significance.
	High velocity, low amplitude (HVLA) technique, chiropractic manipulation, osteopathic manipulation, muscle energy techniques, counter strain, and non-force techniques are all types of manipulative treatment.  This may be applied by osteopathic physicians (D.O.), chiropractors (D.C.), properly trained physical therapists (P.T.), properly trained occupational therapists (O.T.), or properly trained medical physicians.  Under these different types of manipulation exist many subsets of different techniques that can be described as a) direct- a forceful engagement of a restrictive/pathologic barrier, b) indirect- a gentle/non-forceful disengagement of a restrictive/pathologic barrier, c) the patient actively assists in the treatment and d) the patient relaxing, allowing the practitioner to move the body tissues.  When the proper diagnosis is made and coupled with the appropriate technique, manipulation has no contraindications and can be applied to all tissues of the body.  Pre-treatment assessment should be performed as part of each manipulative treatment visit to ensure that the correct diagnosis and correct treatment is employed.
	Manipulation can include hHigh velocity, low amplitude (HVLA) manipulation is performed by taking a joint to its end range of motion and moving the articulation into the zone of accessory joint movement, well within the limits of anatomical integrity.  technique, chiropractic manipulation, osteopathic manipulation, muscle energy techniques and non-force techniques  There is good scientific evidence to suggest that HVLA manipulation can be helpful for patients with acute low back pain problems without radiculopathy when used within the first 4 to 6 weeks of symptoms.  Although the evidence for sub-acute and chronic low back pain and low back pain with radiculopathy is less convincing, it is a generally accepted and well-established intervention for these conditions.  Indications for manipulation include joint pain, decreased joint motion, and joint adhesions.  Contraindications to HVLA manipulation include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthridites, aortic aneurysm, and signs of progressive neurologic deficits.
•	Time to produce effect for all types of manipulative treatment:  1 to 6 treatments.
•	Frequency:  1 Up to 3  5 times per week for the first 2 4 weeks as indicated by the severity of involvement and the desired effect, then 1 up to 2 2 to 3 treatments per week for the next 4 weeks. then 1 to 2 treatments per week for the next 6 weeks.  For further treatments, twice per week or less to maintain function.
•	Optimum duration:  8 to 12 weeks
•	Maximum duration:  3 months.  Extended durations of care beyond what is considered “maximum” may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with comorbidities.  Refer to the Chronic Pain Guidelines for Ccare beyond 3 months. is indicated for certain chronic syndromes in which manipulation is helpful in improving function, decreasing pain and improving quality of life.  Such care should be re-evaluated and documented on a monthly basis.  Treatment may include visits 2 times a month through the 7th month post-injury, then on a monthly basis thereafter through the 10th month post-injury.  Care beyond the 10th month should be reviewed and allowed on a case-by-case basis according to the unique needs of the patient with chronic and/or permanent injury.
d.	Manipulation Under General Anesthesia (MUA):  refers to manual manipulation of the lumbar spine in combination with the use of a general anesthetic or conscious sedation. It is intended to improve the success of manipulation when pain, muscle spasm, guarding, and fibrosis appear to be limiting its application in patients otherwise suitable for their use.  There have been no high quality studies to justify its benefits given the risks of general anesthetic and conscious sedation.  It is not recommended.
e.	Manipulation Under Joint Anesthesia (MUJA):  refers to manipulation of the lumbar spine in combination with a fluoroscopically guided injection of anesthetic with or without corticosteroid agents into the facet joint at the level being manipulated.  There are no controlled clinical trials to support its use.  It is not recommended.
e.f.	Massage — Manual or Mechanical:  Massage is manipulation of soft tissue with broad ranging relaxation and circulatory benefits.  This may include stimulation of acupuncture points and acupuncture channels (acupressure), application of suction cups and techniques that include pressing, lifting, rubbing, pinching of soft tissues by, or with, the practitioner's hands.  Indications include edema (peripheral or hard and non-pliable edema), muscle spasm, adhesions, the need to improve peripheral circulation and range of motion, or to increase muscle relaxation and flexibility prior to exercise.
	In sub-acute low back pain populations there is good evidence that massage can increase function when combined with exercise and patient education.  Some studies have demonstrated a decrease in provider visits and pain medication use with combined therapy.  One study indicated improved results with acupressure massage.  It is recommended that all massage be performed by trained, experienced therapists and be accompanied by an active exercise program and patient education.  In contrast to the sub-acute population, massage is a generally accepted treatment for the acute low back pain population, although no studies have demonstrated its efficacy for this set of patients.
•	Time to produce effect:  Immediate
•	Frequency:  1 to 2 times per week
•	Optimum duration:  6 weeks
•	Maximum duration:  2 months
f.g.	Mobilization (Joint): is a generally well-accepted treatment.  Mobilization is passive movement involving oscillatory motions to the vertebral segment(s).  The passive mobility is performed in a graded manner (I, II, III, IV, or V), which depicts the speed of and depth of joint motion during the maneuver.  For further discussion on Level V joint mobilization please see section on HVLA manipulation [Refer to section 12. d.] It may include skilled manual joint tissue stretching.  Indications include the need to improve joint play, segmental alignment, improve intracapsular arthrokinematics, or reduce pain associated with tissue impingement.  Mobilization should be accompanied by active therapy.  for level v mobilization cContraindications include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthridities, aortic aneurysm, and signs of progressive neurologic deficits.
•	Time to produce effect:  6 to 9 treatments
•	Frequency:  Up to 3 times per week
•	Optimum duration:  4 to 6 weeks
•	Maximum duration:  6 weeks
g.h.	Mobilization (Soft Tissue): is a generally well-accepted treatment.  Mobilization of soft tissue is the skilled application of muscle energy, strain/counter strain, myofascial release, manual trigger point release and manual therapy techniques designed to improve or normalize movement patterns through the reduction of soft tissue pain and restrictions.  These can be interactive with the patient participating or can be with the patient relaxing and letting the practitioner move the body tissues. Indications include muscle spasm around a joint, trigger points, adhesions, and neural compression.  Mobilization should be accompanied by active therapy.
•	Time to produce effect:  2 to 3 weeks 4 to 9 treatments
•	Frequency:  2 to Up to 3 times per week
•	Optimum duration:  4 to 6 weeks
•	Maximum duration:  6 weeks
i.	Short-Wave Diathermy: is an accepted treatment which involves the use of equipment that exposes soft tissue to a magnetic or electrical field.  Indications include enhanced collagen extensibility before stretching, reduced muscle guarding, reduced inflammatory response, and enhanced re-absorption of hemorrhage/hematoma or edema.
•	Time to produce effect:  2 to 4 treatments
•	Frequency:  2 to 3 times per week up to 3 weeks
•	Optimum duration:  3 to 5 weeks
•	Maximum duration:  5 weeks
h.j.	Superficial Heat and Cold Therapy (excluding Infrared Therapy):  is a generally accepted treatment.  Superficial heat and cold are thermal agents applied in various manners that lowers or raises the body tissue temperature for the reduction of pain, inflammation, and/or effusion resulting from injury or induced by exercise.  Includes application of heat just above the surface of the skin at acupuncture points.  Indications include acute pain, edema and hemorrhage, need to increase pain threshold, reduce muscle spasm, and promote stretching/flexibility.  Cold and heat packs can be used at home as an extension of therapy in the clinic setting.
•	Time to produce effect:  Immediate
•	Frequency:  2 to 5 times per week
•	Optimum duration:  3 weeks as primary or intermittently as an adjunct to other therapeutic procedures up to 2 months
•	Maximum duration:  2 months
j. k.	Traction—Manual: is an accepted treatment and an integral part of manual manipulation or joint mobilization.  Indications include decreased joint space, muscle spasm around joints, and the need for increased synovial nutrition and response.  Manual traction is contraindicated in patients with tumor, infection, fracture, or fracture dislocation.
•	Time to produce effect:  1 to 3 sessions
•	Frequency:  2 to 3 times per week
•	Optimum duration:  30 days
•	Maximum duration:  1 month
k. l.	Traction—Mechanical: is indicated for decreased joint space, muscle spasm around joints, and the need for increased synovial nutrition and response. There is no evidence that mechanical traction is useful for low back pain patients without radicular symptoms.  Therefore, it is not recommended in this population.  It may be trialed in patients with radicular findings, and if successful, should be shifted to home traction.  Traction modalities are contraindicated in patients with tumor, infections, fracture, or fracture dislocation.  Non-oscillating inversion traction methods are contraindicated in patients with glaucoma or hypertension.  A home lumbar traction unit can be purchased if therapy proves effective.
•	Time to produce effect:  1 to 3 sessions up to 30 minutes.  If response is negative after 3 treatments, discontinue this modality.
•	Frequency:  2 to 3 times per week.  A home lumbar traction unit can be purchased if therapy proves effective.
•	Optimum duration:  4 weeks
•	Maximum duration:  1 month  4 weeks
l m.	Transcutaneous Electrical Nerve Stimulation (TENS):  is a generally accepted treatment.  TENS should include at least one instructional session for proper application and use.  Indications include muscle spasm, atrophy, and decreased circulation and pain control.  Minimal TENS unit parameters should include pulse rate, pulse width and amplitude modulation. Consistent, measurable functional improvement must be documented prior to the purchase of a home unit.
•	Time to produce effect:  Immediate.
•	Frequency:  Variable.
•	Optimum duration:  3 sessions
•	Maximum duration:  3 sessions.  If beneficial, provide with home unit or purchase if effective.  
m.n.	Ultrasound (including Phonophoresis): is an accepted treatment. Ultrasound uses sonic generators to deliver acoustic energy for therapeutic thermal and/or non-thermal soft tissue effects.  Indications include scar tissue, adhesions, collagen fiber and muscle spasm, and the need to extend muscle tissue or accelerate the soft tissue healing.  Ultrasound with electrical stimulation is concurrent delivery of electrical energy that involves dispersive electrode placement.  Indications include muscle spasm, scar tissue, pain modulation, and muscle facilitation.  
	Phonophoresis is the transfer of medication to the target tissue to control inflammation and pain through the use of sonic generators.  These topical medications include, but are not limited to, steroidal anti-inflammatory and anesthetics.
•	Time to produce effect:  6 to 15 treatments
•	Frequency:  3 times per week
•	Optimum duration:  4 to 8 weeks
•	Maximum duration:  2 months 8 weeks
n.	Vertebral Axial Decompression (VAX-D): a registered trademark for a motorized traction table used to stretch the lower back, is an acronym for vertebral axial decompression.  The patient lies prone on the table in a pelvic harness for 30 to 45 minutes while alternating cycles of stretching and relaxation are applied.  The table has Food and Drug Administration (FDA) approval as a traction device, but no studies have shown any advantage of vertebral axial decompression over ordinary manual therapy for low back pain and it has not been shown to treat conditions associated with herniated discs.
	The evidence in support of vertebral axial decompression is insufficient to support its use in low back injuries.  Proponents of this therapy may submit supporting evidence to the Division if they believe that claims of its effectiveness can be supported by well-designed studies.  Vertebral axial decompression for treatment of low back injuries is not recommended.
n. o.	Vertebral Axial decompression (VAX-D)/DRX, 9000:  Motorized traction devices which purport to produce non-surgical disc decompression by creating negative intradiscal pressure in the disc space include devices with the trade names of VAX-D and DRX 9000.  There are no good studies to support their use. They are not recommended. 
o.p.	Whirlpool/Hubbard Tank: is a generally accepted treatment in which conductive exposure to water at varied temperatures that best elicits the desired effect. (cold vs. heat).  It generally includes massage by water propelled by a turbine or Jacuzzi jet system and has the same thermal effects as hot packs, if water temperature exceeds higher than tissue temperature.  It has the same thermal effects as cold application, if comparable temperature water is used.  Indications include the need for analgesia, relaxing muscle spasm, reducing joint stiffness, and facilitating and preparing for exercise.
•	Time to produce effect:  2 to 4 treatments
•	Frequency:  3 to 5 times per week
•	Optimum duration:  3 weeks as primary, or intermittently as an adjunct to other therapeutic procedures up to 2 months
•	Maximum duration:  2 months
13. 	VOCATIONAL REHABILITATION is a generally accepted intervention, but Colorado limits its use as a result of Senate Bill 87-79. Initiation of vocational rehabilitation requires adequate evaluation of patients for quantification of highest functional level, motivation, and achievement of maximum medical improvement. Vocational rehabilitation may be as simple as returning to the original job or as complicated as being retrained for a new occupation.
It may also be beneficial for full vocational rehabilitation to be started before MMI if it is evident that the injured worker will be unable to return to his/her previous occupation.  A positive goal and direction may aid the patient in decreasing stress and depression, and promote optimum rehabilitation.

F.	THERAPEUTIC PROCEDURES — OPERATIVE
	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 condition(s).  It is imperative to rule out non-physiologic modifiers of pain presentation or non-operative conditions mimicking radiculopathy or instability (e.g., peripheral neuropathy, piriformis syndrome, myofascial pain, scleratogenous or sympathetically mediated pain syndromes, sacroiliac dysfunction, psychological conditions, etc.) prior to consideration of elective surgical intervention. 
	In addition, ooperative treatment is indicated when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions.  All patients being considered for surgical intervention should first undergo a comprehensive neuro-musculoskeletal examination to identify mechanical pain generators that may respond to non-surgical techniques or may be refractory to surgical intervention.
	While sufficient time allowances for non-operative treatment are required to determine the natural cause and response to non-operative treatment of low back pain disorders, timely decision making for operative intervention is critical to avoid de-conditioning and increased disability (exclusive of "emergent" or urgent pathology such as cauda equina syndrome or associated rapidly progressive neurologic loss).
	In general, if the program of non-operative treatment fails, operative treatment is indicated when:
•	Improvement of the symptoms has plateaued and the residual symptoms of pain and functional disability are unacceptable at the end of 6 to 12 weeks of active treatment, or at the end of longer duration of non-operative programs for debilitated patients with complex problems; and/or
•	Frequent recurrences of symptoms cause serious functional limitations even if a non-operative active treatment program provides satisfactory relief of symptoms, and restoration of function on each recurrence.  
•	Mere passage of time with poorly guided treatment is not considered an active treatment program.
	Surgical workup and implementation for simple decompression of patients with herniated nucleus pulposus and sciatica should occur within 6 to 12 weeks after injury at the latest, within the above stated contingencies.  For patients with true, refractory mechanical low back pain in whom fusion is being considered, it is recommended that a decisive commitment to surgical or non-surgical interventions occur within 5 months following injury, at the latest.
	Spinal decompression surgeries and fusion have re-operation rates of approximately 10% or more over the following five years.  Re-operation is indicated only when the functional outcome following the re-operation is expected to be better, within a reasonable degree of certainty, than the outcome of other non-invasive or less invasive treatment procedures.  “Functional outcomes” refers to the patient’s ability to improve functional tolerances such as sitting, standing, walking, strength, endurance, and/or vocational status.  While timely surgical decision-making is critical to avoid de-conditioning and increased disability, a time limited trial of reconditioning should be tried prior to re-operation.  Re-operation has a high rate of complications and failure and may lead to disproportionately increased disability.
	Every post-operative patient should be involved in an active treatment program.  (refer to section E.11.)  Structured rehabilitation Interdisciplinary interventions should be strongly considered post-operatively in any patient not making expected functional progress within three weeks expected time frames. post-operative. (Refer to Interdisciplinary Programs, Section E. 5. b.)
	Return to work restrictions should be specific according to the recommendations in the Ssection E. 10, “Return to Work.”  under Therapeutic Procedures – Non-Operative.  Most non-fusion surgical patients can return to a limited level of duty between 3 to 6 weeks.  Full activity is generally achieved between 6 weeks to 6 months depending on the procedure and healing of the individual.
1.	DISCECTOMY
a.	Description:  To enter into and partially remove the disc.
b.	Complications:  Includes, but are not limited to, nerve damage, wrong level operation, spinal fluid leakage, infection, and hemorrhage.
c.	Surgical Indications:  To include all of the following: Primary radicular symptoms, radiculopathy on exam, correlating imaging study, and failure of non-surgical care.  There is limited evidence that surgery provides initial improvement in symptoms although most lumbar discs resolve naturally with time.   There is good evidence that surgery provides initial improvement of radicular symptoms with respect to chronic low back pain.  There is conflicting evidence that the long-term outcome differs from that of the natural history of healing.
d.	Operative Treatment:  Laminotomy, partial discectomy, and root decompression.  
e. d.     Post-Operative Therapy:  Active and/or passive therapy.  A formal physical therapy program should be implemented post-operatively.  Active treatment, which patients should have had prior to surgery, will frequently require a repeat of the sessions previously ordered. Implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-operative week, barring complications.  Instruction and participation in a long-term home-based program of ROM, strengthening, endurance and stability exercises should be considered 3 to 4 weeks post-op.   
2.	CHEMONUCLEOLYSIS
a.	Description:  Injection of a proteolytic enzyme into the disc to obtain an enzymatic degradation of the nucleus pulposus.
b.	Complications:  Includes, but are not limited to, severe adverse reaction, neurologic complications including transverse myelitis, infection and back muscle spasm.
c.	Surgical Indications:  To include all of the following: Primary radicular symptoms, radiculopathy on exam, correlating imaging study, and failure of non-surgical care.   There is some evidence to support the use of chemonucleolysis over no treatment.  However, more patients require second surgeries after this procedure than after a discectomy.  The failure rate of chemonucleolysis is higher than the failure rate of discectomy.
d.	Operative Treatment:  Injection of a proteolytic enzyme into the disc to obtain an enzymatic degradation of the nucleus pulposus.  Physicians trained in chemonucleolysis and with extensive experience performing the procedure should only perform chemonucleolysis.
e.	Post-Operative Therapy:  Active and/or passive therapy.  Instruction and participation in a long-term home-based program of ROM, strengthening, endurance and stability exercises should be considered 3 to 4 weeks post-op.
3.2.	PERCUTANEOUS DISCECTOMY (NUCLECTOMY) OR LASER DISCECTOMY
a.	Description: An invasive operative procedure to accomplish partial removal of the disc through a needle which allows aspiration of a portion of the disc trocar under imaging control.
b.	Complications: Include, but are not limited to, injuries to the nerve or vessel, infection, and hematoma.
c.	Surgical Indications:  Percutaneous discectomy is indicated only in cases with of suspected septic discitis in order to obtain diagnostic tissue.  These procedures may be used  in the presence of septic discitis for the following: Primary radicular symptoms, radiculopathy on exam, correlating imaging study, and failure of non-surgical care.  The procedure has limited application is not recommended for non-septic cases contained disc herniations or bulges with associated radiculopathy due to lack of evidence to support long-term improvement.  
d.	Operative Treatment: Partial discectomy. & root decompression.  If unsuccessful, open laminectomy should be strongly considered within 2 weeks post-discectomy.
e.	Post-Operative Therapy:  Active and/or passive therapy.  Implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-operative week, barring complications.  Instruction and participation in a long-term home-based program of ROM, strengthening, endurance and stability exercises should be considered 3 to 4 weeks post-op 
3.	LAMINOTOMY/LAMINECTOMY/FORAMENOTOMY/FACETECTOMY
a.	Description: These procedures y provide access to produce neural decompression by partial or total removal of various parts of vertebral bone.
b.	Complications:  Include but are not limited to, nerve injury, post-surgical instability, CSF leakage, and infection.
c.	Surgical Indications:  To include all of the following: Primary radicular symptoms, radiculopathy on exam, correlating imaging study, and failure of non-surgical care.
d.	Operative Treatment:  Laminotomy, partial discectomy & root decompression.
e.	Post-Operative Therapy:  Active and/or passive therapy.  Implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-operative week, barring complications.  Instruction and participation in a long-term home-based program of ROM, strengthening, endurance and stability exercises should be considered 3 to 4 weeks post-op. A formal physical therapy program should be implemented post-operatively.   Active treatment, which patients should have had prior to surgery, will frequently require a repeat of the sessions previously ordered.  The implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-operative week is appropriate in uncomplicated post-surgical cases.  Some patients may benefit from several occupational therapy visits to improve performance of ADLs. Participation in an active therapy program which includes restoration of ROM, core stabilization, strengthening, and endurance is recommended to be initiated 3-6 weeks post-operatively.  The goals of the therapy program should include instruction in a long-term home based exercise program.  (Refer to Section E. 11, Active Therapy.)
5. 4.	SPINAL FUSION
a.	Description:  Use of bone grafts, sometimes combined with metal devices, to produce a rigid connection between two or more adjacent vertebrae. 
b.	Complications:  complications include iInstrumentation failure, bone graft donor, site pain, in-hospital mortality, (superficial infection), deep wound infection, graft extrusion and inpatient mortality.  There is an increased likelihood of complications with instrumented fusion, although the majority are minor. There is some evidence that instrumented 360 degree fusions are most likely to involve major complications.
c.	Surgical Indications:  A timely decision-making process is recommended when considering patients for possible fusion.  There is no good evidence from controlled trials that spinal fusion alone is effective for treatment of any type of acute low back problem, in the absence of spinal fracture or dislocation.  For chronic low back problems, fusion should not be considered within the first 3 5 months of symptoms, except for fracture or dislocation.
	Although there is a statistical correlation between successful radiographic fusion and a good functional outcome, the relationship is not strong in the first two years.  However, a recent observational study appears to indicate clinical deterioration in patients with unsuccessful radiographic fusion at an average of seven years post-operatively.  There is good evidence that instrumented fusion, compared to non-instrumented fusion, produces a slightly better radiographically-confirmed bony union, with small to moderate functional advantages.  studies of surgical procedures report higher rates of complications with instrumented fusion.
	There is good evidence that intensive exercise for approximately 25 hours per week for four weeks combined with cognitive interventions emphasizing the benefits of maintaining usual activity, produces functional results similar to those of posterolateral fusion after one year.  There is some evidence that lumar fusion produces better symptomatic and functional results in patients with chronic non-radicular pain when several months of conservative treatment have not produced a satisfactory outcome.  Fusions associated with decompression are more likely to reduce leg pain. 

