RULE 17, EXHIBIT 1 Low Back Pain Medical Treatment Guidelines Revised: February 3, 2014 Effective: March 30, 2014 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 8, 1998 Effective: March 15, 1998 Revised: October 4, 2001 Effective: December 1, 2001 Revised: September 29, 2005 Effective: January 1, 2006 Revised: April 26, 2007 Effective: July 1, 2007 Presented by: State of Colorado Department of Labor and Employment DIVISION OF WORKERS' COMPENSATION TABLE OF CONTENTS SECTION DESCRIPTION PAGE A. INTRODUCTION .............................................................................................................................. 1 B. GENERAL GUIDELINE PRINCIPLES ............................................................................................ 2 1. APPLICATION OF GUIDELINES ....................................................................................... 2 2. EDUCATION ....................................................................................................................... 2 3. INFORMED DECISION MAKING ....................................................................................... 2 4. TREATMENT PARAMATER DURATION ........................................................................... 2 5. ACTIVE INTERVENTIONS ................................................................................................. 2 6. ACTIVE THERAPEUTIC EXERCISE PROGRAM .............................................................. 2 7. POSITIVE PATIENT RESPONSE ...................................................................................... 2 8. RE-EVALUATION OF TREATMENT EVERY THREE TO FOUR WEEKS ........................ 3 9. SURGICAL INTERVENTIONS ........................................................................................... 3 10. SIX-MONTH TIME FRAME ................................................................................................. 3 11. RETURN TO WORK ........................................................................................................... 3 12. DELAYED RECOVERY ...................................................................................................... 3 13. GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE .......... 3 14. CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI) ........................................ 4 C. OVERVIEW OF CARE ..................................................................................................................... 5 1. LOW BACK PAIN WITHOUT RADICULAR PAIN OR NEUROLOGIC FINDINGS ............ 5 2. LOW BACK PAIN WITH RADICULAR AND OTHER NEUROLOGICAL FINDINGS ......... 7 D. INITIAL DIAGNOSTIC PROCEDURES .......................................................................................... 9 1. HISTORY TAKING AND PHYSICAL EXAMINATION (HX & PE): ..................................... 9 a. History of Present Injury ......................................................................................... 9 b. Past History .......................................................................................................... 10 c. Physical Examination ........................................................................................... 10 d. Relationship to Work and Other Activity .............................................................. 12 2. RADIOGRAPHIC IMAGING: ............................................................................................. 14 3. LABORATORY TESTING: ................................................................................................ 14 E. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES ..................................... 16 1. IMAGING STUDIES: ......................................................................................................... 16 a. Magnetic Resonance Imaging (MRI): .................................................................. 17 b. Specialized MRI Scans ........................................................................................ 17 c. Computed Axial Tomography (CT) ...................................................................... 17 d. Myelography ......................................................................................................... 18 e. CT Myelogram ...................................................................................................... 18 f. Lineal Tomography .............................................................................................. 18 g. Bone Scan (Radioisotope Bone Scanning) ......................................................... 18 h. Other Radioisotope Scanning .............................................................................. 18 i. Dynamic [Digital] Fluoroscopy ............................................................................. 18 2. OTHER TESTS: ................................................................................................................ 19 a. Electrodiagnostic Testing ..................................................................................... 19 b. Injections – Diagnostic ......................................................................................... 20 c. Personality/Psychological/Psychosocial Evaluation ............................................ 32 d. Provocation Discography ..................................................................................... 33 e. Thermography ...................................................................................................... 37 3. SPECIAL TESTS: ............................................................................................................. 37 a. Computer-Enhanced Evaluations ........................................................................ 37 b. Functional Capacity Evaluation (FCE) ................................................................. 37 c. Jobsite Evaluation ................................................................................................ 38 d. Vocational Assessment ........................................................................................ 39 e. Work Tolerance Screening .................................................................................. 39 F. THERAPEUTIC PROCEDURES – NON-OPERATIVE ................................................................. 40 1. ACUPUNCTURE: .............................................................................................................. 40 a. Acupuncture ......................................................................................................... 42 b. Acupuncture with Electrical Stimulation ............................................................... 42 c. Other Acupuncture Modalities .............................................................................. 42 d. Total Time Frames for Acupuncture and Acupuncture with Electrical Stimulation ............................................................................................................................. 42 2. BIOFEEDBACK: ................................................................................................................ 42 a. Electromyogram (EMG) ....................................................................................... 43 b. Skin Temperature................................................................................................. 43 c. Respiration Feedback (RFB) ............................................................................... 43 d. Respiratory Sinus Arrhythmia (RSA) ................................................................... 43 e. Heart Rate Variability (HRV) ................................................................................ 43 f. Electrodermal Response (EDR) ........................................................................... 43 g. Electroencephalograph (EEG, QEEG) ................................................................ 43 3. INJECTIONS – SPINAL THERAPEUTIC: ........................................................................ 44 a. Epidural Steroid Injection (ESI) ............................................................................ 47 b. Intradiscal Steroid Injections ................................................................................ 51 c. Sacroiliac Joint Injection ...................................................................................... 52 d. Transforaminal Injection with Etanercept ............................................................. 53 e. Zygapophyseal (Facet) Injection .......................................................................... 53 4. INJECTIONS – OTHER (INCLUDING RADIO FREQUENCY)......................................... 55 a. Botulinum Toxin Injections ................................................................................... 55 b. Epiduroscopy and Epidural Lysis of Adhesions ................................................... 56 c. Prolotherapy ......................................................................................................... 57 d. Radio Frequency Ablation - Dorsal Nerve Root Ganglion ................................... 58 e. Radio Frequency (RF) Denervation - Medial Branch Neurotomy/Facet Rhizotomy ............................................................................................................................. 58 f. Radio Frequency Denervation - Sacro-iliac (SI) Joint Cooled ............................