	Recombinant Human Bone Morphogenetic Protein (rhBMP-2) is a member of a family of cytokines capable of inducing bone formation.  It is produced from genetically modified cell lines using molecular cloning techniques. At the time of this guideline writing, rhBMP-2 is FDA approved for use in anterior lumbar interbody fusion (ALIF) and is used with a carrier such as a collagen sponge or other matrix, and a cage.  There is some evidence that anterior interbody cage fusion using rhBMP-2 results in shorter operative time compared with the use of iliac crest bone autograft.  Minor pain at the iliac crest donor site may persist for 24 months or longer in approximately 30% of patients who undergo an autograft procedure.  RhBMP-2 avoids the need for harvesting iliac crest donor bone and can therefore, avoid this complication of persistent pain.  There is a potential for patients to develop sensitizing or blocking antibodies to rhBMP-2 or to the absorbable collagen sponge.  the long-term effects are unknown. The rhBMP-2 used with the interbody fusion device is contraindicated for patients with a known hypersensitivity to Recombinant Human Bone Morphogenetic Protein -2, bovine type 1 collagen, or to other components of the formulation.  Use of rhBMP-2 outside the anterior cage may carry a risk of swelling and ectopic bone formation which can encroach on neurovascular structures.  At the time of this guideline writing, it is still investigational.  Information concerning safe and effective dosing and application are being submitted to the FDA.  All other applications are considered off-label and not FDA approved.  There is insufficient information to form a recommendation with instrumentation other than the cage specifically designed for anterior procedures.  If the FDA approves its use for other operative approaches, prior authorization is required. The patient must meet all indications on the device manufacturer’s list and have no contraindications.  The formation of exuberant or ectopic bone growth at the upper levels (L2 - L4) may have a deleterious impact on certain neurovascular structures, such as the aorta and sympathetic nerve chain.  There are also reports of osteoclastic activity with the use of rhBMP-2.
 		Indications for spinal fusion may include:
i.	Neural arch defect – Spondylolytic spondylolisthesis, congenital unilateral neural arch hypoplasia.
ii.	Segmental Instability - Excessive motion, as in degenerative spondylolisthesis, surgically induced segmental instability.
iii.	Primary Mechanical Back Pain/Functional Spinal Unit Failure - Multiple pain generators objectively involving two or more of the following: (a) internal disc disruption (poor success rate if more than one disc involved), (b) painful motion segment, as in annular tears, (c) disc resorption, (d) facet syndrome, and or (e) ligamentous tear.
iv.	Revision surgery for failed previous operation(s) if significant functional gains are anticipated.  Revision surgery for purposes of pain relief must be approached with extreme caution due to the less than 50% success rate reported in medical literature.
v.	Infection, tumor, or deformity of the lumbosacral spine that cause intractable pain, neurological deficit, and/or functional disability.
d.	Pre-Ooperative Surgical Indications: Required pre-operative clinical surgical indications for spinal fusion include all of the following: 
i.	All pain generators are identified adequately defined and treated; and
ii.	All physical medicine and manual therapy interventions are completed; and 
iii.	X-ray, MRI, or CT/Discography demonstrateing disc pathology or spinal instability; and 
iv.	Spine pathology is limited to two levels; and
v.	Psychosocial screen evaluation with confounding issues addressed.  
vi.	For any potential fusion surgery, it is recommended that the injured worker refrain from smoking for at least six weeks prior to surgery and during the period of fusion healing.  Because smokers have a higher risk of non-union and higher post-operative costs, it is recommended that insurers cover a smoking cessation program peri-operatively.
e.	Operative Therapy: Operative procedures may include: a) Intertransverse Fusion; b) Anterior Fusion (with or without rhBMP-2) – generally used for component of discogenic pain where there is no significant radicular component requiring decompression; c) Posterior Interbody Fusion – generally used for component of discogenic pain where posterior decompression for radicular symptoms also performed; or d) Anterior/posterior (360) Fusion – most commonly seen in unstable or potentially unstable situations or non-union of a previous fusion.
f.	Post-Ooperative Therapy: Active and/or passive therapy.  A formal physical therapy program should be implemented post-operatively.  Active treatment, which patients should have had prior to surgery, will frequently require a repeat of the sessions previously ordered.  Implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-operative week, barring complications.  Instruction and participation in a long-term home-based program of ROM, strengthening, endurance and stability exercises should be done once fusion is solid (generally 6 weeks to 6 months post-op). The implementation of a gentle aerobic reconditioning program (e.g., walking), and back education within the first post-operative week is appropriate in uncomplicated post-surgical cases. some patients may benefit from several occupational therapy visits to improve performance of ADLs.  Participation in an active therapy program which includes core stabilization, strengthening, and endurance is recommended to be initiated once the fusion is solid and without complication.  The goals of the therapy program should include instruction in a long-term home based exercise program.  (refer to section e.11, Active therapy.)
g.	Return-to-Work: Barring complications, patients responding favorably to spinal fusion may be able to return to sedentary-to-light work within 6 to 12 weeks post-operatively, light-to-medium work within 6 to 9 months post-operatively and medium-to-medium/heavy work within 6 to 12 months post-operatively.  Patients requiring fusion whose previous occupation involved heavy-to-very-heavy labor should be considered for vocational assessment as soon as reasonable restrictions can be predicted.  As previously noted, tThe practitioner must should release the patient with specific physical restrictions and should obtain a clear job description from the employer, if necessary.  Once an injured worker is off work greater than 6 months, the functional prognosis with or without fusion becomes guarded for that individual.
6.5.	SACROILIAC JOINT FUSION
a.	Description: Use of bone grafts, sometimes combined with metal devices, to produce a rigid connection between two or more adjacent vertebrae providing symptomatic instability as a part of major pelvic ring disruption.
b.	Complications: Instrumentation failure, bone graft donor site pain, in-hospital mortality, deep infection, superficial infection, and graft extrusion.
c.	Surgical Indications: Sacroiliac (SI) joint fusion may be indicated for stabilization of a traumatic severe disruption of the pelvic ring.  This procedure has limited use in minor trauma and would be considered only on an individual case-by-case basis.  In patients with typical mechanical low back pain, this procedure is considered to be under investigational. in Colorado.  Until the efficacy of this procedure for mechanical low back pain is determined by an independent valid prospective outcome study, this procedure is not recommended for mechanical low back pain.
7.6.	IMPLANTABLE SPINAL CORD STIMULATORS are reserved for those low back pain patients with pain of greater than 6 months duration who have not responded to the standard non-operative or operative interventions previously discussed within this document.  Refer to Division’s Chronic Pain Disorder Medical Treatment Guidelines.
8.7.	INTRADISCAL ELECTROTHERMAL ANNULOPLASTY (IDEA)  (more commonly called IDET, or Intradiscal Electrothermal therapy)
a.	Description: An outpatient non-operative procedure.  A wire is guided into the identified painful disc using fluoroscopy.  The wire is then heated at the nuclear annular junction within the disc.  The goal of the procedure is to burn the nerves and to tighten the injured tissue within the disc.  Physicians performing this procedure must have been trained in the procedure and should have performed at least 25 prior discograms.  Prior authorization is required for IDEA.
b.	Complications: Complications include, but are not limited to, discitis, nerve damage, pain exacerbation, and anaphylaxis, probe breakage, and disc herniation.
c.	Surgical Indications: Failure of conservative therapy including physical therapy, medication management, or therapeutic injections.  Indications may include those with chronic low back pain, disc related back pain, or pain lasting greater than 6 months.  There is some evidence to support this procedure.  It continues to be investigational and cannot be generally recommended.  Controlled trials are currently in progress, but results will not be published in the immediate future so functional benefit beyond 12 months is unknown. There is conflicting evidence regarding its effectiveness.  In one of the most recent studies only approximately 40% of patients had greater than 50% relief of pain.  Patients should be aware of these percentages.  Strict adherence to the indications is recommended.  Only patients who meet the following should be considered, including:
i.	All pain generators are identified adequately defined and treated; and
ii.	All physical medicine and manual therapy interventions are completed; and
iii.	X-ray, MRI, or CT/Discography demonstrateing disc pathology; and 
iv.	Spine pathology is limited to two levels; and
v.	Psychosocial screen evaluation with confounding issues addressed.  
vi.	For any potential surgery, it is recommended that the injured worker refrain from smoking for at least six weeks prior to surgery and during the period of healing.
	Additionally, the candidate must should meet the following criteria:
i.	Age not above 60 or under 18; and 
ii.	Normal neurological exam; and
iii.	No evidence of nerve root compression on MRI; and
iv.	Concordant pain reproduction reproduced with provocativeon discography at less than 1ml dye volume (low pressure); and
v.	Functionally limiting low back pain far in excess of leg pain for at least 6 months; and
vi.	No evidence of inflammatory arthritis, spinal conditions mimicking low back pain, moderate to severe spinal stenosis, spinal instability, disc herniation, or medical or metabolic diseases precluding follow-up rehabilitation; and
vii.	disc height greater than 50% of adjacent normal disc. The height of the disc must be sufficient to permit maneuvering of the thermal wire; and
viii.	No Pprevious IDEAT procedure at the same level. within the last 6 months.
d.	Operative Treatment: A wire is guided into the identified painful disc using fluoroscopy and then the wire is heated within the disc.  
e.	Post-Procedure Therapy: Active and/or passive therapy.    Rehabilitation may take as long as 6 months and include stretching during the first month, floor exercises in the second month, 3 to 5 consecutive months of progressive exercise program, and sport activities in the 5th and 6th months as tolerated. Some cases may require epidural injection after the IDET procedure has been performed.  A corset should be used for the first 6 weeks.  sitting upright is limited to 30 to 45 minutes for the first two weeks.  A formal physical therapy program should be implemented post-operatively.  Some patients may benefit from several occupational therapy visits to improve performance of ADLs.  Rehabilitation may take as long as 6 months and include stretching during the first month, floor exercises in the second month, 3 to 5 consecutive months of progressive exercise program, and sport activities in the 5th and 6th months as tolerated.  The goals of the therapy program should include instruction in a long-term home-based exercise program.  (Refer to Section E.11 Active Therapy.)
f.	Return to Work: Barring complications, may be able to return to limited duty after one to two weeks.  A corset should be used for the first six weeks.  sitting upright is limited to 30 to 45 minutes for the first two weeks.  Zero to 10 pounds lifting limits for first 6 weeks post-procedure.  If successful, patients Mmay return to medium work category (20 to 50 pounds per DOT standards) at 3 4 to 6 months. or more.
8.	LASER DISCECTOMY  involves the delivery of laser energy into the center of the nucleus pulposus using a fluoroscopically guided laser fiber under local anesthesia.  The energy denatures protein in the nucleus, causing a structural change which is intended to reduce intradiscal pressure.  Its effectiveness has not been shown.  Laser discectomy is not recommended.
9. 	ARTIFICIAL LUMBAR DISC REPLACEMENT 
a. 	Description:  involves the insertion of a prosthetic device into an intervertebral space from which a degenerated disc has been removed, sparing only the peripheral annulus.  The endplates are positioned under intraoperative fluoroscopic guidance for optimal placement in the sagittal and frontal planes.  The prosthetic device is designed to distribute the mechanical load of the vertebrae in a physiologic manner and maintain range of motion. 
	General selection criteria for lumbar disc replacement includes symptomatic one-level degenerative disc disease.  The patient must also meet fusion surgery criteria, and if the patient is not a candidate for fusion, a disc replacement procedure should not be considered. Additionally, the patient should be able to comply with pre-and post-surgery protocol.
	The theoretical advantage of total disc arthroplasty is that it preserves range of motion and physiologic loading of the disc.  This could be an advantage for adults who are physically active.  Studies do not demonstrate a long-term advantage of measured function or pain over comparison groups undergoing fusion.  The longevity of this prosthetic device has not yet been determined.  Significant technical training and experience is required to perform this procedure successfully.  Surgeons must be well-versed in anterior spinal techniques and should have attended appropriate training courses, or have undergone training during a fellowship.  Mentoring and proctoring of procedures is highly recommended.  Reasonable pre-operative evaluation may include an angiogram to identify great vessel location.  The angiogram may be either with contrast or with magnetic resonance imaging.  An assistant surgeon with anterior access experience is required. 
b. 	Complications:
•	Nerve and vascular injury
•	Dural tears
•	Sexual dysfunction (retrograde ejaculation)
•	Mal-positioning of the prosthesis
•	Suboptimal positioning of the prosthetic may compromise   the long-term clinical result
•	Complex Regional Pain Syndrome (CRPS)
•	Complications from Abdominal Surgery, (e.g., hernia or adhesions)
•	Re-operation due to complications
c. 	Surgical Indications:
•	Symptomatic one-level degenerative disc disease established by objective testing (CT or MRI scan followed by positive provocation discogram) 
•	Symptoms unrelieved after six months of active non-surgical treatment
•	All pain generators are adequately defined and treated
•	All physical medicine and manual therapy interventions are completed
•	Spine pathology limited to one level
•	Psychosocial evaluation with confounding issues addressed
d. 	Contraindications:
•	Significant spinal deformity/scoliosis
•	Facet joint arthrosis
•	Spinal instability
•	Deficient posterior elements
•	Infection
•	Previous spinal surgery at a different level
•	Any contraindications to an anterior abdominal approach (including multiple prior abdominal procedures)
•	Evidence of nerve root compression, depending on the device used
•	Previous compression or burst fracture 
•	Multiple-level degenerative disc disease (DDD)
•	Spinal canal stenosis
•	Spondylolysis
•	Spondylolisthesis greater than 3 mm
•	Osteoporosis or any metabolic bone disease
•	Chronic steroid use or use of other medication known to interfere with bone or soft tissue healing
•	Autoimmune disorder
•	Allergy to device components/materials
•	Depending on the device selected, pregnancy or desire to become pregnant
•	Morbid obesity (e.g., body/mass index [BMI] of greater than 40, over 100 pounds overwieght)
•	Active malignancy
e. 	Post-operative Therapy:  Bracing may be appropriate.  A formal physical therapy program should be implemented post-operatively.  Active treatment, which patients should have had prior to surgery,  will frequently require a repeat of the sessions previously ordered. The implementation of a gentle aerobic reconditioning program (e.g., walking) and back education within the first post-operative week is appropriate in uncomplicated post-surgical cases.  Some patients may benefit from several occupational therapy visits to improve performance of ADLs.   Participation in an active therapy program which includes restoration of ROM, core stabilization, strengthening, and endurance is recommended to be initiated at the discretion of the surgeon.   Lifting and bending are usually limited for several months at least.  Sedentary duty may be able to begin within six weeks in uncomplicated cases.  The goals of the therapy program should include instruction in a long-term home based exercise program.  (Refer to Section E. 11, Active Therapy.)
10.	 Kyphoplasty 
a.	Description:  A asurgical procedure for the treatment of symptomatic thoracic or lumbar vertebral compression fractures, most commonly due to osteoporosis or other metabolic bone disease, and occasionally with post-traumatic compression fractures and minor burst fractures that do not significantly compromise the posterior cortex of the vertebral body.  Pain relief can be expected in approximately 90% of patients.  Vertebral height correction is inconsistent, with approximately 35% to 40% of procedures failing to restore height or kyphotic angle.
b.	Complications:  Cement leakage occurs in approximately 9% of kyphoplasties and may cause complications.  New vertebral compression fracture may occur following kyphoplasty, but their occurence does not appear to exceed that of osteoporotic patients who did not receive treatment. 
c.	Operative Treatment:  Kyphoplasty involves the percutaneous insertion of a trocar and inflatable balloon or expanding polymer into the vertebral body, which re-expands the body, elevating the endplates and reducing the compression deformity.  Polymethylmethacrylate (PMMA) bone cement is injected under low pressure into the cavity created by the balloon inflation.  In contrast to vertebroplasty, which introduces PMMA cement under high pressure, the space created by balloon inflation allows a higher viscosity PMMA to be injected under lower pressure, which may reduce the risks associated with extravertebral extravasation of the material.  There may be an advantage to performing the procedure within one month of the fracture, since the elevation of the endplates may be more readily achieved than when the procedure is delayed. 
d.	Surgical Indications:  Kyphoplasty is an accepted treatment for the following indications: 
•	Compression fracture 
•	Vertebral height loss between 20% and 85%
•	Vertebral height restoration.  Kyphoplasty is more likely to increase vertebral height if performed within 30 days of fracture occurrence
e.	Contraindications: 
•	The presence of neurologic compromise related to fracture
•	high-velocity fractures with a significant burst component
•	significant posterior vertebral body wall fracture
•	severe vertebral collapse (vertebra plana)
•	infection, and
•	coagulopathy 
11.	Vertebroplasty 
a. 	Description:  a procedure for the treatment of painful thoracic and lumbar vertebral compression fractures caused by osteoporosis or other metabolic bone disease.  Polymethylmethacrylate (PMMA) bone cement is injected with high pressure into the vertebral body via an 11- to 13-gauge needle, with the goal of stabilizing the spine and relieving pain. The procedure does not correct spinal deformity.  Pain relief can be expected in approximately 90% of patients.  Vertebral height correction is inconsistent, with approximately 35% to 40% of procedures failing to resore height or kyphotic angle.
b. 	Complications: 
•	Because the bone cement is of low viscosity, its injection under pressure frequently results in extravertebral extravasation of the material, with rare serious complications such as pulmonary embolism.  Cement leakage alone occurs in approximately 40% of vertebroplasties.
•	New vertebral compression fractures may occur following vertebroplasty, but their occurrence does not appear to exceed that of osteoporotic patients who did not receive treatment.
c. 	Indications:
•	Compression fracture of preferably less than 30 days
•	Vertebral height loss between 20% and 85%
•	Intact posterior wall
d. 	Contraindications: 
•	the presence of neurologic compromise related to the fracture;
•	High velocity fractures with a significant burst component.
•	posterior vertebral body wall fracture;
•	Severe vertebral collapse (vertebra plana); and
•	Infection; and
•	Coagulopathy
12. 	Percutaneous radiofrequency disc decompression is an investigational procedure which introduces a 17 gauge cannula under local anesthesia and fluoroscopic guidance into the nucleus pulposus of the contained herniated disc, using radiofrequency energy to dissolve and remove disc material.  Pressure inside the disc is lowered as a result.  There have been no randomized clinical trials of this procedure at this time.  Percutaneous radiofrequency disc decompression is not recommended.
13. 	Nucleus pulposus replacement involves the introduction of a prosthetic implant into the intervertebral disc, replacing the nucleus while preserving the annulus fibrosus.  It is limited to investigational use in the United States at this time.  It is not recommended. 
14.	Epiduroscopy and Epidural Lysis of Adhesions (Refer to Section E. 3, Injections-Therapeutic.)
15.	Intraoperative Monitoring is a common intraoperative electrodiagnostic technique that may include somatosensory evoked potentials (SSEP), motor evoked potentials (MEP), or pedicle screw monitoring.  The monitoring procedure may be used to evaluate spinal cord integrity and screw placement during the operative procedure.  The use of intraoperative monitoring can be anticipated to become more common as percutaneous spinal procedures gain greater acceptance.

RULE 17, EXHIBIT 5

Cumulative Trauma Disorder (CTD) 

Medical Treatment Guidelines

Revised:  April 26, 2007
Effective:  July 1, 2007

Adopted:  November 4, 1996	Effective:  December 30, 1996	
Revised:  January 8, 1998	Effective:  March 15, 1998	
Revised:  May 27, 2003	Effective:  July 30, 2003	
Revised:  September 29, 2005	Effective:  January 1, 2006	

Presented by:

State of Colorado
Department of Labor and Employment
DIVISION OF WORKERS’ COMPENSATION

TABLE OF CONTENTS

SECTION                                         	            DESCRIPTION                    	                PAGE
A.	INTRODUCTION	x
B.	GENERAL GUIDELINES PRINCIPLES	x
1.	APPLICATION OF GUIDELINES	x
2.EDUCATION	x
3.TREATMENT PARAMETER DURATION	x
4.ACTIVE INTERVENTIONS	x
5.ACTIVE THERAPEUTIC EXERCISE PROGRAM	X
6.POSITIVE PATIENT RESPONSE	X
7.RE-EVALUATION TREATMENT EVERY 3 TO 4 WEEKS	X
8.SURGICAL INTERVENTIONS	X
9.SIX-MONTH TIME FRAME	X
10.RETURN-TO-WORK	X
11.DELAYED RECOVERY	X
12.GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE	X
13.CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI)	X
C.	DEFINITIONS AND MECHANISMS OF INJURY	X
D.	INITIAL DIAGNOSTIC PROCEDURES	X
1.HISTORY	X
	a.	Description of Symptoms	X
	b.	Identification of Occupational Risk Factors	X
	c.	Demographics: age, hand dominance, gender, etc.	X
	d.	Past Medical History and Review of Systems	X
	e.	Activities of Daily Living (ADLs)	X
	f.	Avocational Activities	X
	g. 	Social History	X
2.PHYSICAL EXAMINATION	X
3.PAIN BEHAVIOR EVALUATION	X
4.RISK FACTORS	X
5.MEDICAL CAUSALITY ASSESSMENT FOR CUMULATIVE TRAUMA DISORDERS	X
6.STAGING	X
		Stage 1	X
		Stage 2	X
		Stage 3	X
		Stage 4	X
E.	FOLLOW-UP DIAGNOSTIC IMAGING AND OTHER TESTING PROCEDURES	X
1.ELECTRODIAGNOSTIC (EDX) STUDIES	X
2.IMAGING STUDIES	X
	a.	Radiographic Imaging	X
	b.	MRI	X
3.ADJUNCTIVE TESTING	X
	a.	Personality/Psychological/Psychosocial Evaluations	X
	b.	Laboratory Tests	X
	c.	Pinch and Grip Strength Measurements	X
	d.	Quantitative Sensory Testing (QST)	X
4.SPECIAL TESTS	X
	a.	Computer-Enhanced Evaluations	X
	b.	Functional Capacity Evaluation (FCE)	X
	c.	Job Site Evaluation	X
	d.	Vocational Assessment	X
	e.	Work Tolerance Screening	X
F.	THERAPEUTIC PROCEDURES – NON-OPERATIVE	X
1.ACUPUNCTURE	X
	a.	Acupuncture	X
	b.	Acupuncture with Electrical Stimulation	X
	c.	Other Acupuncture Modalities	X
2.BIOFEEDBACK	X
3.INJECTIONS – THERAPEUTIC	X
	a.	Steroid Injections	X
	b.	Trigger Point Injections	X
4.JOB SITE ALTERTIONS	X
	a.	Ergonomic Changes	X
	b.	Interventions	X
	c.	Seating Description	X
	d.	Job Hazard Checklist	X
5.MEDICATIONS	X
	a.	Acetaminophen	X
	b.	Minor Tranquilizer/Muscle Relaxants	X
	c.	Narcotics	X
	d.	Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)	X
	e.	Psychotropic/Anti-anxiety/Hypnotic Agents	X
	f.	Tramadol	X
	g.	Topical Drug Delivery	X
6.OCCUPATIONAL REHABILITATION PROGRAMS	X
	a.	Non-interdisciplinary	X
	b.	Interdisciplinary	X
7.PATIENT EDUCATION	X
8.PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION	X
9.RETURN-TO-WORK	X
	a.	Establishment of Return to Work	X
	b.	Establishment of Activity Level Restrictions	X
	c.	Compliance with Activity Level Restrictions	X
10.SLEEP DISTURBANCES	X
11.THERAPY – ACTIVE	X
	a.	Activities of Daily Living	X
	b.	Functional Activities	X
	c.	Nerve Gliding	X
	d.	Neuromuscular Re-education	X
	e.	Proper Work Techniques	X
	f.	Therapeutic Exercise	X
12.THERAPY – PASSIVE	X
	a.	Electrical Stimulation (Unattended)	X
	b.	Extracorporeal Shock Wave Treatment	X
	c.	Iontophoresis	X
	d.	Laser Irradiation	X
	e.	Manual Therapy Techniques	X
	f.	Massage	X
	g.	Orthotics/Immobilization with Splinting	X
	h.	Superficial Heat and Cold Therapy	X
	i.	Ultrasound	X
13.RESTRICTION OF ACTIVITIES	X
14.VOCATIONAL REHABILITATION	X
G.	OPERATIVE TREATMENT	X
1.PERIPHERAL NERVE DECOMPRESSION	X
	a.	Median Nerve Decompression at the Wrist (carpal tunnel release)	X
	b.	Median Nerve Decompression in the Forearm (pronator teres or flexor 	digitorum superficialis 	release)	X
	c.	Ulnar Nerve Decompression at the Wrist (ulnar tunnel release or Guyon’s canal release)	X
	d.	Ulnar Nerve Decompression/Transposition at the Elbow 	X
	e.	Radial Sensory Nerve Decompression at the Wrist	X
	f.	Radial Nerve Decompression at the Elbow	X
	g.	Thoracic Outlet Syndrome	X
2.TENDON DECOMPRESSION OR DEBRIDEMENT	X
	a.	Subacromial Decompression	X
	b.	Medial or Lateral Epicondyle Release/Debridement	X
	c.	First Extensor Compartment Release (de Quervain’s Tenosynovitis)	X
	d.	Trigger Finger/Thumb Release	X
3.CONSIDERATIONS FOR POST-OPERATIVE THERAPY	X
	a.	Immobilization	X
	b.	Home Program	X
	c.	Supervised Therapy Program	X
Rule 17	MEDICAL TREATMENT GUIDELINES
EXHIBIT 5-CUMULATIVE TRAUMA MEDICAL TREATMENT GUIDELINES
Section F. 5
d.	Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): are useful for pain and inflammation.  In mild cases, they may be the only drugs required for analgesia.  There are several classes of NSAIDs, and the response of the individual injured worker to a specific medication is unpredictable.  For this reason, a range variety of NSAIDs may be tried in each case with the most effective preparation being continued. Patients should be closely educated in and monitored for adverse reactions., including GI toxicity, liver and renal dysfunction, and thrombotic events in the case of COX-2 inhibitors. Intervals for screening are dependent on the patient’s age, health status, concomitant medications usage, and specific NSAID prescribed.  The US Food and Drug Administration advises that many NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial infraction, and stroke, which can be fatal.  Naproxen sodium does not appear to be associated with increased risk of vascular events.  Administration of proton pump inhibitors, histamine 2 blockers, or prostaglandin analog misoprostol along with these NSAIDsS may reduce the risk of duodenal and gastric ulceration but do not impact possible cardiovascular complications.  Due to the cross-reactivity between aspirin and NSAIDs, NSAIDs should not be used in aspirin-sensitive patients, and should be used with caution in all asthma patients.  NSAIDs are associated with abnormal renal function, including renal failure, as well as, abnormal liver function.  Certain NSAIDs may have interactions with various other medications.  Individuals may have adverse events not listed above.  Intervals for metabolic screening are dependent upon the patient's age, general health status and should be within parameters listed for each specific medication.  Complete Blood Count (CBC) and liver and renal function should be monitored at least every six months in patients on chronic NSAIDs and initially when indicated.
i.	Non-Sselective Nonsteroidal Anti-Inflammatory Drugs – 
Includes Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and acetylsalicylic acid (aspirin).  Serious GI toxicity, such as bleeding, perforation, and ulceration can occur at any time, with or without warning symptoms in patients treated with traditional NSAIDs.  Physicians should inform patients about the signs and/or symptoms of serious gastrointestinal toxicity and what steps to take if they occur.  Anaphylactoid reactions may occur in patients taking NSAIDs.  NSAIDs may interfere with platelet function.  Fluid retention and edema have been observed in some patients taking NSAIDs.
•	Optimal duration:  1 week
•	Maximum duration:  1 year.  Use of these substances long-term (3 days per week or greater) is associated with rebound pain upon cessation.
ii.	Selective Cyclo-oxygenase-2 (COX-2) Inhibitors – 
Selective cyclo-oxygenase-2 (COX-2) inhibitors are more recent NSAIDs and differ in adverse side effect profiles from the traditional NSAIDs. The major advantages of selective COX-2 inhibitors over traditional NSAIDs are that they have less gastrointestinal, hepatic and renal toxicity and no platelet effects.  , but may have thrombotic effects. COX-2 inhibitors can worsen renal function in patients with renal insufficiency, thus renal function may need monitoring.
COX-2 inhibitors should not be first-line for low risk patients who will be using an NSAID short-term but are indicated in select patients for whom traditional NSAIDs are not tolerated or in certain high-risk patients.  Serious upper GI adverse events can occur even in asymptomatic patients.  Patients at high risk for GI bleed include those who use alcohol, smoke, are older than 65, take corticosteroids or anti-coagulants, or have a longer duration of therapy.  celecoxib is contraindicated in sulfonamide allergic patients.
•	Optimal duration:  7 to 10 days
•	Maximum duration:  Chronic use is appropriate in individual cases.  Use of these substances long-term (3 days per week or greater) is associated with rebound pain upon cessation.

RULE 17, EXHIBIT 6

Lower Extremity Injury
Medical Treatment Guidelines

Revised:  April 26, 2007
Effective:  July 1, 2007

Adopted:  January 9, 1995	Effective:  March 2, 1995	
Revised:  January 8, 1998	Effective:  March 15, 1998	
Revised:  October 4, 2001	Effective:  December 1, 2001	
Revised:  September 29, 2005	Effective:  January 1, 2006	

	Presented by:
	State of Colorado
	Department of Labor and Employment
DIVISION OF WORKERS' COMPENSATION

TABLE OF CONTENTS

SECTION				      DESCRIPTION					PAGE
A.	INTRODUCTION	x
B.	GENERAL GUIDELINES PRINCIPLES	x
	1.	Application of the Guidelines	x
	2.	Education	x
	3.	Treatment Parameter Duration	x
	4.	Active Interventions	x
	5.	Active Therapeutic Exercise Program	x
	6.	Positive Patient Response	x
	7.	Re-Evaluate Treatment Every 3 to 4 Weeks	x
	8.	Surgical Interventions	x
	9.	Six-Month Time Frame	x
	10.	Return-To-Work	x
	11.	Delayed Recovery	x
	12.	Guidelines Recommendations and InclusIon of Medical Evidence	x
	13.	Care Beyond Maximum Medical Improvement (MMI)	x
C.	INITIAL DIAGNOSTIC PROCEDURES	x
	1.	History-taking and Physical Examination (Hx & PE)	X
	a.	History of Present Injury	X
	b.	Past History	X
	c.	Physical Examination	X
	2.	Radiographic Imaging	X
	3.	Laboratory Tests	X
	4.	Other Procedures	X
	a.	Joint Aspiration	X
D.	SPECIFIC LOWER EXTREMITY INJURY DIAGNOSIS, TESTING AND TREATMENT	X
	1.	Foot and Ankle	X
	a.	Ankle Sprain/Fracture	X
	b.	Talar Fracture	X
	c.	Calcaneal Fractures	X
	d.	Midfoot (Lisfranc’s) Fracture Dislocation	X
	e.	Metatarsal-Phalangeal, Tarsal-Metatarsal and Interphalangeal Joint Arthropathy	X
	f.	Pilon Fracture	X
	g.	Puncture Wounds of the Foot	X
	h.	Achilles Tendon Injury/Rupture	X
	i.	Ankle Osteoarthropathy	X
	j.	Ankle or Subtalar Joint Dislocation	X
	k.	Heel Spur Syndrome/Plantar Fasciitis	X
	l.	Tarsal Tunnel Syndrome	X
	m.	Neuroma	X
	2.	Knee	X
	a.	Chondral Defects	X
	b.	Aggravated Osteoarthritis	X
	c.	Anterior Cruciate Ligament Injury 	X
	d.	Posterior Cruciate Ligament Injury	X
	e.	Meniscus Injury	X
	f.	Patellar Subluxation	X
	g.	Retropatellar Pain Syndrome	X
	h.	Tendonitis/Tenosynovitis	X
	i.	Bursitis of the Lower Extremity	X
	3.	Hip and Leg	X
	a.	Hip Fracture	X
	b.	Pelvic Fracture	X
	c.	Acetabulum Fracture	X
	d.	Hamstring Tendon Rupture	X
	e.	Hip Dislocation 	X
	f	Trochanteric Fracture	X
	g.	Femur Fractures	X
	h.	Tibia Fracture	X
E.	FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES	X
	1.	Imaging Studies	X
	a.	Magnetic Resonance Imaging (MRI)	X
	b.	Computed Axial Tomography (CT)	X
	c.	Lineal Tomography	X
	d.	Bone Scan (Radioisotope Bone Scanning)	X
	e.	Other Radionuclide Scanning	X
	f.	Arthrograms	X
	g.	Diagnostic Arthroscopy (DA)	X
	2.	Other Tests	X
	a.	Personality/Psychological/Psychosocial Evaluations	X
	b.	Electrodiagnostic Testing	X
	c.	Doppler Ultrasonography/Plethysmography	X
	d.	Venogram/Arteriogram	X
	e.	Compartment Pressure Testing and Measurement Devices	X
	3.	Special Tests	X
	a.	Computer Enhanced Evaluations	X
	b.	Functional Capacity Evaluation (FCE)	X
	c.	Jobsite Evaluation	X
	d.	Vocational Assessment	X
	e.	Work Tolerance Screening	X
F.	THERAPEUTIC PROCEDURES – NON-OPERATIVE	X
	1.	Acupuncture	X
	a.	Acupuncture	X
	b.	Acupuncture with Electrical Stimulation	X
	c.	Other Acupuncture Modalities	X
	2.	Biofeedback	X
	3.	Injections – Therapeutic	X
	a.	Joint Injections	X
	b.	Soft Tissue Injections	X
	c.	Trigger Point Injections	X
	d.	Prolotherapy	X
	e.	Intra-Capsular Acid Salts	X
	4.	Medications	X
	a.	Acetaminophen	X
	b.	Minor Tranquilizer/Muscle Relaxants	X
	c.	Narcotics	X
	d.	Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)	X
	e.	Oral Steroids	X
	f.	Psychotropic/Anti-anxiety/Hypnotic Agents	X
	g.	Tramadol	X
	h.	Topical Drug Delivery	X
	5.	Occupational Rehabilitation Programs	X
	a.	Non-interdisciplinary	X
	b.	Interdisciplinary	X
	6.	Orthotics and Prosthetics	X
	a.	Fabrication/Modification of Orthotics	X
	b.	Orthotic/Prosthetic Training	X
	c.	Splints or Adaptive Equipment	X
	7.	Patient Education	X
	8.	Personality/Psychological/Psychosocial Intervention	X
	9.	Restriction of Activity	X
	10.	Return-To-Work	X
	a.	Establishment of a Return-To-Work Status	X
	b.	Establishment of Activity Level Restrictions	X
	c.	Compliance with Activity Restrictions	X
	11.	Therapy – Active	X
	a.	Activities of Daily Living (ADL)	X
	b.	Functional Activities	X
	c.	Functional Electrical Stimulation	X
	d.	Gait Training	X
	e.	Neuromuscular Re-education	X
	f.	Therapeutic Exercise	X
	g.	Wheelchair Management and Propulsion	X
	12.	Therapy – Passive	X
	a.	Continuous Passive Movement (CPM)	X
	b.	Contrast Baths	X
	c.	Electrical Stimulation (Unattended)	X
	d.	Fluidotherapy	X
	e.	Infrared Therapy	X
	f.	Iontophoresis	X
	g.	Manipulation	X
	h.	Manual Electrical Stimulation	X
	i.	Massage – Manual or Mechanical	X
	j.	Mobilization (Joint)	X
	k.	Mobilization (Soft Tissue)	X
	l.	Paraffin Bath	X
	m.	Superficial Heat and Cold Therapy	X
	n.	Short-wave Diathermy	X
	o.	Traction	X
	p.	Transcutaneous Electrical Nerve Stimulation (TENS)	X
	q.	Ultrasound	X
	r.	Vasopneumatic Devices	X
	s.	Whirlpool/Hubbard Tank	X
	13.	VOCATIONAL REHABILITATION	X
G.	THERAPEUTIC PROCEDURES – OPERATIVE	X
	1.	Ankle and Subtalar Fusion	X
	2.	Knee Fusion	X
	3.	Total Knee Replacement	X
	4.	Total Hip Replacement	X
	5.	Amputation	X
	6.	Manipulation Under Anesthesia	X
	7.	Bursectomy	X
	8.	Osteotomy	X
	9.	Hardware Removal	X
	10.  Release of Contracture	X
Rule 17	MEDICAL TREATMENT GUIDELINES
EXHIBIT 6 LOWER EXTREMITY MEDICAL TREATMENT GUIDELINES
Section F. 4 
d.	Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): are useful for pain and inflammation.  In mild cases, they may be the only drugs required for analgesia.  There are several classes of NSAIDs, and the response of the individual injured worker to a specific medication is unpredictable.  For this reason, a range of NSAIDs may be tried in each case with the most effective preparation being continued.  Patients should be closely monitored for adverse reactions.  The US Food and Drug Administration advises that many NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal.  Naproxen sodium does not appear to be associated with increased risk of vascular events.  Administration of proton pump inhibitors, histamine 2 blockers, or prostaglandin analog misoprostol along with these NSAIDs may reduce the risk of duodenal and gastric ulceration but do not impact possible cardiovascular complications.  Due to the cross-reactivity between aspirin and NSAIDs, NSAIDs should not be used in aspirin-sensitive patients, and should be used with caution in all asthma patients.  NSAIDs are associated with abnormal renal function, including renal failure, as well as, abnormal liver function.  Certain NSAIDs may have interactions with various other medications.  Individuals may have adverse events not listed above.  Intervals for metabolic screening are dependent upon the patient's age, general health status and should be within parameters listed for each specific medication.  Complete Blood Count (CBC) and Lliver and renal function should be monitored at least every six months in patients on chronic NSAIDs and initially when indicated.
i.	Non-selective Nonsteroidal Anti-Inflammatory Drugs: 
Includes Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and acetylsalicylic acid (aspirin).  Serious Gastrointestinal (GI) toxicity, such as bleeding, perforation, and ulceration can occur at any time, with or without warning symptoms in patients treated with traditional NSAIDs.  Physicians should inform patients about the signs and/or symptoms of serious gastrointestinal toxicity and what steps to take if they occur.  Anaphylactoid reactions may occur in patients taking NSAIDs.  NSAIDs may interfere with platelet function.  Fluid retention and edema have been observed in some patients taking NSAIDs.
Due to the cross-reactivity between aspirin and NSAIDs, NSAIDs should not be used in aspirin-sensitive patients, and should be used with caution in all asthma patients.  NSAIDs are associated with abnormal renal function, including renal failure, as well as abnormal liver function.  Certain NSAIDs may have interactions with various other medications.  Individuals may have adverse events not listed above.
•	Optimal duration:  1 week
•	Maximum duration:  1 year.  Use of these substances long-term (3 days per week or greater) is associated with rebound pain upon cessation.
ii.	Selective Cyclo-oxygenase-2 (COX-2) Inhibitors: 
COX-2 inhibitors are more recent NSAIDs and differ in adverse side effect profiles from the traditional NSAIDs.  The major advantages of selective COX-2 inhibitors over traditional NSAIDs are that they have less gastrointestinal toxicity and no platelet effects.  COX-2 inhibitors can worsen renal function in patients with renal insufficiency, thus renal function may need monitoring.
COX-2 inhibitors should not be first-line for low risk patients who will be using an NSAID short term but are indicated in select patients for whom traditional NSAIDs are not tolerated or in certain high-risk patients.  Patients most at risk of having a complication from traditional NSAIDs include patients with a prior history of peptic ulcer disease, gastrointestinal bleeding, gastrointestinal perforation, or hemophilia, as well as patients with thrombocytopenia or systemic anticoagulation.   Serious upper GI adverse events can occur even in asymptomatic patients.  Patients at high risk for GI bleed include those who use alcohol, smoke, are older than 65, take corticosteroids or anti-coagulants, or have a longer duration of therapy.  Celecoxib is Food and Drug Administration (FDA) approved for osteoarthritis and rheumatoid arthritis.  Rofecoxib is FDA approved for acute pain and osteoarthritis.  Celecoxib is contraindicated in sulfonamide allergic patients.
•	Optimal duration:  7 to 10 days
•	Maximum duration:  Chronic use is appropriate in individual cases.  Use of these substances long-term (3 days per week or greater) is associated with rebound pain upon cessation.

RULE 17, EXHIBIT 8

Cervical Spine Injury
Medical Treatment Guidelines

Revised:  April, 26, 2007
Effective:  July 1, 2007

Adopted:  January 8, 1998	Effective:  March 15, 1998	
Revised:  October 4, 2001	Effective:  December 1, 2001	
Revised:  September 29, 2005	Effective:  January 1, 2006	

Presented by:
State of Colorado
Department of Labor and Employment
DIVISION OF WORKERS' COMPENSATION

C/S TABLE OF CONTENTS

SECTION	DESCRIPTION	PAGE
A.	INTRODUCTION..........................................................................................................................x
B.	GENERAL GUIDELINES PRINCIPLES	x
1.	APPLICATION OF GUIDELINES	x
2.	EDUCATION		x
3.	TREATMENT PARAMETER DURATION	x
4.	ACTIVE INTERVENTIONS	x
5.	ACTIVE THERAPEUTIC EXERCISE PROGRAM	x
6.	POSITIVE PATIENT RESPONSE	x
7.	RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS	x
8.	SURGICAL INTERVENTIONS	x
9.	SIX-MONTH TIME FRAME	x
10.	RETURN-TO-WORK	x
11.	DELAYED RECOVERY	x
12.	GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE	x
13.	CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI)	x
C.	INITIAL DIAGNOSTIC PROCEDURES	x
1.	HISTORY-TAKING AND PHYSICAL EXAMINATION (Hx & PE)	x
	a. 	History of Present Injury	x
	b. 	Past History	x
	c. 	Physical Examination	x
	d. 	Relationship to Work	x
	de.	Spinal Cord Evaluation	x
	ef. 	Soft Tissue Injury Evaluation	x
2.	RADIOGRAPHIC IMAGING	x
3.	LABORATORY TESTING	x
D.	FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES	xx
1.	IMAGING STUDIES	xx
	a.	Magnetic Resonance Imaging (MRI)	xx
	b.	Computed Axial Tomography (CT)	xx
	c.	Myelogramphy	xx
	d.	CT Myelogram	xx
	e.	Lineal Tomography	xx
	f.	Bone Scan (Radioisotope Bone Scanning)	xx
	g.	Other Radionuclideisotope Scanning	xx
	h.	Dynamic (Digital) Fluoroscopy	xx
2.	OTHER TESTS	xx
	b.a.	Electrodiagnostic Testing	xx
	c.b.	Injections – Diagnostic	xx
	a.c.	Personality/Psychological/Psychosocial Evaluation	xx
	d.	Provocation Discography	xx
	e.	Thermography	xx
3.	SPECIAL TESTS	xx
	a.	Computer-Enhanced Evaluations	xx
	b.	Functional Capacity Evaluations (FCE)	xx
	c.	Jobsite Evaluation	xx
	d.	Vocational Assessment	xx
	e.	Work Tolerance Screening	xx

 E.	THERAPEUTIC PROCEDURES – NON OPERATIVE	xx
1.	ACUPUNCTURE 	xx
	a.	Acupuncture	xx
	b.	Acupuncture with Electrical Stimulation	xx
	c.	total time frames for acupuncture and acupuncture with electrical 	stimulation	xx
	cd.	Other Acupuncture Modalities	xx
2.	BIOFEEDBACK	xx
3.	INJECTIONS – THERAPEUTIC 	xx
	a.	Therapeutic Spinal Injections	xx
		i.  Cervical Epidural Steroid Injection (ESI)	xx
		ii.  Zygapophyseal (Facet) Injection	xx
		iii.-Intradiscal Steroid Therapy	xx
	b	Facet Rhizotomy (Radio Frequency Medial Branch Neurotomy) / Facet Rhizotomy  	xx
	c.	Occipital Nerve Block	xx
	d.	Trigger Point Injections and Dry Needling Treatment	xx
	e..	Prolotherapy	xx
	f.	Epiduroscopy and Epidural Lysis of Adhesions	xx
4.	MEDICATIONS	xx
	a.	Acetaminophen	xx
	b.	Minor Tranquilizer/Muscle Relaxants	xx
	c.	Narcotics	xx
	d.	Nonsteroidal Anti-Inflammatory Drugs (NSAIDSs)	xx
	e.	Oral Steroids	xx
	f.	Intravenous Steroids	xx
	f.g.	Psychotropic/Anti-Anxiety/Hypnotic Agents	xx
	gh..	Tramadol	xx
	h.	Topical Drug Delivery	
5.	OCCUPATIONAL REHABILITATION PROGRAMS	xx
	a.	Non-Iinterdisciplinary	xx
	b.	Interdisciplinary	xx
6.	ORTHOTICS		xx
	a.	Cervical Collars	xx
	b.	Poster Appliances	xx
	c.	Cervicothoracic Orthosis	xx
	d.	Halo Devices	xx
	e.	Other Orthosis Devices and Equipment	xx
7.	PATIENT EDUCATION	xx
8.	PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION	xx
9.	RESTRICTION OF ACTIVITIES	xx
10.	RETURN-TO-WORK	xx
	a.	Establishment of a Return-to-Work Status	xx
	b.	Establishment of Activity Level Restrictions	xx
	c.	Compliance with Activity Restrictions	xx
11.	THERAPY – ACTIVE	xx
	a.	Activities of Daily Living (ADL)	xx
	b.	Aquatic Therapy	xx
	b.c.	Functional Activities	xx
	c.d.	Functional Electrical Stimulation	xx
	e.	Neuromuscular Re-education	xx
	d.f.	Spinal Cervical Lumbar Stabilization	xx
	f.g.	Therapeutic Exercise 	xx
12.	THERAPY – PASSIVE	xx
	a.	Electrical Stimulation (Unattended)	xx
	b.	Infrared Therapy	
	c.b.	Iontophoresis	xx
	d.c.	Manipulation	xx
	d.	Manipulation Under General Anesthesia (MUA)	xx
	e.	Manipulation Under Joint Anesthesia (MUJA)	xx
	e.f.	Massage – Manual or Mechanical	xx
	f.g.	Mobilization (Joint)	xx
	gh.	Mobilization (Soft Tissue)	xx
	i.	Short-wave Diathermy	xx
	hj.	Superficial Heat and Cold Therapy (Excluding Infrared Therapy)	xx
	j.k.	Traction – Manual	xx
	k.l.	Traction – Mechanical	xx
	l.m.	Transcutaneous Electrical Nerve Stimulation (TENS)	xx
	m.n.	Ultrasound (including Phonophoresis)	xx
13.	VOCATIONAL REHABILITATION	xx
F.	THERAPEUTIC PROCEDURES – OPERATIVE	xx
1.	ACUTE FRACTURES & DISLOCATIONS	xx
	a.	Halo Immobilization	xx
	b.	Anterior or Posterior Decompression with Fusion	xx
2.	DISC HERNIATION AND OTHER CERVICAL aggravation of degenerative CONDITIONS	xx
	a.	General Specific Indications	xx
		i.   For Patients with Myelopathy	xx
		ii.   For Patients with Cervical Radiculopathy	xx
		iii.  For Patients with Persistent Non-Rradicular Cervical Pain	xx
	b.	Surgical Procedures	xx
		i.  Cervical Discectomy with or without Fusion	xx
		ii.  Cervical Corpectomy 	xx
		iii. Cervical Laminectomy with or without Foraminotomy or Fusion	xx
		iv. Cervical Laminoplasty	xx
		v.  Percutaneous Discectomy	xx
3.	ARTIFICIAL CERVICAL DISC REPLACEMENT	xx
4.	PERCUTANEOUS RADIOFREQUENCY DISC DECOMPRESSION	xx
5.	EPIDUROSCOPY AND EPIDURAL LYSIS OF ADHESIONS	xx
6.	INTRAOPERATIVE MONITORING	xx

DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
CCR 1101-3
RULE 17, EXHIBIT 8

CERVICAL SPINE INJURY MEDICAL TREATMENT GUIDELINES

A.	INTRODUCTION
This document has been prepared by the Colorado Department of Labor and Employment, Division of Workers’ Compensation (Division) and should be interpreted within the context of guidelines for physicians/providers treating individuals qualifying under Colorado’s Workers’ Compensation Act as injured workers with cervical spine injuries.
Although the primary purpose of this document is advisory and educational, these guidelines are enforceable under the Workers’ Compensation Rules of Procedure, 7 CCR 1101-3.  The Division recognizes that acceptable medical practice may include deviations from these guidelines, as individual cases dictate.  Therefore, these guidelines are not relevant as evidence of a provider’s legal standard of professional care.
To properly utilize this document, the reader should not skip nor overlook any sections.

B.	GENERAL GUIDELINES PRINCIPLES
The principles summarized in this section are key to the intended implementation of all Division of Workers’ Compensation guidelines and critical to the reader’s application of the guidelines in this document.
1.	APPLICATION OF GUIDELINES The Division provides procedures to implement medical treatment guidelines and to foster communication to resolve disputes among the provider, payer, and patient through the Worker’s Compensation Rules of Procedure. In lieu of more costly litigation, parties may wish to seek administrative dispute resolution services through the Division or the Office of Administrative Courts.
2.	EDUCATION of the patient and family, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of cervical spine injuries and disability.  Currently, practitioners often think of education last, after medications, manual therapy, and surgery.  Practitioners must develop and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers, and the community as a whole.  An education-based paradigm should always start with inexpensive communication providing reassuring information to the patient.  More in-depth education currently exists within a treatment regime employing functional restorative and innovative programs of prevention and rehabilitation.  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.
3.	TREATMENT PARAMATER DURATION Time frames for specific interventions commence once treatments have been initiated, not on the date of injury.  Obviously, duration will be impacted by 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.
4.	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 interventions are viewed as a means to facilitate progress in an active rehabilitation program with concomitant attainment of objective functional gains.
5.	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.
6.	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, cognition, 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.
7.	RE-EVALUATEION TREATMENT EVERY 3 TO 4 WEEKS If a given treatment or modality is not producing positive results within 3 to 4 weeks, the treatment should be either modified or discontinued.  Reconsideration of diagnosis should also occur in the event of poor response to a seemingly rational intervention.
8.	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.
9.	SIX-MONTH TIME FRAME The prognosis drops precipitously for returning an injured worker to work once he/she has been temporarily totally disabled for more than six months.  The emphasis within these guidelines is to move patients along a continuum of care and return-to-work within a six-month time frame, whenever possible.  It is important to note that time frames may not be pertinent to injuries that do not involve work-time loss or are not occupationally related.
10.	RETURN-TO-WORK is therapeutic, assuming the work is not likely to aggravate the basic problem or increase long-term pain.  The practitioner must provide specific written physical limitations and the patient should never be released to “sedentary” or “light duty.”  The following physical limitations should be considered and modified as recommended:  lifting, pushing, pulling, crouching, walking, using stairs, bending at the waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors.  Even if there is residual chronic pain, return-to-work is not necessarily 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.
11.	DELAYED RECOVERY Strongly consider a psychological evaluation, if not previously provided, as well as initiating interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to make expected progress 6 to 12 weeks after an injury.  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 limits discussed within this document, but such treatment will require clear documentation by the authorized treating practitioner focusing on objective functional gains afforded by further treatment and impact upon prognosis.
12.	GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE Guidelines are recommendations based on available evidence and/or consensus recommendations.  When possible, guideline recommendations will note the level of evidence supporting the treatment recommendation.  When interpreting medical evidence statements in the guideline, the following apply: 
Consensus means the opinion of experienced professionals based on general medical principles.  Consensus recommendations are designated in the guideline as “generally well accepted,” “generally accepted,” “acceptable/accepted,” or “well-established.”
“Some” means the recommendation considered at least one adequate scientific study, which reported that a treatment was effective.
“Good” means the recommendation considered the availability of multiple adequate scientific studies or at least one relevant high-quality scientific study, which reported that a treatment was effective. 
“Strong” means the recommendation considered the availability of multiple relevant and high quality scientific studies, which arrived at similar conclusions about the effectiveness of a treatment.
All recommendations in the guideline are considered to represent reasonable care in appropriately selected cases, regardless of the level of evidence or consensus statement attached to it.  Those procedures considered inappropriate, unreasonable, or unnecessary are designated in the guideline as “not recommended.”
13.	CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI) 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 this guideline are for pre-MMI care and are not intended to limit post-MMI treatment.  
The remainder of this document should be interpreted within the parameters of these guideline principles that may lead to more optimal medical and functional outcomes for injured workers.

C.	INITIAL DIAGNOSTIC PROCEDURES
The Division recommends the following diagnostic procedures be considered, at least initially, the responsibility of the workers’ compensation carrier to ensure that an accurate diagnosis and treatment plan can be established.  Standard procedures, that should be utilized when initially diagnosing a work-related lower extremity complaint cervical spine complaint, are listed below.
1.	HISTORY-TAKING AND PHYSICAL EXAMINATION (Hx & PE) are generally accepted, well-established and widely used procedures that 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 complementing each other, the objective clinical findings should have preference.  The medical records should reasonably document the following.
a.	History of Present Injury:  A detailed history, taken in temporal proximity to the time of injury, should primarily guide evaluation and treatment. The history should include:
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 normal work body postures, frequency during the workday and lifting/push/pull requirements, should be included in the absence of a known specific incident.
ii.	Relationship to work.  This includes a statement of the probability that the illness or injury is work-related; 
ii. iii.	Location of pain, nature of symptoms, and alleviating/exacerbating factors (e.g. sleep positions),. Of particular importance, is whether especially if raising the arm over the head alleviates radicular-type symptoms;. The history should include both the primary and secondary complaints (e.g., primary neck pain, secondary arm pain, headaches, shoulder girdle complaints). The use of a patient completed pain drawing, Visual Analog Scale (VAS) is highly recommended, especially during the first two weeks following injury to assure that all work related symptoms are being addressed. 
iii. iv.	Presence and distribution of upper and/or lower extremity numbness, paresthesias, or weakness, especially if precipitated by coughing or sneezing;
iv. v.	Prior occupational and non-occupational injuries to the same area including specific prior treatment, chronic or recurrent symptoms, and any functional limitations.  Specific history regarding prior motor vehicles accidents may be helpful; and
v. vi.	Ability to perform job duties and activities of daily living. 
b.	Past History:
i.	Past medical history includes neoplasm, arthritis, and diabetes;
ii.	Review of systems includes symptoms of rheumatologic, neurologic, endocrine, neoplastic, infectious, and other systemic diseases;
iii.	Smoking history; , and
iv.	Vocational and recreational pursuits;.
v. 	History of depression, anxiety, or other psychiatric illness. 
c.	Physical Examination: This should include accepted tests and exam techniques applicable to the area being examined, including:
i.	Visual inspection, including posture;  
ii.	Cervical range of motion, quality of motion, and presence of muscle spasm.  Motion evaluation of specific joints may be indicated.  Range of motion should not be checked in acute trauma cases until fracture and instability have been ruled out on clinical examination, with or without radiographic evaluation;

iii. 	Examination of thoracic spine; 
iv.	Palpation of spinous processes, facets, and muscles noting myofascial tightness, tenderness, and trigger points;
v.	Motor and sensory examination of the upper muscle groups with specific nerve root focus, as well as sensation to light touch, pin prick, temperature, position and vibration.  More than 2 cm difference in the circumferential measurements of the two upper extremities may indicate chronic muscle wasting; and
vi.	Deep tendon reflexes.  Asymmetry may indicate pathology.  Inverted reflexes (e.g. arm flexion or triceps tap) may indicate nerve root or spinal cord pathology at the tested level.  Pathologic reflexes include wrist, clonus, grasp reflex, and Hoffman’s sign.
d. ii	Relationship to Work: This includes a statement of the probability that the illness or injury is work-related.  If further information is necessary to determine work relatedness, the physician should clearly state what additional diagnostic studies or job information is required.
e.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:
i.	Sharp and light touch, deep pressure, temperature, and proprioceptive sensory function;
ii.	Strength testing;
iii.	Anal sphincter tone and/or perianal sensation;
iv.	Presence of pathological reflexes of the upper and lower extremities; or
v.	Presence evidence of an Incomplete Spinal Cord Injury Syndrome—
A)	Anterior Cord Syndrome is characterized by the loss of motor function and perception of pain and temperature below the level of the lesion with preservation of touch, vibration, and proprioception.  This is typically seen after a significant compressive or flexion injury.  Emergent CT or MRI is necessary to look for a possible reversible compressive lesion requiring immediate surgical intervention.  The prognosis for recovery is the worst of the incomplete syndromes.
B)	Brown-Sequard Syndrome is characterized by ipsilateral motor weakness and proprioceptive disturbance with contralateral alteration in pain and temperature perception below the level of the lesion.  This is usually seen in cases of penetrating trauma or lateral mass fracture.  Surgery is not specifically required, although debridement of the open wound may be.
C)	Central Cord Syndrome is characterized by sensory and motor disturbance of all limbs, often upper extremity more than lower, and loss of bowel and bladder function with preservation of perianal sensation.  This is typically seen in elderly patients with a rigid spine following hyperextension injuries.  Surgery is not usually required.
D)	Posterior Cord Syndrome, a rare condition, is characterized by loss of sensation below the level of the injury, but intact motor function.

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vi.	Spinal cord lesions should be classified according to the American Spine Injury Association (ASIA) impairment scale. 

ASIA 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 3
•	D=Incomplete:  Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a grade of 3 or more
•	E= Normal: motor and sensory function are normal	

A worksheet which details dermatomes and muscle testing required is available from ASIA.
e.f.	Soft Tissue Injury Evaluation: Soft tissue injuries are traumatic injuries to the muscles, ligaments, tendons, and/or connective tissue.  The most common mechanism is sudden hyperextension and/or hyperflexion of the neck.  Acceleration/deceleration on the lateral plane may also result in one of these syndromes.  A true isolated cervical strain is not associated with focal neurological symptoms. or The signs and pathophysiology of these injuries is are not well understood.  Soft tissue injuries may include cervical strain, myofascial syndromes, somatic dysfunction, and fractures.  The Quebec Classification is used to categorize soft tissue and more severe cervical injuries:
i.	Grade I — Neck complaints of pain, stiffness, or tenderness only, without physical signs.  Lesion not serious enough to cause muscle spasm. Includes whiplash injury, minor cervical sprains, or strains.  
ii.	Grade II — Neck complaints with musculoskeletal signs, such as limited range of motion.  Includes muscle spasm related to soft tissue injury, whiplash, cervical sprain, and cervicalgia with headaches, sprained cervical facet joints and ligaments.  
iii.	Grade III —Neck complaints, such as limited range of motion, combined with neurologic signs.  Includes whiplash, cervicobrachialgia, herniated disc, cervicalgia with headaches.  
iv.	Grade IV — Neck complaints with fracture or dislocation.  
2.	RADIOGRAPHIC IMAGING of the cervical spine is a generally accepted, well-established and widely used diagnostic procedure.  Basic views are the anterioposterior (AP), lateral, right, and left obliques, swimmer’s, and odontioid.  CT scans may be necessary to visualize C7 and odontoid in some patients.  Lateral flexion and extension views are done to evaluate instability but may have a limited role in the acute setting.  MRI or CT is indicated when spinal cord injury is suspected.  The mechanism of injury and specific indications for the imaging radiograph should be listed on the request form to aid the radiologist and x-ray technician.  Alert, non-intoxicated patients, who have isolated cervical complaints without palpable midline cervical tenderness, or neurologic findings, or other acute or distracting injuries elsewhere in the body, may not require radiographic imaging.  The following Ssuggested indications   include: are:
a.	History of significant trauma, especially blunt trauma, high impact motor vehicle 	accident, rollover, ejection, bicycle or recreational vehicle collision, or 	fall from height where fracture, dislocation, instability, or neurologic deficit is 	suspected greater than one meter. -Quebec Classification Grade III and IV.  	Alert, non-intoxicated patients who have isolated cervical complaints without 	palpable midline cervical tenderness or neurologic findings may not require 	radiographic imaging.
b.b.	Age over 55 65 years.
c.	Suspicion of fracture, dislocation, instability, or neurologic deficit is suspected - Quebec Classification Grade III and IV.  Alert, non-intoxicated patients who have isolated cervical complaints without palpable midline cervical tenderness, or neurologic findings may not require radiographic imaging.
c.d.	Unexplained or persistent cervical pain for at least 6 weeks or pain that is worse with rest.
d.e.	Localized pain, fever, constitutional symptoms, suspected tumor, history of cancer, or suspected systemic illness such as a rheumatic/rheumatoid disorder or endocrinopathy.
3.	LABORATORY TESTING Laboratory tests are generally accepted, well-established and widely used procedures. They are, however, rarely indicated at the time of initial evaluation, unless there is suspicion of systemic illness, infection, neoplasia, or underlying rheumatologic disorder, connective tissue disorder, or based on history and/or physical examination. Laboratory tests can provide useful diagnostic information.  Tests include, but are not limited to:
a.	Complete Blood Count (CBC) with differential can detect infection, blood dyscrasias, and medication side effects;
b.	Erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), Anti-Nuclear Antigen (ANA), Human Leukocyte Antigen (HLA), and C-reactive protein (CRP), can be used to detect evidence of a rheumatologic, infection, or connective tissue disorder;
c.	Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease; and
d.	Liver and kidney function may be performed for prolonged anti-inflammatory use or other medications requiring monitoring.

D.	FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES
One diagnostic imaging procedure may provide the same or distinctive information as obtained by other does another procedures.  Therefore, prudent choice of procedure(s) for a single diagnostic procedure, a complementary of procedures in combination with other procedures(s), or a proper sequential order in multiple sequence of procedures will ensure maximum optimize diagnostic accuracy;, minimize adverse effect to patients and maximize cost effectiveness (by avoiding duplication or redundancy), and minimize potential adverse effects to patients.
All diagnostic imaging procedures have a significant percentage of specificity and sensitivity for various diagnoses.  All imaging procedures have a degree of specificity and sensitivity for various diagnoses. None is specifically characteristic of a certain diagnosis No isolated imaging test can assure a correct diagnosis.  Clinical information obtained by history taking and physical examination should be form the basis for selectionng and interpretation of imaging procedure an imaging procedure and interpreting its results.
Magnetic resonance imaging (MRI), myelography, or computed axial tomography (CT) scanning following myelography may provide useful information for many spinal disorders.  When a diagnostic procedure, in conjunction with clinical information, provides sufficient information to establish an accurate diagnosis, the second diagnostic procedure will become a redundant procedure.  At the same time, a subsequent diagnostic procedure can be a complementary diagnostic procedure if the first or preceding procedures, in conjunction with clinical information, cannot provide an accurate diagnosis.  Usually, preference of a procedure over others depends upon availability, a patient’s tolerance, and/or the treating practitioner’s familiarity with the procedure.
1.	IMAGING STUDIES are generally accepted, well-established and widely used diagnostic procedures.  In general, MRI is the preferred procedure for imaging of cervical nerve root compression or myelopathy.  in the absence of myelopathy or progressive neurological changes, Iimaging usually is not appropriate until conservative therapy has been tried and failed.  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, the clinical findings should have preference.  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 biochemical changes rather than structural deterioration, and may not have pathological significance.  Disc bulging and posterior disc protrusion, while not rare, is more commonly symptomatic in the cervical spine than in the lumbar 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. 
The studies below are listed in frequency of use, not importance:
a.	Magnetic Resonance Imaging (MRI): is the imaging study of choice for most abnormalities of the cervical spine.  MRI is useful in suspected nerve root compression, in myelopathy to evaluate the spinal cord and/or masses, infections such as epidural abscesses or disc space infection, bone marrow involvement by metastatic disease, and/or suspected disc herniation or cord contusion following severe neck injury.  MRI should be performed immediately if there is a question of infection or metastatic disease with cord compression.  It -MRI is contraindicated in patients with certain implanted devices.  
In general, the high field, conventional, MRI provides better resolution.  A lower field scan may be indicated when a patient cannot fit into a high field scanner or is too claustrophobic despite sedation.  Inadequate resolution on the first scan may require a second MRI using a different technique.  All questions in this regard should be discussed with the MRI center and/or radiologist.
Specialized MRI Scans
i. 	MRI with 3-dimensional reconstruction
On rare occasions, MRI with 3-dimensional reconstruction views may be used as a pre-surgical diagnostic procedure to obtain accurate information of characteristics, location, and spatial relationships among soft tissue and bony structures.
ii. 	Dynamic-kinetic MRI of the spine 
Dynamic-kinetic MRI of the spine uses an MRI unit configured with a top-front open design which enables upright, weight-bearing patient positioning in a variety of postures not obtainable with the recumbent images derived from conventional, closed unit MRI systems.  Imaging can be obtained in flexion, extension, and rotation of the spine, as well as in erect positioning.  There is a theoretical advantage to imaging sequences obtained under more physiologic conditions than in the supine position.  There is currently ongoing research to establish whether the theoretical advantages of positional and kinetic MRI result in improved sensitivity and specificity in detecting spine pathology.  Currently it remains investigational, and is not recommended until the correlation with clinical syndromes is firmly established.
b.	Computed Axial Tomography (CT): provides excellent visualization of bone and is used to further evaluate bony masses and suspected fractures not clearly identified on radiographic evaluation.  It may sometimes be done as a complement to MRI scanning to better delineate bony osteophyte formation in the neural foramen.  CT is usually utilized for suspected cervical spine fracture in a patient with negative plain films, or to further delineate a cervical fracture.  CT scanning is also quite useful for congenital anomalies at the skull base and at the C1-2 levels.  Plain CT scanning is poor for the C6-7 or C7-T1 levels because of shoulder artifact.  Instrument-scatter reduction software provides better resolution when metallic artifact is of concern.  
c.	Myelography: is the injection of radiopaque material into the spinal subarachnoid space, with x-rays then taken to define anatomy.  It may be used as a pre-surgical diagnostic procedure to obtain accurate information of characteristics, location, and spatial relationships among soft tissue and bony structures.  Myelography is an invasive procedure with complications including nausea, vomiting, headache, convulsion, arachnoiditis, CSF leakage, allergic reactions, bleeding, and infection. Therefore, myelography should only be considered when CT and MRI are unavailable, for morbidly obese patients or those who have undergone multiple operations, or multiple-operated patients, and when other tests prove non-diagnostic in the surgical candidate.  The use of small needles and a less toxic, water-soluble, nonionic contrast is preferred recommended.
d.	CT Myelogram: provides more detailed information about relationships between neural elements and surrounding anatomy and is appropriate in patients with multiple prior operations or tumorous conditions.  
e.	Lineal Tomography: is infrequently used, yet may be helpful in the evaluation of bone surfaces, bony fusion, or pseudoarthrosis.
f.	Bone Scan (Radioisotope Bone Scanning): is generally accepted, well-established and widely used.  Bone scanning is more sensitive but less specific than MRI.  99MTechnicium Technetium diphosphonate uptake reflects osteoblastic activity and may be useful in diagnosing metastatic/primary bone tumors, stress fractures, osteomyelitis, and inflammatory lesions, but cannot distinguish between these entities.  In the cervical spine, the usual indication is to evaluate for for the evaluation of neoplastic conitions conditions. but can also be used for Other indications include occult fracture or infection.  
g.	Other Radionuclideisotope Sscanning: Indium and gallium scans are generally accepted, well-established, and widely used procedures, usually to help diagnose lesions seen on other diagnostic imaging studies.  67Gallium citrate scans are used to localize tumor, infection, and abcesses abscesses.  111Indium-labeled leukocyte scanning is utilized for localizationing of infection or inflammation and is usually not used for the cervical spine.
h.	Dynamic [Digital] Fluoroscopy:  Dynamic [Digital] Fluoroscopy of the cervical spine measures the motion of intervertebral segments using a videofluoroscopy unit to capture images as the subject performs cervical flexion and extension, storing the anatomic motion of the spine in a computer.  Dynamic fluoroscopy may be used in state-designated trauma centers to evaluate the cervical spine.  Its superiority over MRI has not been established.  If performed, full visualization of the cervical spine (C1 - T1), in accordance with Section C. 2. (Initial Diagnostic Procedures-Imaging), should be accomplished prior to the procedure.
In the post-acute setting in some rare cases, Dynamic [Digital] fluoroscopy may be used but is primarily an investigational tool and therefore, requires prior authorization in the post-acute setting.  No studies have yet demonstrated predictive value in terms of standard operative and non-operative therapeutic outcomes.
2.	OTHER TESTS:  The following studies diagnostic procedures are listed in alphabetical order, by frequency of use, not by importance:
b.a	Electrodiagnostic Testing: include, but are not limited to,
i.  	Electromyography (EMG), and Nerve Conduction studies. Velocities (NCVs). and Somatosensory Evoked Potentials (SSEP). These are generally accepted, well-established and widely used diagnostic procedures.  The SSEP study, although generally accepted, has limited use.  Electrodiagnostic studies EMG and NCS, when performed and interpreted by a trained physician/electrophysiologist, may be useful for patients with suspected neural involvement whose symptoms are persistent or unresponsive to initial conservative treatments.  They are used to differentiate peripheral neural deficits from radicular and spinal cord neural deficits and to rule out concomitant myopathy. However, F-Wave Latencies are not diagnostic for radiculopathy. 

In general, these EMG and NCS diagnostic procedures are complementary to imaging procedures such as CT, MRI, and/or myelography or diagnostic injection procedures.  Electrodiagnostic studies may provide useful, correlative neuropathophysiological information that would be otherwise unobtainable from the standard radiologic studies discussed above.
ii. 	Portable Automated Electrodiagnostic Device (also known as Surface EMG)  This is not a substitute for conventional diagnostic testing in clinical decision-making and therefore, is not recommended. 
iii. 	Somatosensory Evoked Potential (SSEP) is useful for the evaluation of myelopathy.  It is not recommended to identify radiculopathy.  
iv. 	Current Perception Threshold Evaluation (CPT) may be useful as a screening tool, but its diagnostic efficacy in the evaluation of cervical spine pain has not been determined.  Therefore, CPT is not recommended as a diagnostic tool.
c.b	Injections — Diagnostic:
i.	Description — Diagnostic cervical injections are generally accepted well-established procedures.  These injections may be useful for localizing the source of pain, and may have added therapeutic value when combined with injection of therapeutic medication(s).  Each diagnostic injection has inherent risks, and risk versus benefit should always be evaluated when considering injection therapy.  
ii.	Since these procedures are invasive, less invasive or non-invasive procedures should be considered first.  Selection of patients, choice of procedure, and localization of the level for injection should be determined by clinical information indicating strong suspicion for pathologic condition(s) and the source of pain symptoms. Because injections are invasive with an inherent risk, the number of diagnostic procedures should be limited in any individual patient to those most likely to be primary pain generators.  Patients should not receive all of the diagnostic blocks listed merely in an attempt to identify 100% of the pain generators.
iii.	The interpretation of the test results - is are primarily based upon on functional change, symptom report, and pain response; (via a recognized pain scale before and at an appropriate time after the injection). Tthe diagnostic significance of the test result should be evaluated in conjunction with clinical information and the results of other diagnostic procedures.  Injections with local anesthetics of differing duration are required to confirm may be used to support a diagnosis.  In some cases, injections at multiple levels may be required to accurately diagnose cervical pain conditions.  Refer to Section E.3, Injections – Therapeutic for information on specific injections.
It is obligatory that sufficient data be accumulated by the examiner performing this procedure such that the diagnostic value of the procedure is evident to other reviewers.  This entails, at a minimum, documentation of patient response immediately following the procedure with details of any symptoms with a response and the degree of response.  Additionally, a log must be recorded as part of the medical records which documents response, if any, on an hourly basis for, at a minimum, the expected duration of local anesthetic phase of the procedure.  Responses must be identified as to specific body part (e.g., neck, arm pain).  The practitioner must identify the local anesthetic used and the expected duration of response for diagnostic purposes.
Multiple injections provided at the same session without staging may seriously dilute the diagnostic value of these procedures.  Practitioners must carefully weigh the diagnostic value of the procedure against the possible therapeutic value.
iiv.	Special Requirements for Diagnostic Injections  Since multi-planar fluoroscopic y arthroscopic and/or CT guidance during procedures is required to document technique and needle placement;, an experienced physician should perform the procedure.  Permanent images are required to verify needle placement.  The subspecialty disciplines of the physicians performing the injections may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry.  The practitioner should have experience in ongoing injection training workshops have completed a fellowship in pain medicine with interventional training, or its equivalent. provided by organizations such as the International Spinal Injection Society (ISIS) and They must also be knowledgeable in radiation safety.  In addition, practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments of Radiology, as applicable.
iiiv. 	Complications - General complications of diagnostic injections may include transient neurapraxia, nerve injury, infection, headache, vasovagal effects, as well as epidural hematoma, permanent neurologic damage, dural perforation and CSF leakage, and spinal meningeal abscess.  Severe complications are remote but can include spinal cord damage, quadriplegia, and/or death.  Injections at a C2-C3 level frequently cause temporary neuritis with ataxia.
ivi.	Contraindications  Absolute contraindications of to diagnostic injections include: (a) bacterial infection – systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d) possible pregnancy.  
Relative contraindications of to diagnostic injections may include:  (a) allergy to contrast, (b) poorly controlled Diabetes Mellitus, or and hypertension,. (c) aspirin/antiplatelet therapy (drug may be held for 3 days prior to injection), and (d) shellfish allergy, Drugs affecting coagulation require restriction from use.  The following are suggested time period restrictions:
•	Aspirin - withhold for seven days;
•	NSAIDs-withhold for three days;
•	Clopidogrel-withhold for three days;
•	Other anti-platelet therapy and anti-coagulants should also be addressed individually by a knowledgeable specialist. 
vii.	Specific Diagnostic Injections  In general, relief should last for at least the duration of the local anesthetic used and give should significantly reliefve of pain and result in functional improvement.  Refer to “Injections – Therapeutic” for information on specific therapeutic injections.

A)	Medial Branch Blocks are primarily generally-accepted diagnostic injections, used to determine whether a patient is a candidate for facet rhizotomy.  radiofrequency medial branch neurotomy (also known as facet rhizotomy).  The international spine intervention society (ISIS) suggests controlled blocks – using either placebo or an anesthetic with a varying length of activity (i.e., bupivacaine longer than lidocaine).  To be a positive diagnostic block, the patient should report a reduction of pain of 80% or greater from baseline for the length of time appropriate for the local anesthetic used.  In almost all cases, this will mean a reduction of pain to 1 or 2 on the Visual Analog Scale (VAS) 10-point scale correlated with functional improvement.  The patient should also identify activities of daily living (which may include measurements of range of motion) that are impeded by their pain and can be observed to document functional improvement in the clinical setting.  Ideally, these activities should be assessed throughout the observation period for function.  The observer should not be the physician who performed the procedure.  It is suggested that this be recorded on a form similar to ISIS recommendations.
A separate comparative block on a different date should be performed to confirm the level of involvement.  A comparative block uses anesthetics with varying lengths of activity.  Medial Branch blocks are probably not helpful to determine the likelihood of success for spinal fusion.
•	Frequency and Maximum Duration:  May be repeated once for comparative blocks.  Limited to 4 levels
B)	Intra-Articular Facet injections are principally diagnostic yet some patients may obtain therapeutic response.  If the patient demonstrates definite short-term but not long-term response, confirmatory medial branch blocks and possible medial branch neurotomy should be considered.
C)B)	Atlanto-Axial and Atlanto-Occipital injections are generally accepted for diagnosis and treatment but do not lend themselves to denervation techniques owing to variable neuroanatomy.  Injection of this articulation is complicated by the proximity of the vertebral artery, which The vertebral artery may be tortuous at the level of the C1 joint.  Inadvertent injection of the vertebral artery may cause respiratory arrest, seizure, stroke, or permanent neurological sequelae.  Only practitioners skilled in these injections should perform them.
•	Frequency and Maximum Duration:  Once per side
C)	Transforaminal injections are generally accepted and useful in identifying spinal pathology.    When performed for diagnosis, small amounts of local anesthetic should be used to determine the level of nerve root irritation.  The relief should last for at least the duration of the local anesthetic used and give significant relief of pain. A positive diagnostic block should result in a positive diagnostic functional benefit and an 80% reduction in nerve-root generated pain appropriate for the anesthetic used as measured by accepted pain scales (such as a VAS).
•	Time to produce effect:  Less than 30 minutes for local anesthesia; corticosteroids up to 72 hours for most patients
•	Frequency and Maximum Duration:  Once per suspected level.  limited to two levels
D)	Zygapophyseal (Facet) Blocks should not be considered diagnostic blocks, nor should they be done with medial branch blocks.
Facet blocks are generally accepted but should not be considered diagnostic blocks for the purposes of determining the need for a rhizotomy (radiofrequency medial branch neurotomy), nor should they be done with medial branch blocks.
These blocks should not be considered a definitive diagnostic tool.  They may be used diagnostically to direct functional rehabilitation programs.  A positive diagnostic block should result in a positive diagnostic functional benefit and an 80% reduction in pain appropriate for the anesthetic used as measured by accepted pain scales (such as a VAS).  They then may be repeated per the therapeutic guidelines when they are accompanied by a functional rehabilitation program.  (Refer to section E. 3. a. Therapeutic Spinal Injections.)
•	Time to produce effect:  Less than 30 minutes for local anesthesia; corticosteroids up to 72 hours for most patients.
•	Frequency and maximum Duration:  Once per suspected level, limited to two levels.
a.c.	Personality/Psychological/Psychosocial/ Evaluation: are generally accepted and well-established diagnostic procedures with selective use in the acute cervical spine injury population, but have and more widespread use in sub-acute and chronic cervical spine populations.
Diagnostic testing procedures may be useful for patients with symptoms of depression, delayed recovery, chronic pain, recurrent painful conditions, disability problems, and for pre-operative evaluation as well as a possible predictive value for post-operative response.  Psychological testing should provide differentiation between pre-existing depression versus injury-caused depression, as well as post-traumatic stress disorder.
Formal psychological or psychosocial evaluation should be performed on patients not making expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests.  In addition to the customary initial exam, the evaluation of the injured worker should specifically address the following areas:
i.	Employment history;

ii.	Interpersonal relationships — both social and work;

iii.	Leisure activities;

iv.	Current perception of the medical system;

v.	Results of current treatment;

vi.	Perceived locus of control; and

vii.	Childhood history, including abuse and family history of disability.
Results should provide clinicians with a better understanding of the patient, thus allowing for more effective rehabilitation.  The evaluation will determine the need for further psychosocial interventions, and in those cases, a Diagnostic Statistical Manual of Mental Disorders (DSM) diagnosis should be determined and documented.  An individual with a PhD, PsyD, or Psychiatric MD/DO credentials may should perform initial evaluations, which are generally completed within one to two hours.  A professional fluent in the primary language of the patient is strongly preferred.  When such a provider is not available, services of a professional language interpreter must be provided.  When issues of chronic pain are identified, the evaluation should be more extensive and follow testing procedures as outlined in the Division’s Chronic Pain Disorder Medical Treatment Guidelines.

•	Frequency:  One time visit for evaluation.  If psychometric testing is indicated as a portion of the initial evaluation, time for such testing should not exceed an additional two hours of professional time.
d.	Provocation Discography:
i.	Description  Discography is an generally accepted, well-established but rarely indicated, invasive diagnostic procedure to identify or refute a discogenic source of pain for patients who are surgical candidates.  Discography should only be performed by physicians who are experienced and have been proctored in the technique.  discograms have a significant false positive rate. It is essential that all indications, preconditions, special considerations, procedures, reporting requirements, and results, are carefully and specifically followed.  results should be interpreted judiciously.  Fewer studies have been published on cervical and thoracic discography than on lumbar discography.
ii.	Indications  Discography may be indicated when a patient has a history of functionally limiting, unremitting cervical pain of greater than three four months duration, with or without arm pain, which has been unresponsive to all conservative interventions. A patient who does not desire surgical operative therapeutic intervention is not a candidate for an invasive non-therapeutic intervention, such as provocativeon discography.  Discography may prove useful for the evaluation of the pre-surgical spine, such as pseudoarthrosis, discogenic pain at levels above or below a prior spinal fusion, annular tear, or internal disc disruption.  
Discography may show disc degeneration and annular disruption in the absence of cervical pain.  Discography may also elicit concordant pain in patients with mild and functionally inconsequential neck pain.  Because patients with mild neck pain should not be considered for invasive treatment, discography should not be performed on these patients.  The presence of an annular tear does not necessarily identify the tear as a pain generator.
Discography is not useful in previously operated discs. In addition, d Discography may prove useful in evaluationng of the number of cervical spine levels that might require fusion.  It has also been utilized to differentiate organic from psychogenic factors.  CT-Discography provides further detailed information about morphological abnormalities of the disc and possible lateral disc herniations.  
iii.	Preconditions for provocativeion discography include all of the following:
A)	A patient with functionally limiting, unremitting neck and/or arm pain of greater than 3 four months duration in whom conservative treatment has been unsuccessful and in whom the specific diagnosis of the pain generator has not been made apparent on the basis of other noninvasive imaging studies (e.g., MRI, CT, plain films, etc.) and in whom a psychosocial evaluation has been considered.  It is recommended that discography be reserved for use in patients with equivocal MRI findings, especially at levels adjacent to clearly pathological levels.  Discography may be more sensitive than MRI or CT in detecting radial annular tears.  However, radial tears must always be correlated with clinical presentation.
B)	Psychosocial Evaluation has been completed.  There is some evidence that false positives and complaints of long-term pain arising from the procedure itself occur more frequently in patients with somatoform disorders.  Therefore, discograms should not be performed on patients with somatoform disorders.
B)C)	Patients who are considered surgical candidates (e.g., symptoms are of sufficient magnitude and the patient has been informed of the possible surgical options that may be available based upon the results of discography).  Discography should never be the sole indication for surgery. 
C)D)	Informed consent regarding the risks and potential diagnostic benefits of discography has been obtained.
iv.	Complications   I include, but are not limited to, discitis, nerve damage, retropharyngeal abscess, chemical meningitis, pain exacerbation, and anaphylaxis. may occur with discography.  Therefore, prior to consideration of discography, the patient should undergo other diagnostic modalities in an effort to define the etiology of the patient's complaint including psychological screening evaluation, myelography, CT and MRI.
v.	Contraindications  Contraindications for provocative discography may include: (a) active infection of any type or continuing antibiotic treatment for infection; and/or (b) bleeding diathesis or pharmaceutical anticoagulation with warfarin, etc.; and/or (c) significant spinal stenosis at the level being studied as visualized by MRI, myelography or CT scan; and/or (d) presence of clinical myelopathy; and/or (e) effacement of the cord, thecal sac or circumferential absence of epidural fat; and (f) known allergic reactions.
vi.	Special Considerations: 
A)	Discography should not be done by the treating surgeon should not be performed by the physician expected to perform the therapeutic procedure.  The procedure should be carried out by an experienced individual who has received specialized training in the technique of provocativeon discography.
  B)	Discography should be performed in a blinded format that avoids leading the patient with anticipated responses.  The procedure should always include one or more disc levels thought to be normal or nonpainful in order to serve as an internal control.  The patient should not know what level is being injected in order to avoid spurious results.  Adjacent discs may be identified as pain generators in more than half of cases in which discogenic pain is identified at one level.  Because surgery is likely to fail in multi-level discogenic pain, injection of as many levels as feasible can prevent many operative failures.  Abnormal disc levels may be repeated to confirm concordance.
C)	Sterile technique should must be utilized.
D)	Judicious use of light sedation during the procedure is acceptable, and represents the most common practice nationally at the current time, and is recommended by most experts in the field.  The patient must be awake and able to accurately report pain levels during the provocation portion of the procedure.
E)  	CT or MRI must have should established cervical spinal dimensions and ruled out spinal stenosis.
F)	Intradiscal injection of local anesthetic should may be carried out after the provocationve portion of the examination and the patient’s response.
G) 	It is recommended that a post-discogram CT be considered as it frequently provides additional useful information about disc morphology or other pathology.
vii.	Reporting of Discography  In addition to a narrative report, the discography report should contain a standardized classification of (a) disc morphology and (b) the pain response.  Both All results should be clearly separated in the report from the narrative portion.  Asymptomatic annular tears are common and the concordant pain response is an essential finding for a positive discogram.  Alternative reporting techniques using pressure monitors are being investigated and may prove useful in identifying patients with discogenic pain.
When discography is performed to identify the source of a patient’s neck pain, both a concordant pain response and morphological abnormalities must be present at the pathological level prior to initiating any treatment directed at that level.  The patient must be awake during the provocation phase of the procedure; therefore, sedative medication must be carefully titrated.
Caution should be used when interpreting results from discography.  In one study of patients without lumbar pathology, 10 percent of pain-free patients experienced pain with discography and 83 percent of patients with somatization disorder experienced pain with lumbar discography.  No studies have yet been published which measure the frequency of false-positive discography of the cervical spine.  One study using asymptomatic volunteers reported pain in the majority of discs injected, but no subjects reported pain exceeding 6/10 on a pain scale in a normal disc.
A)	Reporting disc morphology as visualized by the post-injection CT scan (when available) should follow the Modified Dallas Discogram Scale where: 

Grade 0 = Normal Nucleus.

Grade 1 = Annular tear confined to inner one-third of annulus fibrosis.

Grade 2 = Annular tear extending to the middle third of the annulus fibrosis.

Grade 3 = Annular tear extending to the outer one-third of the annulus fibrosis.

Grade 4 = A grade 3 tear plus dissection within the outer annulus to involve more than 30 degrees of the disc circumference.

Grade 5 = Full thickness tear with extra-annular leakage of contrast, either focal or diffuse.
B)	Reporting of pain response should be according to the modified Aprill Scheme.  In this scheme, codes are assigned a response during the initial injection (“P” provocative response) and the response to an injection of the local anesthetic (“R” response) where:

P0 = No Pain

P1 = Procedural pain, or pain that is nonconcordant with the patient’s familiar pain 

P2 = Concordant pain

R0 = No pain relief with injection of local anesthetic

R1 = Partial relief

R2 = Complete relief
N = Non-diagnostic, non-physiologic injection.  The final category of “N” is suggested when the discographer concludes that the provocative portion of the injection is non-diagnostic.  For example, a patient with a morphologically normal disc who responds when typical pain is reproduced is considered to have a non-diagnostic or non-physiologic response.  Other circumstances may occur that cause the discographer to conclude that the provocative portion of the injection is invalid.  The category “N” should be used for these situations.
•	Time to produce effect:  Immediate
•	Frequency:  One time only
•	Optimal duration:  One time
•	Maximum duration:  Repeat discography is rarely indicated.
B) 	Reporting of pain response should be consistent with the operational criteria of the International Spine Intervention Society Guidelines (ISIS).  The report must include the level of concordance for neck and arm pain separately using a 10-point VAS, or similar quantitative assessment.  It should be noted that the change in the VAS score before and after provocation is more important than the number reported.
the diagnosis of discogenic pain is less likely when there are more discs with dissimilar pain and fewer with no pain.  At least two discs with no pain on stimulation and one disc with concordant pain registering at least 7 on a 10-point VAS or equivalent should be present to qualify for a diagnosis of discogenic pain.  The VAS score prior to the discogram should be taken into account when interpreting the VAS score reported by the patient during the discogram.
Time Parameters for Provocation Discography are as follows:

•	Frequency: One time only
•	Maximum:  Repeat Discography is rarely indicated
e.	Thermography: is an accepted and established procedure, but has limited no use as a diagnostic test for cervical pain.  It may be used to diagnose regional pain disorders and in these cases, refer to the Division’s Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy Medical Treatment Guidelines.
3.	SPECIAL TESTS are generally well-accepted tests and are performed as part of a skilled assessment of the patients’ capacity to return to work, his/her strength capacities, and physical work demand classifications and tolerance.  The procedures in this subsection are listed in alphabetical order, not by importance.
a.	Computer-Enhanced Evaluations: may include isotonic, isometric, isokinetic and/or isoinertial measurement of movement, range of motion, endurance, or strength.  Values obtained can include degrees of motion, torque forces, pressures, or resistance.  Indications include determining validity of effort, effectiveness of treatment and demonstrated motivation.  These evaluations should not be used alone to determine return to work restrictions.
•	Frequency:  One time for evaluation.  Can monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations.
b.	Functional Capacity Evaluation (FCE):  is a comprehensive or modified evaluation of the various aspects of function as they relate to the worker’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 and financial status, as well as psychosocial, cognitive, and sensory perceptual aspects of competitive employment 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; and (h) non-material and material handling activities; (i) cognitive; (j) visual; and (k) sensory perceptual factors. 
When an FCE is being used to determine return to a specific jobsite, the provider is responsible for fully understanding the job duties.  A jobsite evaluation is frequently necessary.  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.
	Full FCEs are rarely necessary.  in many cases, a work tolerance screening will identify the ability to perform the necessary job tasks.
•	Frequency:  Can be used initially to determine baseline status.  Additional evaluations can be performed to monitor and assess progress and aid in determining the endpoint for treatment.
c.	Jobsite Evaluation:  is a comprehensive analysis of the physical, mental and sensory components of a specific job.  These components may include, but are not limited to: (a) postural tolerance (static and dynamic); (b) aerobic requirements; (c) range of motion; (d) torque/force; (e) lifting/carrying; (f) cognitive demands; (g) social interactions; (h) visual perceptual; (i) sensation; (j) coordination; (k) environmental requirements of a job; (l) (j) repetitiveness; and (k) (m) essential job functions. of a job. 
Job descriptions provided by the employer are helpful but should not be used as a substitute for direct observation.  A jobsite evaluation may include observation and instruction of how work is done, what material changes (desk, chair) should be made, and determination of readiness to return to work. 
Requests for a jobsite evaluation should describe the expected goals for the evaluation.  Goals may include, but are not limited to the following: 
•	To determine if there are potential contributing factors to the person’s condition and/or for the physician to assess causality;
•	To make recommendations for, and to assess the potential for ergonomic changes;
•	To provide a detailed description of the physical and cognitive job requirements;
•	To assist the patient in their return-to-work by educating them on how they may be able to do their job more safely and in a more biomechanically appropriate manner;
•	To give detailed work/activity restrictions.
•	Frequency:  One time with additional visits as needed for follow-up per jobsite.
d.	Vocational Assessment:  Once an authorized practitioner has reasonably determined and objectively documented that a patient will not be able to return to his/her former employment and can reasonably prognosticate final restrictions, implementation of a timely vocational assessment can be performed.  If the injury is such that the practitioner can easily determine that the worker will be unable to return to his/her previous occupation, implementation of the assistance of vocational rehabilitation at that time may aid in the overall medical management and rehabilitation of the patient. The physician may decide that the patient is unable to return to the previous occupation prior to the declaration of Maximum Medical Improvement (MMI).
The vocational assessment should provide valuable guidance in the determination of future rehabilitation program goals.  It should clarify rehabilitation goals, which optimize both patient motivation and utilization of rehabilitation resources. The physician should have identified the expected permanent limitation(s) prior to the assessment. If prognosis for return to former occupation is determined to be poor, except in the most extenuating circumstances, vocational assessment should be implemented within 3 to 12 months post-injury.  Declaration of Maximum Medical Improvement MMI should not be delayed solely due to lack of attainment of a vocational assessment.
•	Frequency:  One time with additional visits as needed for follow-up
e.	Work Tolerance Screening: is a determination of an individual's tolerance for performing a specific job based on a job activity or task and may be used when a full Functional Capacity Evaluation is not indicated.  It may include a test or procedure to specifically identify and quantify work-relevant cardiovascular, physical fitness and postural tolerance.  It may also address ergonomic issues affecting the patient’s return-to-work potential.  May be used when a full Functional Capacity Evaluation is not indicated.

•	Frequency:  One time for evaluation. initial screen.  May monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations visits.

E.	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 injured worker.
First, patients undergoing therapeutic procedure(s) should be released or returned to modified or restricted duty during their rehabilitation at the earliest appropriate time.  Refer to “Return-to-Work” in this section for detailed information.
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, formal psychological or psychosocial screening evaluation should be performed on patients not making expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests.
In cases where a patient is unable to attend an outpatient center, home therapy may be necessary.  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.  Home therapy is usually of short duration and continues until the patient is able to tolerate coming to an outpatient center.
The following procedures are listed in alphabetical order.
1.	ACUPUNCTURE is an accepted and widely used procedure for the relief of pain and inflammation, and there is some scientific evidence to support its use.  The exact mode of action is only partially understood.  Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the brain, promotes deep relaxation, and affects the release of neurotransmitters.  Acupuncture is commonly used as an alternative or in addition to traditional Western pharmaceuticals.  While it is commonly used when pain medication is reduced or not tolerated, it may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten the return of functional activity.  Acupuncture should be performed by credentialed licensed practitioners.
a.	Acupuncture: is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points).  Needles may be inserted, manipulated, and retained for a period of time.  Acupuncture can be used to reduce pain, reduce inflammation, increase blood flow, increase range of motion, decrease the side effect of medication-induced nausea, promote relaxation in an anxious patient, and reduce muscle spasm.
Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain.
•	Time to produce effect:  3 to 6 treatments
•	Frequency:  1 to 3 times per week
•	Optimum duration:  1 to 2 months
•	Maximum duration:  14 treatments
b.	Acupuncture with Electrical Stimulation:  is the use of electrical current (micro-amperage or milli-amperage) on the needles at the acupuncture site.  It is used to increase effectiveness of the needles by continuous stimulation of the acupoint.  Physiological effects (depending on location and settings) can include endorphin release for pain relief, reduction of inflammation, increased blood circulation, analgesia through interruption of pain stimulus, and muscle relaxation.
It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.
c.	Total Time Frames for Acupuncture and Acupuncture with Electrical Stimulation:  time frames are not meant to be applied to each of the above sections separately.  the time frames are to be applied to all acupuncture treatments regardless of the type or combination of therapies being provided.
•	Time to produce effect:  3 to 6 treatments
•	Frequency:  1 to 3 times per week
•	Optimum duration:  1 to 2 months
•	Maximum duration:  14 treatments
Any of the above acupuncture treatments may extend longer if objective functional gains can be documented or when symptomatic benefits facilitate progression in the patient’s treatment program.  Treatment beyond 14 treatments must be documented with respect to need and ability to facilitate positive symptomatic or functional gains.  Such care should be re-evaluated and documented with each series of treatments.
dc.	Other Acupuncture Modalities: Acupuncture treatment is based on individual patient needs and therefore treatment may include a combination of procedures to enhance treatment effect.  Other procedures may include the use of heat, soft tissue manipulation/massage, and exercise.  Refer to Section E.11 and 12, Active Therapy (Therapeutic Exercise) and Passive Therapy sections (Massage and Superficial Heat and Cold Therapy) for a description of these adjunctive acupuncture modalities and time frames.
•	Time to produce effect:  3 to 6 treatments
•	Frequency:  1 to 3 times per week
•	Optimum duration:  1 to 2 months
•	Maximum duration:  14 treatments
2.	BIOFEEDBACK is a form of behavioral medicine that helps patients learn self-awareness and self-regulation skills for the purpose of gaining greater control of their physiology, such as muscle activity, brain waves, and measures of autonomic nervous system activity.  Electronic instrumentation is used to monitor the targeted physiology and then displayed or fed back to the patient visually, auditorially, or tactilely, with coaching by a biofeedback specialist.  Biofeedback is provided by clinicians certified in biofeedback and/or who have documented specialized education, advanced training, or direct or supervised experience qualifying them to provide the specialized treatment needed (e.g., surface EMG, EEG, or other).
Treatment is individualized to the patient’s work-related diagnosis and needs.  Home practice of skills is required for mastery and may be facilitated by the use of home training tapes.  The ultimate goal in of biofeedback treatment is to normalizeing the physiology to the pre-injury status to the extent possible, and involves transfer of learned skills to the workplace and daily life.  Candidates for biofeedback therapy or training must be motivated to learn and practice biofeedback and self-regulation techniques.   
Indications for biofeedback include individuals who are suffering from musculoskeletal injury where in which muscle dysfunction or other physiological indicators of excessive or prolonged stress response affects and/or delays recovery.  Other applications include training to improve self-management of emotional stress/pain responses such as anxiety, depression, anger, sleep disturbance, and other central and autonomic nervous system imbalances.  Biofeedback is often utilized along used in conjunction with other treatment modalities.
•	Time to produce effect: 3 to 4 sessions
•	Frequency:  1 to 2 times per week
•	Optimum duration:  5 to 6 sessions
•	Maximum duration:  10 to 12 sessions.  Treatment beyond 12 sessions must be documented with respect to need, expectation, and ability to facilitate positive symptomatic or functional gains.
3. 	INJECTIONS - THERAPEUTIC
a.	Therapeutic Spinal Injections:
Description — Therapeutic spinal injections are generally accepted well-established procedures. They may be used after initial conservative treatments, such as physical and occupational therapy, medication, manual therapy, exercise, acupuncture, etc., hasve been undertaken.  Therapeutic injections should be used only after imaging studies and diagnostic injections have established pathology. has been demonstrated.  Injections are invasive procedures that can cause catastrophic complications; thus clinical indications and contraindications should be closely adhered to. The purpose of spinal injections is to facilitate active therapy by providing short-term relief through reduction of pain and inflammation.  A concomitant therapeutic exercise program should be considered or may be appropriate for patients receiving therapeutic spinal injections.  All patients should continue appropriate exercise with functionally directed rehabilitation.  Active treatment, which patients should have had prior to injections, will frequently require a repeat of the sessions previously ordered (Refer to section E. 11, Active Therapy).  Injections, by themselves, are not likely to provide long-term relief.  Rather, active rehabilitation with modified work achieves long-term relief by increasing active ROM, strength, and stability.  If the first injection does not provide a diagnostic response with temporary and sustained pain relief substantiated by accepted pain scales, (i.e., 80% pain reduction on Visual Analog Scale), and improvement in function, similar injections should not be repeated.
Special Considerations — For all cervical injections (excluding trigger point and occipital nerve blocks) multi-planar fluoroscopicy, arthrographic and/or CT guidance during procedures is required to document technique and needle placement, and should be performed by a physician experienced in the procedure.  Permanent images are required to verify needle placement.  The subspecialty disciplines of the physicians performing injections may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry. The practitioner should participate in ongoing injection training workshops such as   
those sponsored by the International Society for Injection Studies (ISIS) should have completed a fellowship in pain medicine with interventional training, or its equivalent.  They must also and be knowledgeable in radiation safety.  In addition, practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments of Radiology, as applicable.

Complications  General complications of spinal injections may include (a) transient neurapraxia, local pain, nerve injury, infection, headache, vasovagal effects;. (b) Eepidural hematoma, permanent neurologic damage, dural perforation and CSF leakage, and/or spinal meningeal abscess may also occur. ; and or (c) s  which  Severe More serious complications are remote rare but can include spinal cord damage; quadriplegia; permanent ataxia, and/or death.   Injections at a C2-C3 level frequently cause temporary neuritis with ataxia.  With steroid injections, there may be a dose-dependent suppression of the hypothalamic-pituitary-adrenal axis lasting between one and three months.

Contraindications  Absolute contraindications of to therapeutic injections include: (a) bacterial infection – systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d) possible pregnancy. and (e) shellfish allergy. if certain contrasts are used.  

Relative contraindications of to diagnostic injections may include:  (a) allergy to contrast, (b) poorly controlled Diabetes Mellitus or and hypertension. (c) aspirin/antiplatelet therapy (drug may be held for 3 days prior to injection), (d) shellfish allergy, if contrast to be used Drugs affecting coagulation require restriction from use.  the following are suggested time period restrictions:

•	Aspirin-withhold for seven days;
•	NSAIDs-withhold for three days;
•	Clopidogrel-withhold for 3 days;
•	Other anti-platelet therapy and anti-coagulants should also be addressed individually by a knowledgeable specialist.

i.	Cervical Epidural Steroid Injection (ESI)
A)	Description  Cervical ESIs are injections of corticosteroid into the epidural space.  The purpose of ESI is to reduce pain and inflammation in the acute or subacute phases of injury, restoring range of motion, and thereby, facilitating progress in more active treatment programs.
B)	Needle placement  Radiographic guidance with epidurogram is indicated to document placement and ensure maximal efficacy.  Spinal Multi-planar fluoroscopic imaging is required for all epidural steroid injections.  Contrast epidurograms allow one to verify the flow of medication into the epidural space.  Permanent images are required to verify needle placement.
C)	Indications  Cervical ESIs are useful in patients with symptoms of cervical radicular pain syndromes.  They have less defined usefulness in non-radicular pain.  There is some evidence that epidural steroid injections are effective for patients with radicular pain or radiculopathy (sensory or motor loss in a specific dermatome or myotome).  In one study, 53% of patients had 50% or greater relief of pain at 6 months with only 20% having similar relief at 12 months. Although there is no evidence regarding the effectiveness of ESI for non-radicular pain, it is a generally accepted intervention.   There is some evidence to suggest that epidural injections are not effective for cervical axial pain; however, it is an accepted intervention.  Only patients who have 1) pain affected by activity and 2) annular tears verified by appropriate imaging may have injections for axial pain.

There is some evidence in studies of the lumbar spine that patients who smoke or who have pain unaffected by rest or activity are less likely to have a successful outcome from ESIs.  This may also apply to the cervical spine although there are currently no studies to verify this finding.
MRI or CT scans are required before prior to thoracic and cervical ESIs, to assure that adequate epidural space is present. 
•	Time to Produce Effect:  Local anesthetic, approximately less than 30 minutes; corticosteroid, 48 to 72 hours for 80% of patients and 72 hours to 2 weeks for 20% of patients.  
•	Frequency:  One or more divided levels can be injected in one session.  Whether injections are repeated depends upon the patient’s response to the previous injection. session.   Subsequent injections sessions may occur after 1 to 2 weeks if patient response has been favorable.  Injections can be repeated after a hiatus of three six months if the patient has demonstrated functional gain and pain returns or worsens.  If ESIs are repeated in the future, there should be increasing duration of relief and continued functional gain.  If the first injection does not provide a diagnostic response with temporary and sustained pain relief (at least 2 to 6 weeks) substantiated by accepted pain scales (i.e., 80% pain reduction as measured by tools such as VAS),  and improvement in function, similar injections should not be repeated.
•	Optimal Duration:  Usually 1 to 3 sessions of injection(s), over a period of six months depending upon each patient’s response and functional gain.
•	Maximum Duration:  Up to 3 to 4 Two sessions consisting of up to three injections each may be done in one year, as per the patient’s response to pain and function.  Patients should be reassessed after each injection session for an 80% improvement in pain (as measured by accepted pain scales) and evidence of functional improvement. 
ii.	Zygoapophyseal (Facet) Injection
A)	Description  A generally accepted i Intra-articular or pericapsular injection of local anesthetic and corticosteroid.  There is conflicting evidence to support long-term therapeutic effect using facet injections.  There is no justification for a combined facet and medial branch block. 
B)	Indications- Patients with pain 1) suspected to be facet in origin based on exam findings and 2) affecting activity; OR patients who have refused a rhizotomy; OR patients who have facet findings with a thoracic component.  In these patients, facet injections may be occasionally useful in facilitating a functionally-directed rehabilitation program and to aid in identifying pain generators.  Patients with recurrent pain should be evaluated with more definitive diagnostic injections, such as medial nerve branch injections, to determine the need for a rhizotomy.  Because facet injections are not likely to produce long-term benefit by themselves and are not the most accurate diagnostic tool, they should not be performed at more than two levels.  
Facet injections may be repeated if they result in increased documented functional benefit for at least 4 to 6 weeks and at least an 80% initial improvement in pain scales as measured by accepted pain scales (such as VAS).
B)	Indications  Facet injections may be considered in those patients whose history and examination are suggestive of a facet pain generator.  The therapeutic value of facet injections provides short-term pain relief for patients to progress through a functionally directed rehabilitation program. Facet injections determine level(s) of facet involvement and the degree of pain coming from the posterior elements.  If the patient demonstrates definite short-term but not long-term response confirmatory medial branch blocks and possible medial branch neurotomy should be considered. 
•	Time to produce effect:  Approximately Up to 30 minutes for local anesthetic; 48 to corticosteroid up to 72 hours. for corticosteroid. 
•	Frequency: 1 injection per level with a diagnostic response.  1 to 3 sessions for each joint. If the first injection does not provide a diagnostic response of temporary and sustained pain relief substantiated by accepted pain scales, (i.e., 80% pain reduction substantiated by tools such as VAS), and improvement in function, similar injections should not be repeated.  At least 4 to 6 weeks of functional benefit should be obtained with each therapeutic injection. 
•	Optimalum duration:  1 to 3 sessions of 2 to 3 injections for each applicable joint per year. Not to exceed two joint levels. 
•	Maximum Duration:  4 per level per year.  Prior authorization must be obtained for injections beyond two levels.
•	Maximum duration:  3 intra-synovial or medial branch nerve injections per joint can be done for facilitating a therapeutic exercise program. 
iii.	Intradiscal Steroid Therapy:  Intradiscal Steroid Therapy consists of injection of a steroid preparation into the intervertebral disc under fluoroscopic guidance at the time of discography.  There is good evidence that it is not effective in the treatment of suspected discogenic low back pain.  There is no support for its use in the cervical spine and its use is not recommended.	
b.	Facet Rhizotomy (Radio Frequency (RF) Medial Branch Neurotomy):/ facet rhizotomy:
i.	Description  A procedure designed to denervate the facet joint by ablating the corresponding sensory medial periarticular facet nerve branches.  Continuous pPercutaneous radio-frequency is the method generally used. 
There is good evidence to support this procedure in the cervical spine but benefits beyond one year are not yet established.  Radio-frequency medial branch neurotomy rhizotomy is the procedure of choice over alcohol, phenol, or cryoablation. Precise positioning of the probe under fluoroscopic guidance is recommended, required since the maximum effective radius diameter of the device is 2 mm a 5 x 8 millimeter oval.   Permanent images should be recorded to verify placement of the device.
ii.	Indications   Those patients with proven, significant, facetogenic pain.  This procedure is not recommended for patients with multiple pain generators or involvement of more than 3 medial branch nerves.  
Individuals should have met the following indications:  pPain of well-documented facet origin, unresponsive to active and/or passive therapy, manual therapy, and in which a psychosocial evaluation.  screening has been performed (e.g., pain diagram, thorough psychosocial history, screening questionnaire).  It is generally recommended that this procedure not be performed until three months of active therapy and manual therapy have been completed.  All patients should continue appropriate exercise with functionally directed rehabilitation.  Active treatment, which patients will have had prior to the procedure, will frequently require a repeat of the sessions previously ordered (Refer to section E. 11, Active Therapy).  This procedure is commonly used to provide a window of pain relief allowing for participation in active therapy.  
All patients must should have a successful response to a diagnostic medial nerve branch blocks and a separate comparative block.  ISIS suggests controlled blocks-using either placebo or anesthetics with varying lengths of activity (i.e., bupivacaine longer than lidocaine).    A successful response is considered to be a 90 percent or greater relief of pain for the length of time appropriate to the local anesthetic used (i.e., bupivacaine greater than lidocaine).  To be a positive diagnostic block the patient should report a reduction of pain of 80% or greater from baseline for the length of time appropriate for the local anesthetic used.  In almost all cases this will mean a reduction of pain to 1 or 2 on the VAS 10-point scale correlated with functional improvement.  The patient should also identify activities of daily living (which may include measurements of range of motion) that are impeded by their pain and can be observed to document functional improvement in the clinical setting.  Ideally, these activities should be assessed throughout the observation period for function.  The observer should not be the physician who performed the procedure.  It is suggested that this be recorded on a form similar to ISIS recommendations.
A separate comparative block should be performed on a different date to confirm the level of involvement.  A comparative block uses anesthetics with varying lengths of activity.
iii.	Complications  Bleeding, infection, or neural injury.  The clinician must be aware of the risk of developing a localized neuritis, and rarely, a deafferentation centralized pain syndrome as a complication of this and other neuro-ablative procedures.
iv.	Post-Procedure Therapy  Active and/or passive therapy.  Implementation of a gentle reconditioning program within the first post-procedure week is recommended, barring complications.  Instruction and participation in a long-term home-based program of ROM, cervical, scapular, and thoracic strengthening, postural or neuromuscular re-education, endurance, and stability exercises should be done 3 to 4 weeks accomplished over a period of four to ten visits post-procedure.
v. 	Requirements for repeat RF neurotomy (or additional level RF neurotomies).  In some cases pain may recur [ISIS].  Successful rhizotomy usually provides from six to eighteen months of relief.  
Before a repeat RF Neurotomy is done, a confirmatory medial branch injection should be performed if the patient’s pain pattern presents differently than in the initial evaluation.  in occasional patients, additional levels of RF neurotomy may be necessary.  The same indications and limitations apply.
c.	Occipital Nerve Block:

i.	Description  Occipital nerve blocks are generally accepted injections used both diagnostically and therapeutically in the treatment of occipital neuralgia.  Target is tThe greater occipital nerve is the target.  
ii.	Indications  Diagnosis and treatment of occipital neuralgia/cephalgia.  Peripheral block of the greater occipital nerve may be appropriate as initial treatment.  It may be indicated in patients unresponsive to peripheral nerve block or those patients in need of additional diagnostic information. may undergo this injection.
iii.	Complications  Bleeding, infection, neural injury.  Post procedural ataxia is common and usually lasts 30 minutes post procedure.  Because the occipital artery runs with the occipital nerve, inadvertent intravascular injection is a risk of this procedure and may lead to systemic toxicity and/or seizures.
•	Time to Produce Effect:  Approximately 30 minutes for local anesethetic; 48 to 72 hours for corticosteroid.
•	Optimal Duration:  1 to 3 sessions for each joint.
•	Maximum Duration:  Continue up to 3 injections if progressive symptomatic and functional improvement can be documented.
d e.	Trigger Point Injections and Dry Needling Treatment:
i.	Description  Trigger point injections are a generally accepted treatment.  Trigger point injection treatment can consists of dry needling or injection of local anesthetic with or without, corticosteroid into highly localized, extremely sensitive bands of skeletal muscle fibers that produce local and referred pain when activated.  Medication is injected in a four-quadrant manner in the area of maximum tenderness.  Injection efficacy can be enhanced if injections are immediately followed by myofascial therapeutic interventions, such as vapo-coolant spray and stretch, ischemic pressure massage (myotherapy), specific soft tissue mobilization and physical modalities.  The effectiveness of trigger point injection is uncertain, in part due to the difficulty of demonstrating advantages of active medication over injection of saline.  There is conflicting evidence regarding the benefit of trigger point injections.  A truly blinded study comparing dry needle treatment of trigger points is not feasible.  There is no evidence that injection of medications improves the results of trigger-point injections.  Needling alone may be responsible account for some of the therapeutic response.
There is no indication for conscious sedation for patients receiving trigger point injections.  The patient must be alert to help identify the site of the injection.
ii.	Indications  Trigger point injections may be used to relieve myofascial pain and facilitate active therapy and stretching of the affected areas.  They are to be used as an adjunctive treatment in combination with other treatment modalities such as functional restoration programs.  Trigger point injections should be utilized primarily for the purpose of facilitating functional progress.  Patients should continue in an aggressive aerobic and stretching therapeutic exercise program as tolerated throughout the time period they are undergoing intensive myofascial interventions.  Myofascial pain is often associated with other underlying structural problems and any abnormalities need to be ruled out prior to injection.
Trigger point injections are indicated in those patients where well circumscribed trigger points have been consistently observed, demonstrating a local twitch response, characteristic radiation of pain pattern and local autonomic reaction, such as persistent hyperemia following palpation.  Generally, these injections are not necessary unless consistently observed trigger points are not responding to specific, noninvasive, myofascial interventions within approximately a 6-week time frame.
iii.	Complications  Potential but rare complications of trigger point injections include infection, pneumothorax, anaphylaxis, penetration of viscera, neurapraxia, and neuropathy.  If corticosteroids are injected in addition to local anesthetic, there is a risk of local myopathy developing.  Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be immediately repositioned. 
•	Time to Produce Effect:  Local anesthetic 30 minutes; no anesthesia 24 to 48 hours
•	Frequency:  Weekly, suggest no more than 4 injection sites per session per week to avoid significant post-injection soreness
•	Optimal Duration:  4 Weeks
•	Maximum Duration:  8 weeks.  Occasional patients may require 2 to 4 repetitions of trigger point injection series over a 1 to 2 year period.
df.	Prolotherapy: also known as sclerotherapy, consists of a series of injections of hypertonic dextrose, with or without glycerine and phenol, into the ligamentous structures of the neck.  There is no evidence that Pprolotherapy is effective in cervical pain.  The injections are invasive, may be painful to the patient, and are not generally accepted or widely used.  Therefore, the use of Pprolotherapy for cervical pain is not recommended. 
g.	Epiduroscopy and Epidural Lysis of Adhesions:  is not recommended in the cervical spine secondary to the potential for dural puncture, hematoma, and spinal cord injury.
4.	MEDICATIONS Medication use in the treatment of cervical injuries is appropriate for controlling acute and chronic pain and inflammation.  Use of medications will vary widely due to the spectrum of injuries from simple strains to post-surgical healing.  All drugs should be used according to patient needs.  A thorough medication history, including use of alternative and over the counter medications, should be performed at the time of the initial visit and updated periodically. Treatment for pain control is initially accomplished with acetaminophen and/or NSAIDs.  The patient should be educated regarding the interaction with prescription and over-the-counter medications as well as the contents of over-the-counter herbal products. 
Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are useful in the treatment of inflammation.  These same medications can be used for pain control.  
Narcotic medications should be prescribed with strict time, quantity, and duration guidelines, and with definitive cessation parameters. Pain is subjective in nature and should be evaluated using a scale to rate effectiveness of the narcotic prescribed. 
Tramadol, a centrally acting non-narcotic, can be useful to provide pain relief.  Other medications, including antidepressants, may be useful in selected patients with chronic pain
The following are listed in alphabetical order:
a.	Acetaminophen: is an effective analgesic with antipyretic but not anti-inflammatory activity.  Acetaminophen is generally well tolerated, causes little or no gastrointestinal irritation, and is not associated with ulcer formation.  Acetaminophen has been associated with liver toxicity in overdose situations or in chronic alcohol use. Patients may not realize that many over-the-counter preparations may contain acetaminophen.  The total daily dose of acetaminophen is recommended not to exceed 4 grams per 24-hour period from all sources, including narcotic-acetaminophen combination preparations. 
•	Optimum duration:  7 to 10 days.
•	Maximum duration:  Chronic use as indicated on a case-by-case basis. Use of this substance long-term for 3 days per week or greater may be associated with rebound pain upon cessation. 
b.	Minor Tranquilizer/ Muscle Relaxants:  are appropriate for muscle spasm, mild with pain. and sleep disorders. There is strong evidence that muscle relaxants are more effective than placebo for providing short-term pain relief in acute low back pain.  Similar effects can be expected for cervical pain.  When prescribing these agents, physicians must seriously consider side effects of drowsiness or dizziness, and the fact that benzodiazepines may be habit-forming.
•	Optimum duration:  1 week.
•	Maximum duration:  4 weeks. 2 weeks (or longer if used only at night).
c.	Narcotics: should be primarily reserved for the treatment of severe cervical pain.  There are circumstances where prolonged use of narcotics is justified based upon specific diagnosis, and in these cases, it should be documented and justified.  In mild-to-moderate cases of cervical pain, narcotic medication should be used cautiously on a case-by-case basis.  Adverse effects include respiratory depression, the development of physical and psychological dependence, and impaired alertness.
Narcotic medications should be prescribed with strict time, quantity, and duration guidelines, and with definitive cessation parameters.  Pain is subjective in nature and should be evaluated using a scale to rate effectiveness of the narcotic prescribed.  Any use beyond the maximum should be documented and justified based on the diagnosis and/or invasive procedures.
•	Optimum duration:  3 to 7 days.
•	Maximum duration:  2 weeks.  Use beyond two weeks is acceptable in appropriate cases. Refer to Chronic Pain Guidelines which gives a detailed discussion regarding medication use in chronic pain management. 
d.	Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): are useful for pain and inflammation.  In mild cases, they may be the only drugs required for analgesia.  There are several classes of NSAIDs, and the response of the individual injured worker to a specific medication is unpredictable.  For this reason, a range of NSAIDs may be tried in each case with the most effective preparation being continued.  Patients should be closely monitored for adverse reactions. The US Food and Drug Administration advises that many NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal.  Naproxen sodium does not appear to be associated with increased risk of vascular events.  Administration of proton pump inhibitors, histamine 2 blockers, or prostaglandin analog misoprostol along with these NSAIDs may reduce the risk of duodenal and gastric ulceration but do not impact possible cardiovascular complications.  Due to the cross-reactivity between aspirin and NSAIDs, NSAIDs should not be used in aspirin-sensitive patients, and should be used with caution in all asthma patients.  NSAIDs are associated with abnormal renal function, including renal failure, as well as abnormal liver function.  Certain NSAIDs may have interactions with various other medications.  Individuals may have adverse events not listed above.  Intervals for metabolic screening are dependent upon the patient's age, general health status and should be within parameters listed for each specific medication.  Complete blood count (CBC), and L liver and renal function should be monitored at least every six months in patients on chronic NSAIDs and initially when indicated.
i.	Non-selective Nonsteroidal Anti-Inflammatory Drugs
Includes NSAIDs and acetylsalicylic acid (aspirin).  Serious GI toxicity, such as bleeding, perforation, and ulceration can occur at any time, with or without warning symptoms in patients treated with traditional NSAIDs.  Physicians should inform patients about the signs and/or symptoms of serious gastrointestinal toxicity and what steps to take if they occur.  Anaphylactoid reactions may occur in patients taking NSAIDs.  NSAIDs may interfere with platelet function.  Fluid retention and edema have been observed in some patients taking NSAIDs.
Due to the cross-reactivity between aspirin and NSAIDs, NSAIDs should not be used in aspirin-sensitive patients, and should be used with caution in all asthma patients.  NSAIDs are associated with abnormal renal function, including renal failure, as well as abnormal liver function.  Certain NSAIDs may have interactions with various other medications.  Individuals may have adverse events not listed above.
•	Optimal duration:  1 week
•	Maximum duration:  1 year Use of these substances long-term for (3 days per week or greater) is associated with rebound pain upon cessation.
ii.	Selective Cyclo-oxygenase-2 (COX-2) Inhibitors
Selective cyclo-oxygenase-2 (COX-2) inhibitors are more recent NSAIDs and differ in adverse side effect profiles from the traditional NSAIDs.  The major advantages of selective COX-2 inhibitors over traditional NSAIDs are that they have less gastrointestinal toxicity and no platelet effects.  COX-2 inhibitors can worsen renal function in patients with renal insufficiency, thus renal function may need monitoring.
COX-2 inhibitors should not be first-line for low risk patients who will be using an NSAID short term but are indicated in select patients for whom traditional NSAIDs are not tolerated. or in certain high-risk patients.  Patients most at risk of having a complication from traditional NSAIDs include patients with a prior history of peptic ulcer disease, gastrointestinal bleeding, gastrointestinal perforation, or hemophilia, as well as patients with thrombocytopenia or systemic anticoagulation.  Serious upper GI adverse events can occur even in asymptomatic patients.  Patients at high risk for GI bleed include those who use alcohol, smoke, are older than 65, take corticosteroids or anti-coagulants, or have a longer duration of therapy.  Celecoxib is FDA approved for osteoarthritis and rheumatoid arthritis.  Rofecoxib is FDA approved for acute pain and osteoarthritis.  Celecoxib is contraindicated in sulfonamide allergic patients.
•	Optimal duration:  7 to 10 days
•	Maximum duration:  Chronic use is appropriate in individual cases.  Use of these substances long-term ( for 3 days per week or greater) is associated with rebound pain upon cessation.
e.	Oral Steroids: have limited use but are accepted in cases requiring potent anti-inflammatory drug effect.  A and should not be routinely recommended. except in cases of suspected spinal cord compression.  
f.	Intravenous Steroids: The risks of permanent neurological damage from acute spinal cord compression generally outweigh the risks of pharmacologic side effects of steroids in an emergent situation.
f. g.	Psychotropic/Anti-anxiety/Hypnotic Agents: may be useful for treatment of mild and chronic pain, dysesthesias, sleep disorders, and depression.  Antidepressant medications, such as tricyclics and Selective Serotonin Reuptake Inhibitors (SSRIs), are useful for affective disorder and chronic pain management.  Tricyclic antidepressant agents, in low dose, are useful for chronic pain but have more frequent side effects.  
Anti-anxiety medications should generally be limited to are best used for short-term use. treatment (i.e., less than 6 months).  Accompanying sleep disorders are best treated with sedating antidepressants prior to bedtime.  Frequently,   cCombinations of the above agents are may be useful. 
As a general rule, physicians should access the patient’s prior history of substance abuse or depression prior to prescribing any of these agents. Due to the habit-forming potential of the benzodiazepines and other drugs found in this class, they are not routinely recommended.  Refer to the Chronic Pain Guidelines which give a detailed discussion regarding medication use in chronic pain management. 
•	Optimum duration:  1 to 6 months.
•	Maximum duration:  6 to 12 months, with monitoring.
g.h.	Tramadol: is useful in relief of pain and has been shown to provide pain relief equivalent to that of commonly prescribed NSAIDs.  Although Tramadol may cause impaired alertness, it is generally well tolerated, does not cause gastrointestinal ulceration, or exacerbate hypertension or congestive heart failure.  Tramadol should be used cautiously in patients who have a history of seizures or who are taking medication that may lower the seizure threshold, such as monoamine oxiydase (MAO) inhibitors, SSRIs, and tricyclic antidepressants.  This medication has physically addictive properties and withdrawal may follow abrupt discontinuation and is not recommended for those with prior opioid addiction.  
•	Optimal Duration:  3 to 7 days
•	Maximum Duration:  2 weeks.  Use beyond 2 weeks is acceptable in appropriate cases.
h.	Topical Drug Delivery: may be an alternative treatment for localized musculoskeletal disorders and is an acceptable form of treatment in selected patients although there is no scientific evidence to support its use in cervical injury.  It is necessary that all topical agents be used with strict instructions for application as well as maximum number of applications per day to obtain the desired benefit and avoid potential toxicity.  As with all medications, patient selection must be rigorous to select those patients with the highest probability of compliance.  Refer to Section E.12.c, Iontophoresis in the Passive Therapy section for information regarding topical iontophoretic agents.  
5.	OCCUPATIONAL REHABILITATION PROGRAMS

a.	Non-Iinterdisciplinary: These generally accepted programs are work-related, outcome-focused, individualized treatment programs.  Objectives of the program include, but are not limited to, improvement of cardiopulmonary and neuro-musculoskeletal functions (strength, endurance, movement, flexibility, stability, and motor control functions), patient education, and symptom relief.  The goal is for patients to gain full or optimal function and return to work.  The service may include the time-limited use of passive modalities with progression to achieve active treatment and/or simulated/real work.
i.	Work Conditioning
These programs are usually initiated once reconditioning has been completed but may be offered at any time throughout the recovery phase. It should be initiated when imminent return of a patient to modified or full duty is not an option, but the prognosis for returning the patient to work at completion of the program is at least fair to good.  
•	Length of visit:  1 to 2 hours per day
•	Frequency:  2 to 5 visits per week
•	Optimum duration:  2 to 4 weeks
•	Maximum duration:  6 weeks.  Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.
ii.	Work Simulation 
Work simulation is a program where an individual completes specific work-related tasks for a particular job and return to work.  Use of this program is appropriate when modified duty can only be partially accommodated in the work place, when modified duty in the work place is unavailable, or when the patient requires more structured supervision.  The need for work place simulation should be based upon the results of a Functional Capacity Evaluation and/or Jobsite Analysis.
•	Length of visit:  2 to 6 hours per day
•	Frequency:  2 to 5 visits per week
•	Optimum duration:  2 to 4 weeks
•	Maximum duration:  6 weeks.  Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.
b.	Interdisciplinary:  programs are well-established treatment for patients with sub-acute and functionally impairing cervical spine pain.  They are characterized by a variety of disciplines that participate in the assessment, planning, and/or implementation of an injured workers program with the goal for patients to gain full or optimal function and return to work.  There should be close interaction and integration among the disciplines to ensure that all members of the team interact to achieve team goals.  Programs should include cognitive-behavioral therapy as there is good evidence for its effectiveness in patients with chronic low back pain and it is probably effective in cervical spine pain.  These programs are for patients with greater levels of perceived  disability, dysfunction, deconditioning and psychological involvement.  For patients with chronic pain, refer to Division’s Chronic Pain Disorder Medical Treatment Guidelines.
i.	Work Hardening
Work Hardening is an interdisciplinary program addressing a patient’s employability and return to work.  It includes a progressive increase in the number of hours per day that a patient completes work simulation tasks until the patient can tolerate a full workday.  This is accomplished by addressing the medical, psychological, behavioral, physical, functional, and vocational components of employability and return-to-work.
This can include a highly structured program involving a team approach or can involve any of the components thereof.  The interdisciplinary team should, at a minimum, be comprised of a qualified medical director who is board certified with documented training in occupational rehabilitation,  ; team physicians having experience in occupational rehabilitation, ; occupational therapy, ; physical therapy, ;case manager,; and psychologist.  As appropriate, the team may also include: chiropractor, RN, or vocational specialist or Certified Biofeedback Therapist.
•	Length of visit:  up to 8 hours/day
•	Frequency:  2 to 5 visits per week
•	Optimal duration:  2 to 4 weeks
•	Maximum duration:  6 weeks.  Participation in a program beyond six weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.
ii.	Spinal Cord Programs
Spinal Cord Systems of Care provide coordinated, case-managed, and integrated service for people with spinal cord dysfunction, whether due to trauma or disease.  The system includes an inpatient component in an organization licensed as a hospital and an outpatient component.  Each component endorses the active participation and choice of the persons served throughout the entire program.  The Spinal Cord System of Care also provides or formally links with key components of care that address the lifelong needs of the persons served.
This can include a highly structured program involving a team approach or can involve any of the components thereof.  The interdisciplinary team should, at a minimum, be comprised of a qualified medical director who is board certified and trained in rehabilitation, a case manager, occupational therapy, physical therapy, psychologist, rehabilitation RN and MD, and therapeutic recreation specialist.  As appropriate, the team may also include: rehabilitation counselor, respiratory therapist, social worker, or speech-language pathologist.
Timeframe durations for any spinal cord program should be determined based upon the extent of the patient’s injury and at the discretion of the rehabilitation physician in charge.
6.	ORTHOTICS Primary principles and objectives of the application of cervical orthosis include: (a) control of the position through the use of control forces; (b) application of corrective forces to abnormal curvatures; (c) aid in spinal stability when soft tissues or osteoligamentous structures cannot sufficiently perform their role as spinal stabilizers; and (d) restrict spinal segment movement after acute trauma or surgical procedure.  In cases of traumatic cervical injury, the most important objective is the protection of the spinal cord and nerve root.
a.	Cervical Collars:
i.	Soft Collars are well-tolerated by most patients but may not significantly restrict motion in any plane and are associated with delayed recovery.  There is no evidence that their use promotes recovery from cervical sprain. In acute strain/sprain type injuries, use of cervical collars may prolong disability, limit early mobilization, promote psychological dependence, and limit self-activity.  There is some evidence that patients encouraged to continue usual activity have less neck stiffness and headache than patients placed in cervical collars following motor vehicle crashes.
ii.	Rigid Collars, such as a Philadelphia Orthosis, are useful post-operative or in emergency situations.  These collars restrict flexion and extension motion, and to a lesser degree, lateral bending and rotation.  Duration of wear post-surgery is dependent upon the surgeon and degree of cervical healing but is generally not used beyond 8 weeks.
b.	Poster Appliances: such as the Miami brace, restrict flexion and extension motion to about the same degree as a Philadelphia collar and to a greater degree, lateral bending and rotation.  Not recommended in sprain or strain injuries.
c.	Cervicothoracic Orthosis: such as Yale and sternal occipital mandibular immobilization (SOMI) type braces, restrict flexion and extension motion to a fuller degree than the Philadelphia collar and to a better degree lateral bending and rotation.  Not recommended in sprain or strain type injuries.  
d.	Halo Devices: are used in the treatment of cervical fracture, dislocation, and instability at the discretion of the treating surgeon.  Refer to Halo Devices in the Operative Treatment section.  
e.	Other Orthosis Devices and Equipment: Special orthosis or equipment may have a role in the rehabilitation of a cervical injury such as those injuries to a cervical nerve root resulting in upper extremity weakness or a spinal cord injury with some degree of paraparesis or tetraparesis.  Use of such devices would be in a structured rehabilitation setting as part of a comprehensive rehabilitation program.
7.	PATIENT EDUCATION No treatment plan is complete without addressing issues of individual and/or group patient education as a means of prolonging the beneficial effects of treatment, as well as, facilitating self-management of symptoms and injury prevention.  The patient should be encouraged to take an active role in the establishment of functional outcome goals.  They should be educated on their specific injury, assessment findings, and plan of treatment.  Instruction on proper body mechanics and posture, positions to avoid, self-care for exacerbation of symptoms, and home exercise should also be addressed.
•	Time to produce effect:  Varies with individual patient
•	Frequency:  Should occur at each visit
8.	PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION is a generally accepted, widely used, and well-established intervention.  This group of therapeutic and diagnostic modalities includes, but is not limited to;, individual counseling, group therapy, stress management, psychosocial crises intervention, hypnosis and meditation.  Any screening evaluation or diagnostic workup should clarify and distinguish between pre-existing versus aggravated versus purely causative psychological conditions.  Psychosocial intervention is recommended as an important component in the total management program that should be implemented as soon as the problem is identified.  This can be used alone or in conjunction with other treatment modalities.  Providers treating patients with chronic pain should refer to the Division’s Chronic Pain Disorder Medical Treatment Guidelines.
•	Time to produce effect:  2 to 4 weeks
•	Frequency:  1 to 3 times weekly for the first 4 weeks (excluding hospitalization, if required), decreasing to 1 to 2 times per week for the second month.  Thereafter, 2 to 4 times monthly.
•	Optimum duration:  6 weeks to 3 months
•	Maximum duration:  3 to 12 months.  Counseling is not intended to delay but to enhance functional recovery.  For select patients, longer supervised treatment may be required, and if further counseling beyond 3 months is indicated, extensive documentation addressing which pertinent issues are preexisting versus aggravated versus causative, as well as projecting a realistic functional prognosis, should be provided by the authorized treating practitioner every 4 to 6 weeks during treatment.
9.	RESTRICTION OF ACTIVITIES There is some evidence to support the continuation of normal daily activities as the recommended treatment for acute and chronic cervical injuries without neurologic symptoms.  Complete work cessation should be avoided, if possible, since it often further aggravates the pain presentation.  Modified return-to-work is almost always more efficacious and rarely contraindicated in the vast majority of injured workers with cervical spine injuries.
10.	RETURN-TO-WORK Early return-to-work should be a prime goal in treating occupational injuries given the poor return-to-work prognosis for an injured worker who has been out of work for more than six months.  It is imperative that the patient be educated regarding the benefits of return-to-work, restrictions, and follow-up if problems arise.  When attempting to return a patient to work after a specific injury, clear objective restrictions of activity level should be made.  An accurate job description may be   with detailed physical duty descriptions is often necessary to assist the physician in making return-to-work recommendations. This may require a jobsite evaluation. 
Employers should be prepared to offer transitional work.  This may consist of temporary work in a less demanding position, return to the regular job with restrictions, or gradual return to the regular job.  Company policies which encourage return-to-work with positive communication are most likely to have decreased worker disability.
Return-to-work is defined as any work or duty that the patient is able to perform safely., and Iit may not be the patient’s regular work.  Due to the large spectrum of injuries of varying severity and varying physical demands in the work place, it is not possible to make specific return-to-work guidelines for each injury.  Therefore, the Division recommends the following:
a.	Establishment of a Return-To-Work Status: Ascertaining a return-to-work status is part of medical care, should be included in the treatment and rehabilitation plan, and addressed at every visit.  A description of daily activity limitations is part of any treatment plan and should be the basis for restriction of work activities.  In most non-surgical cases, the patient should be able to return to work in some capacity or in an alternate position consistent with medical treatment within several days unless there are extenuating circumstances. Injuries requiring more than two weeks off work should be thoroughly documented.
b.	Establishment of Activity Level Restrictions: Communication is essential between the patient, employer, and provider to determine appropriate restrictions and return-to-work dates.  It is the responsibility of the physician to provide clear concise restrictions, and it is the employer’s responsibility to determine if temporary duties can be provided within the restrictions.  For cervical spine extremity injuries, the following should be addressed when describing the patient’s activity level:
•	Total body position including upper trunk, especially rotation and flexion.  To include duration and frequency.
•	Upper extremity requirements including reaching above the shoulder, repetitive motions, pushing, pulling and lifting or carrying requirements.  Duration and frequency should be included.
•	Sitting duration and frequency with regard to posture, work height(s), and movements of the head and neck.
•	Visual field requirements in respect to limitations in head and neck movements and tolerance to looking upward and downward. 
•	Use of adaptive devices or equipment for proper office ergonomics or to enhance capacities can be included.
c.	Compliance with Activity Restrictions: In some cases, compliance with restriction of activity levels may require a complete jobsite evaluation, a functional capacity evaluation (FCE), or other special testing. Refer to the “Special Tests” section of this guideline.
11.	THERAPY — ACTIVE The following active therapies have some evidence to support their use and are widely used and accepted methods of care for a variety of work-related injuries.  They are based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion, and can alleviate discomfort.  Active therapy requires an internal effort by the individual to complete a specific exercise or task.  This form of therapy requires supervision from a therapist or medical provider such as verbal, visual, and/or tactile instruction(s).  At times, the provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is predominately executed by the patient.
Patients should be instructed to continue active therapies at home as an extension of the treatment process in order to maintain improvement levels.  Follow-up visits to reinforce and monitor progress and proper technique are recommended. Home exercise can include exercise with or without mechanical assistance or resistance and functional activities with assistive devices.
The following active therapies are listed in alphabetical order:
a.	Activities of Daily Living (ADL): are well-established interventions which involve instruction, active-assisted training, and/or adaptation of activities or equipment to improve a person's capacity in normal daily activities such as self-care, work re-integration training, homemaking, and driving.
•	Time to produce effect:  4 to 5 treatments
•	Frequency:  3 to 5 times per week
•	Optimum duration:  4 to 6 weeks
•	Maximum duration:  6 weeks
b.	Aquatic Therapy:  is a well-accepted treatment which consists of the therapeutic use of aquatic immersion for therapeutic exercise to promote strengthening, core stabilization, endurance, range of motion, flexibility, body mechanics, and pain management.  Aquatic therapy includes the implementation of active therapeutic procedures in a swimming or therapeutic pool.  The water provides a buoyancy force that lessens the amount of force gravity applies to the body.  The decreased gravity effect allows the patient to have a mechanical advantage and more likely have a successful trial of therapeutic exercise.  The therapy may be indicated for individuals who: 
•	cannot tolerate active land-based or full-weight bearing therapeutic procedures;
•	require increased support in the presence of proprioceptive deficit;
•	are at risk of compression fracture due to decreased bone density;
•	have symptoms that are exacerbated in a dry environment;
•	have a preference for water.
•	Would have a higher probability of meeting active therapeutic goals than in a dry environment.
	The pool should be large enough to allow full extremity range of motion and fully erect posture.  Aquatic vests, belts, and other devices may be used to provide stability, balance, buoyancy, and resistance.
•	Time to produce effect:  4 to 5 treatments
•	Frequency:  3 to 5 times per week
•	Optimum duration:  4 to 6 weeks
•	Maximum duration:  8 weeks
	A self-directed program is recommended after the supervised aquatics program has been established, or, alternatively a transition to a self-directed dry environment exercise program. 
b.c.	Functional Activities: are well-established interventions which involve the use of therapeutic activities to enhance mobility, body mechanics, employability, coordination, balance, and sensory motor integration.
•	Time to produce effect:  4 to 5 treatments
•	Frequency:  3 to 5 times per week
•	Optimum duration:  4 to 6 weeks
•	Maximum duration:  6 weeks
c.d.	Functional Electrical Stimulation:  is an accepted treatment in which the application of electrical current to elicit involuntary or assisted contractions of atrophied and/or impaired muscles.  Indications include It may be indicated for muscle atrophy, due to radiculopathy. weakness, and sluggish muscle contraction secondary to pain, injury, neuromuscular dysfunction, peripheral nerve lesion, or radicular symptoms.
•	Time to produce effect:  2 to 6 treatments
•	Frequency:  3 times per week
•	Optimum duration:  8 weeks
•	Maximum duration:  8 weeks.  If beneficial, provide with home unit.
e.	Neuromuscular Re-education: is a generally accepted treatment.  It is the skilled application of exercise with manual, mechanical, or electrical facilitation to enhance strength, movement patterns, neuromuscular response, proprioception, kinesthetic sense, coordination, education of movement, balance, and posture.  Indications include the need to promote neuromuscular responses through carefully timed proprioceptive stimuli, to elicit and improve motor activity in patterns similar to normal neurologically developed sequences, and improve neuromotor response with independent control.
•	Time to produce effect:  2 to 6 treatments
•	Frequency:  3 times per week
•	Optimum duration:  4 to 8 weeks
•	Maximum duration:  8 weeks
d. f.	Spinal Cervical Lumbar Stabilization: is a generally accepted treatment. The goal of this therapeutic program whose goal is to strengthen the spine in its neural and anatomic position.  The stabilization is dynamic which allows whole body movements while maintaining a stabilized spine.  It is the ability to move and function normally through postures and activities without creating undue vertebral stress.
•	Time to produce effect:  4 to 8 treatments
•	Frequency:  3 to 5 times per week
•	Optimum duration:  4 to 8 weeks
•	Maximum duration:  8 weeks
f.g.	Therapeutic Exercise:  is a generally well-accepted treatment.  Therapeutic exercise with or without mechanical assistance or resistance, may include isoinertial, isotonic, isometric and isokinetic types of exercises.  Indications include the need for cardiovascular fitness, reduced edema, improved muscle strength, improved connective tissue strength and integrity, increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle recruitment, improved proprioception and coordination, increased range of motion and are used to promote normal movement patterns.  Therapeutic exercise Ccan also include complementary/alternative exercise movement therapy (with oversight of a physician or appropriate healthcare professional).
•	Time to produce effect:  2 to 6 treatments
•	Frequency:  3 to 5 times per week
•	Optimum duration:  4 to 8 weeks
•	Maximum duration:  8 weeks
12.	THERAPY — PASSIVE Most of the following passive therapies and modalities are generally accepted methods of care for a variety of work-related injuries.  Passive therapy includes those treatment modalities that do not require energy expenditure on the part of the patient. They are principally effective during the early phases of treatment and are directed at controlling symptoms such as pain, inflammation and swelling and to improve the rate of healing soft tissue injuries.  They should be used adjunctively with active therapies such as postural stabilization and exercise programs to help control swelling, pain, and inflammation during the active rehabilitation process.  Please refer to Section B. 4., General Guideline Principles, Active Interventions.  They Passive therapies may be used intermittently as a therapist deems appropriate or regularly if there are specific goals with objectively measured functional improvements during treatment. 
While protocols for On occasion, specific diagnoses and post-surgical conditions may warrant durations of treatment beyond those listed as "maximum.” fFactors such as exacerbation of symptoms, re-injury, interrupted continuity of care, and comorbidities may also extend durations of care.  Having sSpecific goals with objectively measured functional improvement during treatment can support must be cited to justify extended durations of care.  It is recommended that, if after  6 to 8 visits no functional gain treatment effect is observed, after the number of treatments under “time to produce effect” has been completed, alternative treatment interventions, further diagnostic studies or further consultations should be pursued.
The following passive therapies are listed in alphabetical order:
a.	Electrical Stimulation (Unattended):  is an accepted treatment. Electrical Stimulation oOnce applied, unattended electrical stimulation requires minimal on-site supervision by the physical therapist, occupational therapist, or other nonphysical provider.  Indications include pain, inflammation, muscle spasm, atrophy, decreased circulation, and the need for osteogenic stimulation. A home unit should be purchased if treatment is effective and frequent use is recommended.
•	Time to produce effect:  2 to 4 treatments
•	Frequency:  Varies, depending upon indication, between 2 to 3 times/day to 1 time/week.  Provide home unit if frequent use. A home unit should be purchased if treatment is effective and frequent use is recommended.
•	Optimum duration:  1 to 3 months 4 treatments for clinic use
•	Maximum duration:  3 months  8 treatments for clinic use

b.	Infrared Therapy: is a radiant form of heat application.  Indications include the need to elevate the pain threshold before exercise and to alleviate muscle spasm to promote increased movement.

•	Time to produce effect:  2 to 4 treatments
•	Frequency:  3 to 5 times per week
•	Optimum duration:  3 weeks as primary, or intermittently as an adjunct to other therapeutic procedures up to 2 months
•	Maximum duration:  2 months
c.b.	Iontophoresis: is an accepted treatment which consists of the transfer of medication, including, but not limited to, steroidal anti-inflammatories and anesthetics, through the use of electrical stimulation.  Indications include pain (Llidocaine), inflammation (hydrocortisone, salicylate), edema (mecholyl, hyaluronidase, salicylate), ischemia (magnesium, mecholyl, iodine), muscle spasm (magnesium, calcium), calcific deposits (acetate), scars and keloids (chlorine, sodium chloride, iodine, acetate).  there is no proven benefit for this therapy in the cervical spine.
•	Time to produce effect:  1 to 4 treatments
•	Frequency:  3 times per week with at least 48 hours between treatments
•	Optimum duration:  4 to 6 weeks
•	Maximum duration:  6 weeks
d c.	Manipulation: is a generally accepted, well-established, and widely used therapeutic intervention for cervical pain.  Manipulative treatment (not therapy) is defined as the therapeutic application of manually guided forces by an operator to improve physiologic function and/or support homeostasis that has been altered by the injury or occupational disease, and has associated clinical significance.
High velocity, low amplitude (HVLA) technique, chiropractic manipulation, osteopathic manipulation, muscle energy techniques, counter strain, and non-force techniques are all types of manipulative treatment.  This may be applied by osteopathic physicians (D.O.), chiropractors (D.C.), properly trained physical therapists (P.T.), properly trained occupational therapists (O.T.), or properly trained medical physicians.   Under these different types of manipulation exist many subsets of different techniques that can be described as a) direct- a forceful engagement of a restrictive/pathologic barrier, b) indirect- a gentle/non-forceful dis-engagement of a restrictive/pathologic barrier, c) the patient actively assisting in the treatment and d) the patient relaxing, allowing the practitioner to move the body tissues.  When the proper diagnosis is made and coupled with the appropriate technique, manipulation has no contraindications and can be applied to all tissues of the body.  Pre-treatment assessment should be performed as part of each manipulative treatment visit to ensure that the correct diagnosis and correct treatment is employed.
Manipulation can include hHigh velocity, low amplitude (HVLA) manipulation is performed by taking a joint to its end range of motion and moving the articulation into the zone of accessory joint movement, well within the limits of anatomical integrity.  technique, chiropractic manipulation, osteopathic manipulation, muscle energy techniques and non-force techniques  It is performed by taking a joint to its end range of motion and moving the articulation into the zone of accessory joint movement, well within the limits of anatomical integrity   There is good scientific evidence to suggest that HVLA manipulation can be effective for relieving pain, and decreasing muscle spasm, and to increase range of motion to improve function for patients with cervical pain.  There is some evidence to show that manipulation of the cervical spine with exercise may be effective prophylactic treatment for cervicogenic headaches. can be beneficial for relief of tension-type, cervicogenic, and migraine headaches.  Contraindications to HVLA manipulation include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthridites arthritides, and signs of progressive neurologic deficits, myelopathy, vertebrobasilar insufficiency, or carotid artery disease. Relative contraindications include stenosis, spondylosis, and disc herniation.
•	Time to produce effect for all types of manipulative treatment:  1 to 6 treatments.
•	Frequency:  Up to 3 1 to 5 times per week for the first 2 4 weeks as indicated by the severity of involvement and the desired effect, then 1up to  2 to 3 treatments per week for the next 4 weeks. ,then 1 to 2 treatments per week for the next 6 weeks.   For further treatments, twice per week or less to maintain function. 
•	Optimum duration:  8 to 12 weeks
•	Maximum duration:  3 months.  Extended durations of care beyond what is considered “maximum” may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with comorbidities. Refer to the Chronic Pain Guidelines for cCare beyond 3 months. is indicated for certain chronic syndromes in which manipulation is helpful in improving function, decreasing pain and improving quality of life.  Such care should be re-evaluated and documented on a monthly basis.  Treatment may include visits 2 times a month through the 7th month post-injury, then on a monthly basis thereafter through the 10th month post-injury.  Care beyond the 10th month should be reviewed and allowed on a case-by-case basis according to the unique needs of the patient with chronic and/or permanent injury.
e. d.	Manipulation Under General Anesthesia (MUA):  refers to manual manipulation of the cervical spine in combination with the use of a general anesthetic or conscious sedation.  It is intended to improve the success of manipulation when pain, muscle spasm, guarding, and fibrosis appear to be limiting its application in patients otherwise suitable for its use.  There have been no high quality studies to justify MUAs benefits.  given the risks of general anesthetic and conscious sedation, It is not recommended.
f. e	Manipulation Under Joint Anesthesia (MUJA):  refers to manipulation of the cervical spine in combination with a fluoroscopically guided injection of anesthetic with or without corticosteroid agents into the facet joint at the level being manipulated.  There are no controlled clinical trials to support its use.  It is not recommended.
e. f. Massage — Manual or Mechanical: Massage is a generally well-accepted treatment consisting of manipulation of soft tissue with broad ranging relaxation and circulatory benefits.  This may include stimulation of acupuncture points and acupuncture channels (acupressure), application of suction cups and techniques that include pressing, lifting, rubbing, pinching of soft tissues by or with the practitioner's hands.  Indications include edema (peripheral or hard and non-pliable edema), muscle spasm, adhesions, the need to improve peripheral circulation and range of motion, or to increase muscle relaxation and flexibility prior to exercise.  
	As with all passive therapies, massage must be accompanied by exercise and patient education.
•	Time to produce effect:  Immediate
•	Frequency:  1 to 2 times per week
•	Optimum duration:  6 weeks
•	Maximum duration:  2 months
f.g.	Mobilization (Joint):  is a generally well-accepted treatment consisting of passive movement involving oscillatory motions to the vertebral segment(s).  The passive mobility is performed in a graded manner (I, II, III, IV, or V), which depicts the speed of and depth of joint motion during the maneuver.  For further discussion on Level V joint mobilization please see section on HVLA manipulation [Section 12. c.] It may include skilled manual joint tissue stretching.  Indications include the need to improve joint play, segmental alignment, improve intracapsular arthrokinematics, or reduce pain associated with tissue impingement.  Mobilization should be accompanied by active therapy. For Level V mobilization, cContraindications include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthridites arthritides, aortic aneurysm, and signs of progressive neurologic deficits, myelopathy, vertebrobasilar insufficiency, or carotid artery disease. Relative contraindications include stenosis, spondylosis, and disc herniation.
•	Time to produce effect:  6 to 9 treatments
•	Frequency:  Up to 3 times per week
•	Optimum duration:  4 to 6 weeks
•	Maximum duration:  6 weeks
gh.	Mobilization (Soft Tissue): is a generally well-accepted treatment. Mobilization of soft tissue is the skilled application of muscle energy, strain/counter strain, myofascial release, manual trigger point release and other manual therapy techniques designed to improve or normalize movement patterns through the reduction of soft tissue pain and restrictions.  These can be interactive with the patient participating or can be with the patient relaxing and letting the practitioner move the body tissues.  Indications include muscle spasm around a joint, trigger points, adhesions, and neural compression.  Mobilization should be accompanied by active therapy.
•	Time to produce effect:  2 to 3 weeks 4 to 9 treatments
•	Frequency:  2 to Up to 3 times per week
•	Optimum duration:  4 to 6 weeks
•	Maximum duration:  6 weeks
i.i.	Short-Wave Diathermy: is an accepted treatment which involves the use of equipment that exposes soft tissue to a magnetic or electrical field.  Indications include enhanced collagen extensibility before stretching, reduced muscle guarding, reduced inflammatory response, and enhanced reabsorption of hemorrhage/hematoma or edema.
•	Time to produce effect:  2 to 4 treatments
•	Frequency:  2 to 3 times per week up to 3 weeks
•	Optimum duration:  3 to 5 weeks
•	Maximum duration:  5 weeks
h.j.	Superficial Heat and Cold Therapy (excluding Infrared Therapy):  is a generally accepted treatment. Superficial heat and cold are thermal agents applied in various manners that lowers or raises the body tissue temperature for the reduction of pain, inflammation, and/or effusion resulting from injury or induced by exercise.  It iIncludes application of heat just above the surface of the skin at acupuncture points.  Indications include acute pain, edema and hemorrhage, need to increase pain threshold, reduce muscle spasm, and promote stretching/flexibility.  Cold and heat packs can be used at home as an extension of therapy in the clinic setting.
•	Time to produce effect:  Immediate
•	Frequency:  2 to 5 times per week
•	Optimum duration:  3 weeks as primary or intermittently as an adjunct to other therapeutic procedures up to 2 months
•	Maximum duration:  2 months
j.k.	Traction — Manual: is an accepted treatment and an integral part of manual manipulation or joint mobilization.  Indications include decreased joint space, muscle spasm around joints, and the need for increased synovial nutrition and response.  Manual traction is contraindicated in patients with tumor, infection, fracture, or fracture dislocation.
•	Time to produce effect:  1 to 3 sessions
•	Frequency:  2 to 3 times per week
•	Optimum duration:  30 days
•	Maximum duration:  1 month
k.l.	Traction — Mechanical:  is a generally accepted treatment and most commonly used for patients with radicular findings.  It is sometimes used to treat symptoms from decreased joint space and muscle spasm around the joints.    , and the need for increased synovial nutrition and response.  If successful it should be shifted to home traction.  Traction modalities are contraindicated in patients with tumor, infections, fracture, or fracture dislocation.  Non-oscillating inversion traction methods are contraindicated in patients with glaucoma or hypertension.  A home cervical traction unit may be purchased if therapy proves effective.
•	Time to produce effect:  1 to 3 sessions up to 30 minutes.  If response is negative after 3 treatments, discontinue this modality
•	Frequency:  2 to 3 times per week. A home cervical traction unit may be purchased if therapy proves effective.
•	Optimum duration:  4 weeks
•	Maximum duration:  1 month 4 weeks

l.m.	Transcutaneous Electrical Nerve Stimulation (TENS): is a generally accepted treatment which should include at least one instructional session for proper application and use.  Indications include muscle spasm, atrophy, and decreased circulation and pain control.  Minimal TENS unit parameters should include pulse rate, pulse width and amplitude modulation.  Consistent, measurable, functional improvement must be documented prior to the purchase of a home unit. 
•	Time to produce effect:  Immediate
•	Frequency:  Variable
•	Optimum duration:  3 sessions
•	Maximum duration:  3 sessions.  If beneficial, Purchase or provide with home unit or purchase if effective.
M.n.	Ultrasound (Including Phonophoresis): is an accepted treatment which uses sonic generators to deliver acoustic energy for therapeutic thermal and/or non-thermal soft tissue effects.  Indications include scar tissue, adhesions, collagen fiber and muscle spasm, and the need to extend muscle tissue or accelerate the soft tissue healing.  Ultrasound with electrical stimulation is concurrent delivery of electrical energy that involves dispersive electrode placement.  Indications include muscle spasm, scar tissue, pain modulation, and muscle facilitation.  
	Phonophoresis is the transfer of medication through the use of sonic generators to the target tissue to control inflammation and pain.  These topical medications include, but are not limited to, steroidal anti-inflammatory and anesthetics.  
•	Time to produce effect:  6 to 15 treatments
•	Frequency:  3 times per week
•	Optimum duration:  4 to 8 weeks
•	Maximum duration:  2 months 8 weeks
13. 	VOCATIONAL REHABILITATION is a generally accepted intervention, but Colorado limits its use as a result of Senate Bill 87-79. Initiation of vocational rehabilitation requires adequate evaluation of patients for quantification highest functional level, motivation, and achievement of maximum medical improvement. Vocational rehabilitation may be as simple as returning to the original job or as complicated as being retrained for a new occupation.
It may also be beneficial for full vocational rehabilitation to be started before MMI if it is evident that the injured worker will be unable to return to his/her previous occupation.  A positive goal and direction may aid the patient in decreasing stress and depression and promote optimum rehabilitation.

F.	THERAPEUTIC PROCEDURES — OPERATIVE
All operative interventions should be based on a positive correlation with clinical findings, the natural history of the disease, the clinical course, and diagnostic tests.  A comprehensive assimilation of these factors should have led to a specific diagnosis with positive identification of the pathologic condition(s).  It is imperative for the clinician to rule out non-physiologic modifiers of pain presentation, or non-operative conditions mimicking radiculopathy or instability (peripheral compressive neuropathy, chronic soft tissue injuries, and psychological conditions), prior to consideration of elective surgical intervention.  Early intervention may be required in acute incapacitating pain or in the presence of progressive neurological deficits.  Patients who are not candidates for or refuse surgical treatment should be treated with non-operative therapy as indicated.
Operative treatment is indicated when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions.  All patients being considered for surgical intervention should first undergo a comprehensive neuromusculoskeletal examination to identify mechanical pain generators that may respond to non-surgical techniques, or may be refractory to surgical intervention.
In situations requiring the possible need for re-surgery, a second opinion may be necessary.  Psychological evaluation is strongly encouraged when surgery is being performed for isolated axial pain to determine if the patient will likely benefit from the treatment.  
Structured rehabilitation and psychological evaluation Interdisciplinary interventions should be strongly considered post-operatively in patients not making expected functional progress in the immediate post-operative period.  within expected time frames (Refer to Interdisciplinary Programs, Section E. 5. b). 
Return to work activity restrictions should be specific according to the recommendations in Ssection E 10, Return to Work.  Most cervical non-fusion surgical patients can return to a limited level of duty between 3 to 6 weeks.  Full activity is generally achieved between 6 weeks to 6 months, depending on the procedure and healing of the individual.
1.	ACUTE FRACTURES & DISLOCATIONS Decisions regarding the need for surgery in acute traumatic injury will depend on the specific injury type and possibility of long-term neurologic damage. Acute disc herniations may occur in the presence of traumatic injury.
a.	Halo Immobilization:
i.	Description — Intervention that restricts flexion-extension motion. Halo vest will provide significant but not complete rotational control and is the most effective device for treating unstable injuries to the cervical spine.  
ii.	Complications — May include pin infection, pin loosening, and palsy of the sixth cranial nerve.
iii.	Surgical Indications — Cervical fractures requiring the need for nearly complete restriction of rotational control, and to prevent graft dislodgment, spine mal-alignment, or pseudoarthrosis.  Decision for use of halo is at the discretion of the surgeon based upon the patients’ specific injury.  Not indicated for unstable skull fractures or if skin overlying pin sites is traumatized.
iv.	Operative Treatment — Placement of the pins and apparatus.
v.	Post-Operative Therapy — Traction may be required for re-alignment and or fracture reduction (amount to be determined by surgeon), active and/or passive therapy, pin care.  
b.	Anterior or Posterior Decompression with Fusion: 
i.	Description — To provide relief of pressure on the cervical spinal column cord and nerve roots, and alignment and stabilization of the spine.  May involve the use of bone grafts, sometimes combined with metal devices, to produce a rigid connection between two or more adjacent vertebrae.
ii.	Complications — Instrumentation failure such as screw loosening, plate failure, or dislodgement (more common in posterior instrumentation), bone graft donor site pain, in-hospital mortality, deep wound infection, superficial infection, graft extrusion, cerebral spinal fluid (CSF) leak, laryngeal nerve damage (anterior approach), and iatrogenic kyphosis.
iii.	Surgical Indications — When a significant or progressive neurological deficit exists in the presence of spinal canal compromise.  Whether early decompression and reduction of neural structures enhances neurological recovery continues to be debated.  Currently, a reasonable approach would be to treat non-progressive neurological deficits on a semi-urgent basis, when the patient's systemic condition is medically stable.
iv.	Operative Treatment — Both anterior and posterior surgical decompression of the cervical spine are widely accepted.  The approach is guided by location of the compressive pathology as well as the presence of other concomitant injuries.  Posterior stabilization and fusion alone may be indicated for patients who have been realigned with traction and do not have significant canal compromise.  The anterior approach is acceptable if there is disc and/or vertebral body anteriorly compromising the canal.  , or be performed posterioly if the compressive pathology arises posteriorly.  The posterior approach is may be indicated in radiculopathy in the absence of myelopathy and with evidence of pseudoarthrosis on radiographs, or if the compression pathology is arising posteriorly. 
The number of levels involved in the fracture pattern determines the choice between the use of wire techniques versus spinal plates.  In injuries treated with an anterior decompression procedure, anterior bone grafting alone does not provide immediate internal fixation and an anterior cervical plate is significantly beneficial.  Patients who undergo surgery for significant fracture dislocations of the spine (three column level injury) with canal compromise are best managed with anterior cervical decompression, fusion, and plating but in some cases posterior stabilization and fusion are also considered.  
Allografts may be used for single bone graft fusion; however autografts are generally preferable for multi-level fusions unless a strut graft is required.
Recombinant Human Bone Morphogenetic Protein (rhBMP-2) is a member of a family of cytokines capable of inducing bone formation.  It is produced from genetically modified cell lines using molecular cloning techniques.  Use of rhBMP-2 in the cervical spine may carry a risk of swelling and ectopic bone formation which can encroach on neurovascular structures and on the esophagus.  As of the date of adoption the FDA had not approved its use in the cervical spine.  At the time of this guideline, cervical application of rhBMP-2 is investigational and remains outside the purview of the guidelines.  If the FDA approves its use in the cervical spine, prior authorization is required.  The patient must meet all indications on the device manufacturer's list and have no contraindications.
v.	Post-Operative Treatment — Active or passive therapy, cervical bracing.   Home programs should include instruction in ADL’s, stretching, and sitting, and a daily walking program. Cervical bracing may be appropriate (usually 6-12 weeks with fusion).  Home programs with instruction in ADLs, sitting, posture, and a daily walking program should be an early part of the rehabilitation process.  Referral to a formal rehabilitation program, with emphasis on cervical, scapular, and thoracic strengthening, and restoration of ROM,  may be is appropriate once participation in a home-based fitness program has been completed, the fusion is solid and without complication.  Active treatment, which patients should have had prior to surgery will frequently require a repeat of the sessions previously ordered. The goals of the therapy program should include instruction in a long-term home-based exercise program.   (Refer to Section E. 11-Active Therapy).
2.	DISC HERNIATION AND OTHER CERVICAL AGGRAVATION OF DEGENERATIVE CONDITIONS Operative treatment is indicated only when the natural history of an operatively treatable problem is better than the natural history of benign neglect the problem without operative treatment.  All patients being considered for surgical intervention should undergo a comprehensive neuromuscular examination to identify pain generators that may respond to nonsurgical techniques or may be refractory to surgical intervention.  Timely decision making for operative intervention is critical to avoid deconditioning, and increased disability of the cervical spine.  
General Recommendations — There is some evidence to suggest that recovery from cervical radiculopathy in patients without clinical signs of spinal cord compression at one year is similar with one-level fusion, physical therapy, or rigid cervical collar use. For patients with whiplash injury (Quebec Classification Grade Levels I or II), there is no evidence of any beneficial effect of operative treatment.  Refer to Section C. 1. f. (Soft Tissue Injury Evaluation), for Discussion on Quebec Classification Levels. 
If cervical fusion is being considered, it is recommended that the injured worker refrain from smoking for at least six weeks prior to surgery and during the time of healing. Because smokers have a higher risk of non-union and higher post-operative costs, it is recommended that insurers cover a smoking cessation program peri-operatively.
General Indications for Surgery — Operative intervention should be considered and a consultation obtained when improvement of symptoms has plateaued and the residual symptoms of pain and functional disability are unacceptable at the end of six weeks of treatment, or at the end of longer duration of non-operative intervention for debilitated patients with complex problems.  Choice of hardware instrumentation is based on anatomy, the patient’s pathology, and surgeon’s experience and preference.  
a.	General Specific Indications include: 
	a.  i.	For Patients with Myelopathy: immediate surgical evaluation and treatment is indicated.
	ii  b.	For Patients with Cervical Radiculopathy: specific indications include:
	A) i.	Early intervention may be required for acute incapacitating pain or in the presence of progressive neurological deficits.
	B) i.	Persistence Persistent or recurrent arm pain with functional limitations, unresponsive to conservative treatment after six weeks; or
	C) ii.	Progressive functional neurological deficit; or 
	D) iii.	Static neurological deficit associated with significant radicular pain; and 
	E) iv.	Confirmatory imaging studies consistent with clinical findings.  
	iii c.	For Patients with Persistent Non-radicular Cervical Pain: in the absence of a radiculopathy, it is recommended that a decisive commitment to surgical or nonsurgical interventions be made within 4 to 5 months following injury.  The effectiveness of three-level cervical fusion for non-radicular pain has not been established.  In patients with non-radicular cervical pain for whom fusion is being considered, required pre-operative indications include all of the following:
	A)	In general, if the program of non-operative treatment fails, operative treatment is indicated when:
•	Improvement of the symptoms has plateaued, and the residual symptoms of pain and functional disability are unacceptable at the end of 6 to 12 weeks of active treatment, or at the end of longer duration of non-operative programs for debilitated patients with complex problems; and/or
•	Frequent recurrences of symptoms cause serious functional limitations even if a non-operative active treatment program provides satisfactory relief of symptoms, and restoration of function on each recurrence.
•	Mere passage of time with poorly guided treatment is not considered an active treatment program.
	B) i.	All pain generators are identified adequately defined and treated; and  
	C) ii.	All physical medicine and manual therapy interventions are completed; and
	D) iii.	X-ray, MRI, or CT/discography demonstrating disc pathology or spinal instability; and 
	E) iv.	Spine pathology limited to two levels; and 
	F) v.	Psychosocial evaluation for confounding issues addressed. 
	G) vi.	For any potential surgery, it is recommended that the injured worker refrain from smoking for at least six weeks prior to surgery and during the period of healing.  Because smokers have a higher risk of non-union and higher post-operative costs, it is recommended that insurers cover a smoking cessation program peri-operatively.
b.	Surgical Procedures include:
	d.i.	Cervical Discectomy with or without Fusion:
	i.A)	Description — Procedure to relieve pressure on one or more nerve roots or spinal cord.  It may be performed with or without the use of a microscope.
	ii.B)	Complications — May include strut graft dislodgment (multi-level decompression), infection, hemorrhage, CSF leak, hematoma, catastrophic spinal cord injury causing varying degrees of paralysis, pseudoarthrosis, in-hospital mortality, non-union of fusion, donor site pain (autograft only).  Anterior approach: permanent or transient dysphonia, permanent or transitory dysphagia, denervation, esophageal perforation, and airway obstruction.
	iii.C)	Surgical Indications — Radiculopathy from ruptured disc or spondylosis, spinal instability, or patients with non-radicular neck pain meeting fusion criteria.  There is no evidence that discectomy with fusion versus discectomy without fusion has superior long-term results.  Discectomy alone is generally considered in patients with pure radicular symptoms from their herniated disc and who have sufficiently large foramen that disc space collapse is unlikely to further compromise the nerve root.  Failure rates increase with disease at more than two levels.
	iv.D)	Operative Treatment — Allografts may be used for single bone graft fusion; however autografts are generally preferable for multi-level fusions unless a large strut graft is required.  Cervical plating may be used to prevent graft dislodgment especially for multi-level disease.
		Recombinant Human Bone Morphogenetic Protein (rhBMP-2) is a member of a family of cytokines capable of inducing bone formation.  It is produced from genetically modified cell lines using molecular cloning techniques.  Use of rhBMP-2 in the cervical spine may carry a risk of swelling and ectopic bone formation which can encroach on neurovascular structures and on the esophagus.  As of the date of adoption the FDA has not approved its use in the cervical spine.  At the time of this guideline, cervical application of rhBMP-2 is investigational and remains outside the purview of the guidelines.  If the FDA approves its use in the cervical spine, prior authorization is required.  The patient must meet all indications on the device manufacturer's list and have no contraindications.
	v.E)	Post-Operative Therapy — Long-term neck Cervical bracing may be appropriate (usually (6 to - 12 weeks) with fusion).  Active and/or passive therapy.   Initial home rehabilitation programs should include instruction in ADL’s, posture, and contain a daily walking program.  Home programs with instruction in ADLs, sitting, posture, and a daily walking program should be an early part of the rehabilitation process.  Referral to a formal rehabilitation program, with emphasis on cervical, scapular, and thoracic strengthening  and restoration of ROM may be is appropriate for most patients at 8 to 16 weeks post-operatively, once fusion is solid and without complication.  Active treatment, which patients should have had prior to surgery, will frequently require a repeat of the sessions previously ordered. and should be strongly considered in patients not making expected functional progress in the immediate post-operative period.  The goals of the therapy program should include instruction in a long-term home-based exercise program.  (Refer to Section E. 11, Active Therapy).
	e.ii.	Cervical Corpectomy:
	A) i.	Description — Removal of a portion or the entire vertebral body from the front of the spine.  May also include removal of the adjacent discs.  Usually involves fusion.
	B) ii.	Complications — May include strut graft dislodgment (multi-level decompression), infection, hemorrhage, CSF leak, hematoma, catastrophic spinal cord injury causing varying degrees of paralysis, pseudoarthrosis, in-hospital mortality, non-union of fusion, donor site pain (autograft only).  Anterior approach: permanent or transient dysphonia, permanent or transitory dysphagia, denervation, esophageal perforation, and airway obstruction.
	C) iii.	Surgical Indications — Single or two-level spinal stenosis, spondylothesis, spondylolisthesis, or severe kyphosis, with cord compression.  
	D) iv.	Operative Treatment — Neural decompression, fusion with instrumentation, or halo vest placement to maintain cervical position.  Hemicorpectomy may be done when only a portion of the vertebral body needs to be resected.  Allografts may be used for single bone graft fusion; however, autografts are generally preferable for multi-level fusions unless a large strut graft is required.
	E)v.	Post-Operative Therapy — Dependent upon number of vertebral bodies involved, healing time may be longer than discectomy. Active and/or passive therapy,  Hhalo vest care is required.  Home programs with instruction in ADLs, sitting, posture, and a daily walking program should be an early part of the rehabilitation process.  Referral to a formal rehabilitation program with emphasis on cervical, scapular, and thoracic strengthening is appropriate for most patients once the cervical spine is deemed stable and without complication.  Active treatment, which patients should have had prior to surgery, will frequently require a repeat of the sessions previously ordered. The goals of the therapy program should include instruction in a long-term home-based exercise program.  Initial home rehabilitation programs should include instruction in ADL’s, posture, and contain a daily walking program.  Referral to a formal rehabilitation program may be appropriate for most patents at 8 to 16 weeks post-operatively and should be strongly considered in patients not making expected functional progress in the immediate post-operative period.  (Refer to Section E. 11, Active Therapy). 
	iii. f.	Cervical Laminectomy with or without Foraminotomy or Fusion:
	A) i.	Description — Surgical removal of the posterior portion of a vertebrae in order to gain access to the spinal cord or nerve roots.
	B) ii.	Complications — May include perineural fibrosis, kyphosis in fractures without fusion or with failed fusion, nerve injury, post surgical instability (with foraminotomies), CSF leak, infection, in-hospital mortality, non-union of fusion, donor site pain (autograft only).
	C) iii.	Surgical Indications — Neural decompression.
	D) iv.	Operative Treatment — Laminotomy, partial discectomy, and nerve root decompression.
	E) v.	Post-Operative Therapy — Neck bracing. active and/or passive therapy.  Initial home rehabilitation programs should include instruction in ADL’s, posture, and contain a daily walking program.   Cervical bracing may be appropriate (usually 6 to 12 weeks with fusion).  Home programs with instruction in ADLs, sitting, posture, and a daily walking program should be an early part of the rehabilitation process.  Referral to a formal rehabilitation program may be appropriate for most patients at 8 to 16 weeks post-operatively and should be strongly considered in patients not making expected functional progress in the immediate post-operative period. with emphasis on cervical, scapular, and thoracic strengthening and restoration of ROM is appropriate for most patients once the cervical spine is deemed stable and without complication.  Active treatment, which patients should have had prior to surgery, will frequently require a repeat of the sessions previously ordered. The goals of the therapy program should include instruction in a long-term home-based exercise program.  (Refer to Section E. 11, Active Therapy). 
	iv.g.	Cervical Laminoplasty:
	A) i.	Description — Technique that increases anterior or posterior dimensions of the spinal canal while leaving posterior elements partially intact.  It may be performed with or without the use of a microscope.
	B) ii.	Complications — Loss of cervical motion, especially extension.
	C) iii.	Surgical Indications — Multi-level disease: cervical spinal stenosis or spondylitic myelopathy.  Not indicated in cervical kyphosis.
	D) iv.	Operative Treatment — Posterior approach, with or without instrumentation.
	E) v.	Post-Operative Therapy — Active and/or passive therapy.  May include 4 to 12 weeks of cervical bracing.  Home programs with instruction in ADLs, sitting, posture, and daily walking program should be an early part of the rehabilitation process.  Referral to a formal rehabilitation program with emphasis on cervical, scapular, and thoracic strengthening and restoration of ROM is appropriate once the cervical spine is stable and without complication.  Active treatment which patients should have had prior to surgery will frequently require a repeat of the sessions previously ordered. The goals of the therapy program should include instruction in a long-term, home-based exercise program.  Initial home rehabilitation programs should include instruction in ADL’s, posture, and contain a daily walking program.  Referral to a structured rehabilitation program may be appropriate for most patients at 8 to 16 weeks post-operatively and should be strongly considered in patients not making expected functional progress in the immediate post-operative period.  (Refer to Section E. 11, Active Therapy).
	v.	PERCUTANEOUS DISCECTOMY:
	a)	Description — An invasive operative procedure to accomplish partial removal of the disc through a needle which allows aspiration of a portion of the disc trocar under imaging control.
	b)	Complications: — Include, but are not limited to, injuries to the nerve or vessel, infection, and hematoma.
	c)	Surgical Indications —  Percutaneous discectomy is indicated only in cases of suspected septic discitis in order to obtain diagnostic tissue.  The procedure is not recommended for contained disc herniations or bulges with associated radiculopathy due to lack of evidence to support long-term improvement.
	d)	Operative Treatment — Partial discectomy 
3.	Artificial Cervical Disc Replacement involves the insertion of a prosthetic device into the cervical intervertebral space with the goal of permitting physiologic motion at the treated cervical segment.  At the time of this writing, it is not recommended as it is not FDA approved and there are no studies demonstrating long-term superiority of this device over cervical fusion.  If cervical artificial disc replacement becomes FDA approved, pre-authorization must be obtained to assure that the patient meets all indications (including those listed on the device manufacturer's list) and has no contraindications to the procedure.
4. 	Percutaneous Radiofrequency Disc Decompression of the cervical spine is an investigational procedure which introduces a 19 gauge cannula under local anesthesia and fluoroscopic guidance into the nucleus pulposus of a contained herniated disc, using radiofrequency energy to dissolve and remove disc material.  Pressure inside the disc is lowered as a result.  There have been no randomized clinical trials of this procedure at this time.  It is not recommended.
5.	Epiduroscopy and Epidural Lysis of Adhesions  Refer to Section E. 3, Therapeutic Injections.
6.  	Intraoperative Monitoring is a common intraoperative electrodiagnostic technique that may include somatosensory evoked potentials (SSEP), motor evoked potentials (MEP), or pedicle screw monitoring.  The monitoring procedure may be used to evaluate spinal cord integrity and screw placement during the operative procedure.  The use of intraoperative monitoring can be anticipated to become more common as percutaneous spinal procedures gain greater acceptance.

RULE 17, EXHIBIT 9

Chronic Pain Disorder
Medical Treatment Guidelines

Revised:    April 26 2007
Effective:  July 1, 2007

Adopted:  January 8, 1998	Effective:  March 15, 1998	
Revised:  May 27, 2003	Effective:  July 30, 2003	
Revised:  September 29, 2005	Effective:  January 1, 2006	

Presented by:

State of Colorado

Department of Labor and Employment
DIVISION OF WORKERS’ COMPENSATION
TABLE OF CONTENTS

SECTION                                                   DESCRIPTION                                                              PAGE
A.	INTRODUCTION..........................................................................................................................x
B.	GENERAL GUIDELINE PRINCIPLES.........................................................................................X
1.	APPLICATION OF GUIDELINES	X
2.	EDUCATION	X
3.	TREATMENT PARAMETER DURATION	X
4.	ACTIVE INTERVENTIONS	X
5.	ACTIVE THERAPEUTIC EXERCISE PROGRAM	X
6.	POSITIVE PATIENT RESPONSE	X
7.	RE-EVALUATION TREATMENT EVERY 3 TO 4 WEEKS	X
8.	SURGICAL INTERVENTIONS	X
9.	SIX-MONTH TIME FRAME	X
10.	RETURN-TO-WORK	X
11.	DELAYED RECOVERY	X
12.	GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE	X
13.	TREATMENT OF PRE-EXISTING CONDITIONS	X
C.	INTRODUCTION TO CHRONIC PAIN.........................................................................................X
D.	DEFINITIONS...............................................................................................................................X
1.	AFTERSENSATION	X
2.	ALLODYNIA	X
3.	ANALGESIA	X
4.	BIOPSYCHOSOCIAL	X
5.	CENTRAL PAIN	X
6.	CENTRAL SENSITIZATION	X
7.	DYSESTHSIA	X
8.	HYPERALGESIA	X
9.	HYPERALGESIA (POSITIVE SENSORY PHENOMENA)	X
10.	HYPERPATHIA	X
11.	HYPOALGESIA	X
12.	HYPOESTHESIA (NEGATIVE SENSORY PHENOMENA)	X
13.	MALINGERING	X
14.	MYOFASCIAL PAIN	X
15.	MYOFASCIAL TRIGGER POINT	X
16.	NEURALGIA	X
17.	NEURITIS		X
18.	NEUROGENIC PAIN	X
19.	NEUROPATHIC PAIN	X
20.	NEUROPATHY	X
21.	NOCICEPTOR	X
22.	PAIN BEHAVIOR	X
23.	PAIN THRESHOLD	X
24.	PARESTHESIA	X
25.	PERIPHERAL NEUROGENIC PAIN	X
26.	PERIPHERAL NEUROPATHIC PAIN	X
27.	SUMMATION	X
28.	SYMPATHETICALLY MAINTAINED PAIN (SMP)	X
29.	TENDER POINTS	X

E.	INITIAL EVALUATION & DIAGNOSTIC PROCEDURES	X
1.	HISTORY AND PHYSICAL EXAMINATION (Hx & PE)............................	....... ...........X
	a.	Medical History	X	                                                                                                      10
	b.	Pain History	X
	c.	Medical Management History	X
	d.	Substance Use/Abuse	X
	e.	Other Factors Affecting Treatment Outcome	X
	f.	Physical Examination	X
2.	PERSONALITY/PSYCHOSOCIAL/PSYCHOLOGICAL EVALUATION	X
	a.	Qualifications	X
	b.	Clinical Evaluation	X
	c.	Tests of Psychological Functioning	X
3.	DIAGNOSTIC STUDIES	X
4.	LABORATORY TESTING	X
5.	INJECTIONS - DIAGNOSTIC	X
	a.   	Spinal Diagnostic Injections	X
		i.  Medial Branch Blocks	X
		ii. Transforaminal Injections	X
		iii. Zygapophyseal (Facet) blocks	X
		iv. Atlanto-Axial and Atlanto-Occipital Injections	X
		v.  Sacroiliac Joint Injection	X
	b.	Other Diagnostic Injections	X
		i.  Sympathetic Injections	X
		ii. Peripheral Nerve Blocks	X
6.	SPECIAL TESTS	X
	a.	Computer-Enhanced Evaluations	X
	b.	Functional Capacity Evaluation (FCE)	X
	c.	Job Site Evaluation	X
	d.	Vocational Assessment	X
	e.	Work Tolerance Screening	X
F. 	THERAPEUTIC PROCEDURES- NON-OPERATIVE	X
1.	ACUPUNCTURE	X
	a.	Acupuncture	X
	b.	Acupuncture with Electrical Stimulation	X
	c.	Other Acupuncture Modalities	X
2.	BIOFEEDBACK	X
	a.	EMG/Electromyogram (EMG)	X
	b.	Skin Temperature	X
	c.	Respiratory Feedback (RFB)	X
	d.	Respiratory Sinus Arrhythmia (RSA)	X
	e.	Heart Rate Variability (HRV)	X
	f.	Electrodermal Response (EDR)	X
	g.	Electroencephalograph (EEG, QEEG)	X
3.	COMPLEMENTARY ALTERNATIVE MEDICINE (CAM)	X
	a.	Alternative Medical Systems	X
	b.	Mind-Body Interventions	X
	c.	Biological Based Practices	X
	d.	Body-Based Therapy	X
	e.	Energy-Based Practices	X
4.	DISTURBANCES OF SLEEP	X
5.	INJECTIONS - THERAPEUTIC	X
	a.	Spinal Therapeutic Injections	X
		a.i.  Epidural Steroid Spinal Injections	X
		b. ii. Zygapophyseal (Facet) Injection	X
		f. iii. Sacro-iliac Joint Injection	X
	c.  Selective Nerve Root Blocks (SNRB)	
	d. b.	Trigger Point Injections		
	e. c.	Botulinum Toxin (Botox) Injection 	X
6.	INTERDISCIPLINARY REHABILITATION PROGRAMS	X
	a.	Formal Rehabilitation Programs	X
	b.	Informal Rehabilitation Programs	X
7.	MEDICATIONS	X
	a.	Alpha-Acting Agents	X
	b.	Anticonvulsants	X
	c.	Antidepressants	X
	d.	Hypnotics and Sedatives	X
	e.	Skeletal Muscle Relaxants	X
	f.	Opioids	X
	g.	Nonsteroidal Anti-Inflammatory Drugs	X
	h.	Topical Drug Delivery	X
	i.	Herbal/Dietary Supplements	X
	j.	Other Agents	X
8.	ORTHOTICS/PROSTHETICS/EQUIPMENT	X
9.	PATIENT EDUCATION	X
10.	PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTIONS	X
11.	RESTRICTION OF ACTIVITIES	X
12.	RETURN-TO-WORK	X
	a.	Job History Interview	X
	b.	Coordination of Care	X
	c.	Communication	X
	d.	Establishment of Return-to-Work Status	X
	e.	Establishment of Activity Level Restrictions	X
	f.	Rehabilitation and Return-to-Work	X
	g.	Vocational Assistance	X
13.	THERAPY – ACTIVE	X
	a.	Activities of Daily Living (ADL)	X
	b.	Aquatic Therapy	X
	c.	Functional Activities	X
	d.	Functional Electrical Stimulation	X
	e.	Lumbar Stabilization	X
	f.	Neuromuscular Re-education	X
	g.	Therapeutic Exercise	X
	h.	Work Conditioning	X
	i.	Work Stimulation	X
14.	THERAPY - PASSIVE	X
	a.	Electrical Stimulation (Unattended)	X
	b.	Infrared Therapy	X
	c.	Iontophoresis	X
	d.	Manipulation	X
	e.	Massage – Manual or Mechanical	X
	f.	Mobilization (Joint)	X
	g.	Mobilization (Soft Tissue)	X
	h.	Superficial Heat and Cold Therapy	X
	i.	Traction – Manual	X
	j.	Traction – Mechanical	X
	k.	Transcutaneous Electrical Nerve Stimulation (TENS)	X
	l. 	Ultrasound	X
G.	THERAPEUTIC PROCEDURES – OPERATIVE	X
1.	NEUROSTIMULATION.....	....................................................................................................X
2.	INTRATHECAL DRUG DELIVERY	X
3.	NEUROABLATION WITH RHIZOTOMY AS THE EXCEPTION	X
4.	FACET RHIZOTOMY	X
H.	MAINTENANCE MANAGEMENT..............................................................................................X
1.	HOME EXERCISE PROGRAMS AND EXERCISE EQUIPMENT	X
2.	EXERCISING PROGRAMS REQUIRING SPECIAL FACILITIES	X
3.	PATIENT EDUCATION MANAGEMENT	X
4.	PSYCHOLOGICAL MANAGEMENT	X
5.	NON-NARCOTIC MEDICATION MANAGEMENT	X
6.	NARCOTIC MEDICATION MANAGEMENT	X
7.	THERAPY MANAGEMENT	X
8.	INJECTION THERAPY	X
9. 	PURCHASE OR RENTAL OF DURABLE MEDICAL EQUIPMENT	X
Rule 17	MEDICAL TREATMENT GUIDELINES
EXHIBIT 9 CHRONIC PAIN DISORDER MEDICAL TREATMENT GUIDELINES
SECTION E. 
5.  	INJECTIONS-DIAGNOSTIC
	a. 	Spinal Diagnostic Injections:
Description — generally accepted, well-established procedures.  These injections may be useful for localizing the source of pain, and may have added therapeutic value when combined with injection of therapeutic medication(s).  Each diagnostic injection has inherent risks, and risk versus benefit should always be evaluated when considering injection therapy.  Since these procedures are invasive, less invasive or non-invasive procedures should be considered first.  Selection of patients, choice of procedure, and localization of the level for injection should be determined by clinical information indicating strong suspicion for pathologic condition(s) and the source of pain symptoms.
Because injections are invasive with an inherent risk, the number of diagnostic procedures should be limited in any individual patient to those most likely to be primary pain generators.  Patients should not receive all of the diagnostic blocks listed merely in an attempt to identify 100% of the pain generators.
The interpretation of the test results are primarily based on functional change, symptom report, and pain response (via a recognized pain scale before and at an appropriate time after the injection). The diagnostic significance of the test result should be evaluated in conjunction with clinical information and the results of other diagnostic procedures.  Injections with local anesthetics of differing duration may be used to support a diagnosis.  In some cases, injections at multiple levels may be required to accurately diagnose cervical conditions.  Refer to Section on Injections – Therapeutic for information on specific injections.
It is obligatory that sufficient data be accumulated by the examiner performing this procedure such that the diagnostic value of the procedure is evident to other reviewers.  This entails, at a minimum, documentation of patient response immediately following the procedure with details of any symptoms with a response and the degree of response.  Additionally, a log must be recorded as part of the medical record which documents response, if any, on an hourly basis for, at a minimum, the expected duration of the local anesthetic phase of the procedure.  Responses must be identified as to specific body part (e.g., low back, neck, leg, or arm pain).  The practitioner must identify the local anesthetic used and the expected duration of response for diagnostic purposes.  
Multiple injections provided at the same session without staging may seriously dilute the diagnostic value of these procedures.  Practitioners must carefully weigh the diagnostic value of the procedure against the possible therapeutic value.
Special Requirements for Diagnostic Injections  Since multi-planar, fluoroscopy during procedures is required to document technique and needle placement, an experienced physician should perform the procedure.  Permanent images are required to verify needle placement for all spinal procedures. The subspecialty disciplines of the physicians performing injections may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry.  The practitioner who performs spinal injections for low back pain should document hands-on training through workshops of the type offered by organizations such as the International Spine Intervention Society (ISIS) and/or completed a fellowship in pain medicine with interventional training.    The practitioner who performs spinal injections for cervical pain should have completed a fellowship in pain medicine with interventional training, or its equivalent.  Practitioners performing spinal injections for low back and cervical pain must also be knowledgeable in radiation safety.  
Complications  General complications of diagnostic injections may include transient neurapraxia, nerve injury, infection, headache, vasovagal effects, as well as epidural hematoma, permanent neurologic damage, dural perforation and CSF leakage, and spinal meningeal abscess.  Severe complications of cervical injections are remote but can include spinal cord damage, quadriplegia, and/or death.   Injections at a C2-C3 level frequently cause temporary neuritis with ataxia.
Contraindications  Absolute contraindications to diagnostic injections include: (a) bacterial infection – systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d) possible pregnancy.  
Relative contraindications of diagnostic injections may include:  (a) allergy to contrast or shellfish, (b) poorly controlled Diabetes Mellitus or and hypertension.  Drugs affecting coagulation require restriction from use.  the following are suggested time period restrictions:

•	Aspirin-withhold for seven days
•	NSAIDs-withhold for three days
•	Clopidogrel-withhold for 3 days
•	Other anti-platelet therapy and anti-coagulants should also be addressed individually by a knowledgeable specialist
Specific Diagnostic Injections  In general, relief should last for at least the duration of the local anesthetic used and should significantly relieve pain and result in functional improvement.  Refer to Section F.5, Therapeutic Injections for information on other specific therapeutic injections. The following injections are used primarily for diagnosis:
a. i.	Medial Branch Blocks: are primarily diagnostic, used to confirm the 	diagnosis of cervical facet pain.  When used for diagnosis, two injections 	at different times with different duration of local anesthetic are 	recommended.  Medial Branch Blocks are primarily diagnostic 	injections, used to determine whether a patient is a candidate for 	radiofrequency medial branch neurotomy (also known as facet 	rhizotomy).  ISIS suggests controlled blocks – using either 	placebo or anesthetics with varying lengths of activity (i.e., 	bupivacaine longer than lidocaine).  To be a positive diagnostic 	block, the patient should report a reduction of pain of 80% or 	greater relief from baseline for the length of time appropriate 	for the local anesthetic used.  In almost all cases, this will mean a 	reduction of pain to 1 or 2 on the visual analog scale (VAS) 10-	point scale correlated with functional improvement.  The patient 	should also identify activities of daily living (which may include 	measurements of range of motion) that are impeded by their pain 	and can be observed to document functional improvement in the 	clinical setting.  Ideally, these activities should be assessed 	throughout the observation period for function.  The observer 	should not be the physician who performed the procedure.  It is 	suggested that this be recorded on a form similar to ISIS 	recommendations. 
A separate comparative block on a different date should be performed to confirm the level of involvement.  A comparative block uses anesthetics of varying lengths of activity.  Medial Branch blocks are probably not helpful to determine the likelihood of success for spinal fusion.
•	Frequency and Maximum Duration:  May be repeated once for comparative blocks.  Limited to 4 levels.
ii.	Transforaminal Injections are useful in identifying spinal pathology. When performed for diagnosis, small amounts of local anesthetic up to a total volume of 1.0 cc should be used to determine the level of nerve root irritation.  A positive diagnostic block should result in a positive diagnostic functional benefit and an 80% reduction in nerve-root generated pain appropriate for the anesthetic used as measured by accepted pain scales (such as a VAS). 
•	Time to produce effect:  Less than 30 minutes for local anesthesia; corticosteroids up to 72 hours for most patients
•	Frequency and Maximum Duration:  Once per suspected level.  limited to two levels
iii. b. 	Zygapophyseal (facet) blocks: Intra-Articular Facet Injections: are principally diagnostic yet some patients may obtain therapeutic response.  If the patient demonstrates definite short-term but not long-term response, confirmatory medial branch blocks and possible medial branch neurotomy should be considered. Facet blocks are generally accepted but should not be considered diagnostic blocks for the purposes of determining the need for a rhizotomy (radiofrequency medial branch neurotomy), nor should they be done with medial branch blocks.  
These blocks should not be considered a definitive diagnostic tool.  They may be used diagnostically to direct functional rehabilitation programs.  A positive diagnostic block should result in a positive diagnostic functional benefit and an 80% reduction in pain appropriate for the anesthetic used as measured by accepted pain scales (such as a Visual Analog Scale).  They then may be repeated per the therapeutic guidelines when they are accompanied by a functional rehabilitation program.  (Refer to section F. 5. a. Therapeutic Spinal Injections).
•	Time to produce effect:  Less than 30 minutes for local anesthesia; corticosteroids up to 72 hours for most patients
•	Frequency and Maximum Duration:  Once per suspected level, limited to two levels
c.iv.	Atlanto-Axial and Atlanto-Occipital Injections: are generally accepted for diagnosis and treatment but do not lend themselves to denervation techniques owing to variable neuroanatomy.  Injection of this articulation is complicated by the proximity of the vertebral artery, which.  The vertebral artery may be tortuous at the level of the C1 joint.  Inadvertent injection of the vertebral artery may cause respiratory arrest, seizure, stroke, or permanent neurological sequelae.  Only practitioners skilled in these injections should perform them.
•	Frequency an d Maximum Duration:  Once per side
d. v.	Sacroiliac Joint Injection:	
	Description  a generally accepted injection of local anesthetic in an intra-articular fashion into the sacroiliac joint under fluoroscopic guidance.  Long-term therapeutic effect has not yet been established.	
	Indications  Primarily diagnostic to rule out sacroiliac joint dysfunction versus other pain generators.  Intra-articular injection can be of value in diagnosing the pain generator.  There should be documented relief from previously painful maneuvers (e.g., Patrick’s test) and at least 80% pain relief on post-injection physical exam (as measured by accepted pain scales such as VAS) correlated with functional improvement.  Sacroiliac joint blocks should facilitate functionally directed rehabilitation programs.  

•	Time to produce effect:  Up to 30 minutes for local anesthetic

•	Frequency and Maximum Duration: 1

b.	Other Diagnostic Injections:
These injections are frequently employed in assessing the type of pain a patient may be having.  They also aid in ascertaining possible mechanisms and origins of the pain as well as the site of the pain source.  Some diagnostic injections have therapeutic properties that may be used to both diagnose and treat chronic pain.  In those cases, refer to Section F.5, Non-Operative Treatment – Therapeutic Injections for specific information regarding these injections.
Description — generally accepted, well-established procedures.  These injections may be useful for localizing the source of pain, and may have added therapeutic value when combined with injection of therapeutic medication(s).  Each diagnostic injection has inherent risks, and risk versus benefit should always be evaluated when considering injection therapy.  Since these procedures are invasive, less invasive or non-invasive procedures should be considered first.  Selection of patients, choice of procedure, and localization of the level for injection should be determined by clinical information indicating strong suspicion for pathologic condition(s) and the source of pain symptoms.
The interpretation of the test result is primarily based upon pain response; the diagnostic significance of the test result should be evaluated in conjunction with clinical information and the results of other diagnostic procedures.  Injections with local anesthetics of differing duration are required to confirm a diagnosis.  In some cases, injections at multiple levels may be required to accurately diagnose pain.  Refer to Section F.5, Therapeutic Injections for information on specific injections.
Special Requirements for Diagnostic Injections  Since fluoroscopic, arthrographic and/or CT guidance during procedures is required to document technique and needle placement, an experienced physician should perform the procedure.  The subspecialty disciplines of the physicians may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry.  The practitioner should have experience in ongoing injection training workshops provided by organizations such as the International Spine Injection Society (ISIS) and be knowledgeable in radiation safety.  In addition, practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments of Radiology, as applicable.
Complications  General complications of diagnostic injections may include transient neurapraxia, nerve injury, infection, headache, vasovagal effects, as well as epidural hematoma, permanent neurologic damage, dural perforation and CSF leakage, and spinal meningeal abscess.  Severe complications of cervical injections are remote but can include spinal cord damage, quadriplegia, and/or death.  
Contraindications  Absolute contraindications of diagnostic injections include: (a) bacterial infection – systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d) possible pregnancy.  
Relative contraindications of diagnostic injections may include:  (a) allergy to contrast or shellfish, (b) poorly controlled Diabetes Mellitus or hypertension, and (c) aspirin/NSAIDs/antiplatelet therapy (drug may be held for 3 days or more, depending on the medication, prior to injection).  
Specific Diagnostic Injections  In general, relief should last for at least the duration of the local anesthetic used and give significant relief of pain.  Refer to Section F.5, Therapeutic Injections for information on other specific therapeutic injections. The following injections are used primarily for diagnosis:

[Insert Here:  i. Sympathetic Injections]
[Insert Here: ii.  Peripheral Nerve Blocks]

Rule 17	MEDICAL TREATMENT GUIDELINES
EXHIBIT 9 CHRONIC PAIN DISORDER MEDICAL TREATMENT GUIDELINES

SECTION F.  
5.	INJECTIONS—THERAPEUTIC Injections may be diagnostic, prognostic, or therapeutic.  Diagnostic injections are frequently employed in assessing the type of pain a patient may be having.  It also aids in ascertaining possible mechanisms and origins of the pain as well as the site of the pain source.  Prognostic injection may be done, before administration of a neurolytic agent or subjecting such patient to a neurosurgical procedure, to ensure that benefits achieved with the prognostic nerve block or injection may exhibit a similar sensation that the patient may experience with a more permanent procedure.  Therapeutic injections are employed after diagnostic blocks or injections have determined the nature and location of a pain syndrome. 
When considering the use of injections in chronic pain management, the treating physician must carefully consider the inherent risks and benefits.  First, it is understood that these injections are seldom meant to be “curative” but may have diagnostic or prognostic qualities and when used for therapeutic purposes they are employed in conjunction with other treatment modalities for maximum benefit.  
Second, education of the patient should include the proposed goals of the injections, expected gains, risks or complications, and alternative treatment.  
Lastly, reassessment of the patient’s status in terms of functional improvement should be documented after each injection and/or series of injections.  Any continued use of injections should be monitored using objective measures such as:
i.	Return-to-work or maintaining work status.
ii.	Fewer restrictions at work or performing activities of daily living
iii.	Decrease in usage of medications
iv.	Measurable functional gains, such as increased range of motion for documented increase in strength.
Visual analog scales (VAS) provide important subjective data but are not an appropriate    cannot be used to measure of function. 
The physician must be aware of the possible placebo effect as well as the long-term effects of injections related to the patient’s physical and mental status.  Strict adherence to contraindications, both absolute and relative, may prevent potential complications.  Subjecting the patient to potential risks, i.e., needle trauma, infection, nerve injury, or systemic effects of local anesthetics and corticosteroids, must be considered before the patient consents to such procedures.
a.	Spinal Therapeutic Injections
General Description –The following injections are considered to be reasonable treatment for patients with chronic pain.  Other injections not listed may be beneficial.  Therapeutic injections are generally accepted, well-established procedures. They may be used after initial conservative treatment, such as physical and occupational therapy, medication, manual therapy, exercise, acupuncture etc., has been undertaken.  Therapeutic injections should be used only after pathology has been demonstrated.  Injections are invasive procedures that can cause serious complications; thus clinical indications and contraindications should be closely adhered to. Therapeutic spinal injections may be used after initial conservative treatments, such as physical and occupational therapy, medication, manual therapy, exercise, acupuncture, etc., have been undertaken.  Therapeutic injections should be used only after imaging studies and diagnostic injections have established pathology.  Injections are invasive procedures that can cause serious complications; thus clinical indications and contraindications should be closely adhered to.  The purpose of spinal injections is to facilitate active therapy by providing short-term relief through reduction of pain and inflammation.  All patients should continue appropriate exercise with functionally directed rehabilitation.  Active treatment, which patients should have had prior to injections, will frequently require a repeat of the sessions previously ordered (Refer to section F. 13, Active Therapy).  Injections, by themselves, are not likely to provide long-term relief.  Rather, active rehabilitation with modified work acheives long-term relief by increasing active ROM, strength, and stability.  If the first injection does not provide a diagnostic response with temporary and sustained pain relief substantiated by accepted pain scales, (i.e., 80% pain reduction), and improvement in function, similar injections should not be repeated.  Cervical Injections are invasive procedures that can cause catastrophic complications.  Refer to the Cervical Spine Injury guideline for more specific contraindications.  It is recommended that all patients participate in an appropriate exercise program that may include a functionally directed rehabilitation program.  
Special Considerations – For all spinal injections (excluding trigger point, botox and occipital or peripheral nerve blocks) multi-planar fluoroscopy ic, arthrographic and/or CT guidance during procedures is required to document technique and needle placement, and should be performed by a physician experienced in the procedure.  Permanent images are required to verify needle placement.  The subspecialty disciplines of the physicians may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry. The practitioner  who performs injections for low back pain should document hands on training through workshops of the type offered by organizations such as the should participate in ongoing injection training workshops such as those sponsored by International  Spine Intervention Society for Injection Studies (ISIS) and/or completed a fellowship in pain medicine with interventional training.  and be knowledgeable in radiation safety.  The practitioner who performs injections for cervical pain should have completed fellowship training in pain medicine with interventional training, or its equivalent.   Practitioners who perform spinal injections for low back and cervicl pain 
must also be knowledgeable of radiation safety. 
In addition, practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments of Radiology, as applicable. 
Complications – General complications of these spinal injections may include (a) transient neurapraxia, local pain, nerve injury, infection, headache, urinary retention and vasovagal effects; (b) epidural hematoma, permanent neurologic damage, dural perforation and cerebral spinal fluid (CSF) leakage, and/or spinal meningeal abscess may also occur; and/or (c) suppression of the hypothalamic pituitary adrenal axis, which may be steroid dose dependent.  Permanent paresis, anaphylaxis and arachnoiditis have been rarely reported with the use of epidural steroids.  With steroid injections, there may be a dose-dependent suppression of the hypothalamic-pituitary adrenal axis lasting between one and three months.  For cervical injections, severe complications are remote but can include spinal cord damage, quadriplegia, and/or death.
Contraindications – Absolute contraindications of therapeutic injections include: (a) bacterial infection – systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, and (d) possible pregnancy.  
Relative contraindications of diagnostic injections may include: (a) allergy to contrast or shellfish, (b) poorly controlled Diabetes Mellitus or and hypertension.  , and (c) aspirin/NSAIDs/antiplatelet therapy (drug may be held for 3 days or more, depending on the medication, prior to injection).  Drugs affecting coagulation require restriction from use.  The following are suggested time period restrictions:
•	Aspirin -- withhold for seven days
•	NSAIDs -- withhold for three days
•	Clopidogrel -- withhold for three days
•	Other anti-platelet therapy and anti-coagulants should also be addressed individually by a knowledgeable specialist.
Specific Therapeutic Injections – The following injections are considered to be reasonable treatment for patients with chronic pain.  Other injections not listed may be beneficial.  Please refer to specific treatment guidelines for indications, complications, and contraindications of each.  
a. i.	Epidural Steroid Spinal Injections:
Description – Epidural steroid injections (ESI) deliver corticosteroid into the epidural space.  The purpose of ESI is to reduce pain and inflammation, restoring range of motion and thereby facilitating progress in more active treatment programs.  ESI uses three approaches: transforaminal, translaminar (midline), and caudal.  There is good evidence to support a preference for a transforaminal approach.  The evidence also suggests that the transforaminal approach can deliver medication to the target tissue with few complications and is therefore used to identify the specific site of pathology.  This is also the preferred approach for post-surgical patients.
For ESI in the low back, the transforaminal approach is the preferred method for unilateral, single-level pathology and for post-surgical patients.  Also for the low back, there is good evidence that the transforaminal approach can deliver medication to the target tissue with few complications and can be used to identify the specific site of pathology.  The interlaminar approach is the preferred approach for multi-level pathology or spinal stenosis in the lumbar spine.  Caudal therapeutic injections may be used, but it is difficult to target the exact treatment area, due to diffuse distribution.
Needle Placement – Spinal imaging Multi-planar fluoroscipic imaging is required for all transforaminal epidural steroid injections.  Since injections performed without radiographic guidance result in an increased risk of incorrect needle placement, spinal imaging is recommended for caudal and translaminar injections if available within 30 miles of the patient’s home.  Contrast epidurograms allow one to verify the flow of medication into the epidural space.  Permanent images are required to verify needle placement.
Indications – There is some evidence that epidural steroid injections are effective for patients with radicular pain or radiculopathy (sensory or motor loss in a specific dermatome or myotome).  Although there is no evidence regarding the effectiveness of ESI for non-radicular pain, it is a generally accepted intervention.  Only patients who have 1) pain affected by activity and 2) annular tears verified by appropriate imaging may have injections for axial pain.  Selected cases of vertebral compression fracture may be helped by ESI.  
There is some evidence that ESI injections in the low back are not effective for spinal stenosis without radicular findings.  Additionally, there is some evidence in studies of the lumbar spine that patients who smoke or who have pain unaffected by rest or activity are less likely to have a successful outcome from ESIs.
•	Time to produce effect:  Local anesthetic, less than approximately 30 minutes; corticosteroid, 48 to 72 hours for 80% of patients and 72 hours to 2 weeks for 20% of patients.  
•	Frequency:  One or more divided levels can be injected in one session.  Whether injections are repeated depends upon the patient’s response to the previous injection session.  Subsequent injection sessions may occur after 1 to 2 weeks if patient response has been favorable.  Injections can be repeated after a hiatus of three six months if the patient has demonstrated functional gain and pain returns or worsens.  If ESIs are repeated in the future, there should be increasing duration of relief and continued functional gain. If the first injection does not provide a diagnostic response of temporary and sustained pain relief (at least 2 to 6 weeks) substantiated by accepted pain scales (i.e., 80% pain reduction as measured by tools such as VAS) and improvement in function, similar injections should not be repeated.
•	Optimum:  Usually 1 up to 3 injection(s) over a period of six months in a series, depending upon each patient’s response and functional gain.  These should be performed in a 3 to 9 week period of time.
•	Maximum:  Two sessions (consisting of up to three injections each) Up to 3 to 4 series of injections may be done in one year based upon the patient’s response to pain and function.  Patients should be reassessed for measurable functional improvement after each injection session for an 80% improvement in pain (as measured by accepted pain scales) and evidence of functional improvement.  The time between series should not be less than 4 to 6 months.
b. ii.	Zygoapophyseal (Facet) Injection:
Description – A generally accepted I intra-articular or pericapsular injection of local anesthetic and corticosteroid.  Medial branch nerve blocks may be diagnostic only.  There is conflicting evidence to support a long-term therapeutic effect using facet injections.  There is no justification for a combined facet and medial branch block.
Indications – Patients with pain 1) suspected to be facet in origin based on exam findings and 2) affecting activity; OR patients who have refused a rhizotomy; OR patients who have facet findings with a thoracic component.  In these patients, facet injections may be occasionally useful in facilitating a functionally-directed rehabilitation program and to aid in identifying pain generators.  Patients with recurrent pain should be evaluated with more definitive diagnostic injections, such as medial nerve branch injections, to determine the need for a rhizotomy.  Because facet injections are not likely to produce long-term benefit by themselves and are not the most accurate diagnostic tool, they should not be performed at more than two levels.
Facet injections may be repeated if they result in increased documented functional benefit for at least 4 to 6 weeks and at least an 80% initial improvement in pain as measured by accepted pain scales (such as VAS).  
Facet injections may be considered in those patients whose history and examination are suggestive of a facet pain generator.  Lumbar facet injections are primarily of diagnostic value. The therapeutic value of facet injections provides short-term pain relief for patients to progress through a functionally directed rehabilitation program.  These injections are useful when used in conjunction with Manipulation Under Joint Anesthesia (MUJA).  Facet injections determine level(s) of lumbar facet involvement and the degree of pain coming from the posterior elements.  Facet injections may help determine the best therapeutic exercise approach (i.e., lumbar stabilization vs. sacroiliac stabilization).
•	Time to produce effect:  Up to Approximately 30 minutes for local anesthetic; 48 to corticosteroid up to 72 hours. for corticosteroid.  
•	Frequency:  1 injection per level with a diagnostic response.  If the first injection does not provide a diagnostic response of temporary and sustained pain relief substantiated by accepted pain scales, (i.e., 80% pain reduction substantiated by tools such as VAS), and improvement in function, similar injections should not be repeated. At least 4 to 6 weeks of functional benefit should be obtained with each therapeutic injection.
•	Optimum duration:  Usually 1 2 to 3 up to 3 injections for each applicable joint per year.  Not to exceed two joint levels.  (s) in a series, depending upon each patient’s response and functional gain.  These should be performed in a 3 to 9 week period of time.
•	Maximum Duration:  4 per level per year.  Prior authorization must be obtained for injections beyond two levels. 
•	Maximum:  Up to 3 to 4 series of injections may be done based upon the patient’s response to pain and function.  Patients should be reassessed for measurable functional improvement after each injection session.  The time between series should not be less than 4 to 6 months.
f. iii.	Sacro-iliac Joint Injection:
Description –  A generally accepted I injection of local anesthetic in an intra-articular fashion into the sacro-iliac joint under radiographic guidance. under radiographic guidance, which m May include the use of corticosteroids. in an intra-articular fashion into the sacroiliac joint.  Long-term therapeutic effect has not yet been established.
Indications – Primarily diagnostic to rule out sacroiliac joint dysfunction vs. other pain generators.  Intra-articular injection can be of value in diagnosing the pain generator.  There should be documented relief from previously painful maneuvers (e.g., Patrick’s test) on post-injection physical exam. These injections may be repeated if they result in increased documented functional benefit for at least 6 weeks and at least an 80% initial improvement in pain scales as measured by accepted pain scales (such as VAS).   Once diagnosis has been documented by intrajoint injection, posterior ligament block may be as effective as intra-joint injection for therapeutic value unless the primary pain is coming from an anterior capsular pain generator.  Therapeutic responses to these injections vary but  s Sacroiliac joint blocks may should facilitate a functionally directed rehabilitation programs.
•	Time to produce effect:  Approximately 30 minutes for local anesthetic; 48 to 72 hours for corticosteroid.  If the first injection does not provide a diagnostic response of temporary and sustained pain relief substantiated by accepted pain scales, (i.e., 80% pain reduction substantiated by tools such as VAS), and improvement in function, similar injections should not be repeated. At least 6 weeks of functional benefit should be obtained with each therapeutic injection.
•	Frequency and Optimum Duration:  Usually 1 2 to 3 injections per year.  If the first injection does not provide a diagnostic response of temporary and sustained pain relief substantiated by accepted pain scales, (i.e., 80% pain reduction substantiated by tools such as VAS), and improvement in function, similar injections should not be repeated. At least 6 weeks of functional benefit should be obtained with each therapeutic injection. (s) in a series, depending upon each patient’s response and functional gain.  These should be performed in a 3-9 week period of time.
•	Maximum Duration:  4 3 injections per year.    Up to 3 to 4 series of injections may be done based upon the patient’s response to pain and function.  Patients should be reassessed for measurable functional improvement after each injection session.  The time between series should not be less than 4 to 6 months.
c.	Selective Nerve Root Blocks (SNRB):
Description – Diagnostic and therapeutic blocks for radiculopathy.  Therapeutic SNRB's serve as selective epidural with contrast flowing proximally into the epidural space.  These are frequently useful in postoperative patients.  The volume of medication used may be higher than with the diagnostic SNRB.  
Indications – When used for diagnosis, small amounts of local anesthetic (with or without steroid) up to a total volume of 1.0 to 1.5 cc should be used to determine the level of nerve root irritation.  The relief should last for at least the duration of the local anesthetic used and give significant relief of pain.  
Needle Placement – Selective placement for the needle is documented by neurogram under fluoroscopic or CT imaging.  The transforaminal approach is useful and safer in patients with spinal stenosis in the cervical or thoracic areas where an interlaminar ESI may be contraindicated.
•	Time to produce effect:  30 minutes for local anesthetic; 48 to 72 hours for 80% of patients and 2 weeks for 20% of patient when cortisone is used.
•	Optimum:  Usually 1 up to 3 injection(s) in a series, depending upon each patient’s response and functional gain.  These should be performed in a 3 to 9 week period of time.
•	Maximum:  Up to 3 to 4 series of injections may be done based upon the patient’s response to pain and function.  Patients should be reassessed for measurable functional improvement after each injection session.  The time between series should not be less than 4 to 6 months.
d. b.	Trigger Point Injections: 
Description – Trigger point injection consists of dry needling or injection of local anesthetic with or without corticosteroid into highly localized, extremely sensitive bands of skeletal muscle fibers that produce local and referred pain when activated.  Medication is injected in the area of maximum tenderness.  Injection efficacy can be enhanced if injections are immediately followed by myofascial therapeutic interventions, such as vapo-coolant spray and stretch, ischemic pressure massage (myotherapy), specific soft tissue mobilization and physical modalities.  The effectiveness of trigger point injection is uncertain, in part due to the difficulty of demonstrating advantages of active medication over injection of saline.  Needling alone may be responsible for some of the therapeutic response.
Indications – Trigger point injections may be used to relieve myofascial pain and facilitate active therapy and stretching of the affected areas.  They are to be used as an adjunctive treatment in combination with other active treatment modalities.  Trigger point injections should be utilized primarily for the purpose of facilitating functional progress.  Patients should continue in an aggressive aerobic and stretching therapeutic exercise program as tolerated throughout the time period they are undergoing intensive myofascial interventions.  Trigger point injections are indicated in those patients where well-circumscribed trigger points have been consistently observed, demonstrating a local twitch response characteristic radiation of pain pattern and local autonomic reaction, such as persistent hyperemia following palpation.  Generally, these injections are not necessary unless consistently observed trigger points are not responding to specific, noninvasive, myofascial interventions within approximately a 4-week timeframe.  
Complications – Potential but rare complications of trigger point injections include infection, pneumothorax, anaphylaxis, penetration of viscera, neurapraxia and neuropathy.  If corticosteroids are injected in addition to local anesthetic, there is a risk of local myopathy developing.  Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be immediately repositioned.
•	Time to produce effect:  Local anesthetic 30 minutes; 24 to 48 hours for no anesthesia.
•	Frequency:  Weekly.  Suggest no more than 4 injection sites per session per week to avoid significant post-injection soreness.
•	Optimum duration:  4 sessions.
•	Maximum duration:  8 weeks.  Some patients may require 2 to 4 repetitions of trigger point injection series over a 1 to 2 year period.
e. c.	Botulinum Toxin (Botox) Injection:
Description – Used to temporarily weaken or paralyze muscles.  May reduce muscle pain in conditions associated with spasticity, dystonia, or other types of painful muscle spasm.  Neutralizing antibodies develop in at least 4% of patients treated with botulinum toxin type A, rendering it ineffective. Several antigenic types of botulinum toxin have been described.  Botulinum toxin type B, first approved by the Food and Drug Administration (FDA) in 2001, is similar pharmacologically to botulinum toxin type A, and there is good evidence of its efficacy in improving function in cervical dystonia (torticollis).  It appears to be effective in patients who have become resistant to the type A toxin.  The immune responses to botulinum toxins type A and B are not cross-reactive, allowing type B toxin to be used when type A action is blocked by antibody.  Experimental work with healthy human volunteers suggests that muscle paralysis from type B toxin is not as complete or as long lasting as that resulting from type A.  The duration of treatment effect of botulinum toxin type B for cervical dystonia has been estimated to be 12 to 16 weeks. EMG needle guidance may permit more precise delivery of botulinum toxin to the target area.
Indications – To improve range of motion and reduce painful muscle spasm.  May be useful in musculoskeletal conditions associated with muscle spasm or headaches.  There should be evidence of limited range of motion prior to the injection. May be useful in central neurologic conditions that produce spasticity or dystonia (e.g., brain injury, spinal cord injury, or stroke). 
Complications – Over-weakening of injected muscles, allergic reaction to medications.  Rare systemic effects include flu-like syndrome, weakening of distant muscle.  There is an increased risk of systemic effects in patients with motor neuropathy or disorders of the neuromuscular junction.  
•	Time to produce effect:  24 to 72 hours post injection with peak effect by 4 to 6 weeks.
•	Frequency:  No less than 3 months between re-administration.  
•	Optimum duration:  3 to 4 months.
•	Maximum duration:  Currently unknown.  Repeat injections should be based upon functional improvement and therefore used sparingly in order to avoid development of antibodies that might render future injections ineffective.  

Rule 17	MEDICAL TREATMENT GUIDELINES
EXHIBIT 9 CHRONIC PAIN DISORDER MEDICAL TREATMENT GUIDELINES

SECTION F. 7. g

g.	Nonsteroidal Anti-Inflammatory Drugs: 
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are useful for pain and inflammation.  In mild cases, they may be the only drugs required for analgesia.  There are several classes of NSAIDs and the response of the individual injured worker to a specific medication is unpredictable.  For this reason a range of NSAIDs may be tried in each case with the most effective preparation being continued.  Patients should be closely monitored for adverse reactions.  The US Food and Drug Administration advises all NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal.  Naproxen sodium does not appear to be associated with increased risk of vascular events.  Administration of proton pump inhibitors, histamine 2 blockers, or prostaglandin analog misoprostol along with these NSAIDs may reduce the risk of duodenal and gastric ulceration but do not impact possible cardiovascular complications.  Due to the cross-reactivity between aspirin and NSAIDs, NSAIDs should not be used in aspirin-sensitive patients, and should be used with caution in all asthma patients.  NSAIDs are associated with abnormal renal function, including renal failure, as well as, abnormal liver function.   Certain NSAIDs may have interactions with various other medications.  Individuals may have adverse events not listed above.  Intervals for metabolic screening are dependent upon the patient’s age, general health status and should be within parameters listed for each specific medication.  Complete blood count (CBC), liver and renal function should be monitored at least every six months in patients on chronic NSAIDs and initially when indicated.  COX-2 inhibitors differ in adverse side effect profiles from the traditional NSAIDs.  The major advantage of COX-2 inhibitors over traditional NSAIDs is that they have less gastrointestinal toxicity and do not inhibit platelet aggregation.   
i.	Non-Sselective Nonsteroidal Anti-Inflammatory Drugs NSAIDs
A)	Description – Inhibit cyclooxygenase (COX) enzymes, which are involved in several inflammatory processes.  
B)	Indications – Pain and inflammation.
C)	Major Contraindications – Renal and liver failure.
D)	Major Side Effects – Serious GI toxicity, such as bleeding, perforation, and ulceration can occur at any time, with or without warning symptoms.  Renal insufficiency.  Anaphylactic reactions, interference with platelet function, fluid retention and edema has been observed in some patients.  Exacerbation of hypertension.
E)	Drug Interactions – Varies with medication.  Should not be used in aspirin-sensitive patients.
F)	Recommended Laboratory Monitoring – Renal function.
Includes NSAIDs and acetylsalicylic acid (aspirin).  Serious GI toxicity, such as bleeding, perforation, and ulceration can occur at any time, with or without warning symptoms in patients treated with traditional NSAIDs.  Physicians should inform patients about the signs and/or symptoms of serious gastrointestinal toxicity and what steps to take if they occur.  Anaphylactoid reactions may occur in patients taking NSAIDs.  NSAIDs may interfere with platelet function.  Fluid retention and edema have been observed in some patients taking NSAIDs.
•	Optimal duration:  1 week
•	Maximum duration:  1 year.  Use of these substances long-term (3 days per week or greater) is associated with rebound pain upon cessation.
ii.	Selective Cyclo-oxygenase-2 (COX-2) Inhibitors
A)	Description – Inhibit the COX-2 enzyme, allowing the COX-1 enzyme to continue its protective effects on the gastric mucosa. Differ in adverse side effect profiles from non-selective NSAIDs in that they have less GI toxicity and no platelet effect.
B)	Indications – Recommended in select patients whom traditional NSAIDS are not tolerated or in patients at high risk of peptic ulcer. Celecoxib is FDA approved for osteoarthritis and rheumatoid arthritis.  Rofecoxib is FDA approved for acute pain and osteoarthritis.
C)	Major Contraindications – Celecoxib is contraindicated in sulfonamide allergic patients.
D)	Major Side Effects – COX-2 inhibitors can worsen renal function in patients with renal insufficiency.
E)	Drug Interactions – Varies with medication.
F)	Recommended Laboratory Monitoring – Renal function
COX-2 inhibitors are more recent NSAIDs and differ in adverse side effect profiles from the traditional NSAIDs.  The major advantages of selective COX-2 inhibitors over traditional NSAIDs are that they have less gastrointestinal toxicity and no platelet effects.  COX-2 inhibitors can worsen renal function in patients with renal insufficiency; thus, renal function may need monitoring.
COX-2 inhibitors should not be first-line for low risk patients who will be using an NSAID short term but are indicated in select patients for whom traditional NSAIDs are not tolerated.  Serious upper GI adverse events can occur even in asymptomatic patients.  Patients at high risk for GI bleed include those who use alcohol, smoke, are older than 65, take corticosteroids or anti-coagulants, or have a longer duration of therapy. Celecoxib is contraindicated in sulfonamide allergic patients.  
•	Optimal duration:  7 to 10 days
•	Maximum duration:  Chronic use is appropriate in individual cases.  Use of these substances long-term (3 days per week or greater) is associated with rebound pain upon cessation.