- Initial Phase of Specialized Care (Non-Operative Interventions)
These therapeutic procedures generally are applied during the acute phase following symptom onset with an overriding principle of symptom control. Common therapeutic procedures may involve, but are not necessarily restricted to, education/reassurance, pharmacologic pain control, non-pharmacologic pain control (modalities), rest, gentle exercise, manipulation, etc. (see "Initial Phase of Specialized Care").
Initial Phase of Specialized Care
Time from Symptom Onset
This assumes the patient did not improve in Phase I (See the "Phase I Treatment Algorithm" in the original guideline document.)
In the absence of surgical indicators, this phase of specialty care may constitute the major therapeutic intervention over the first 6-12 weeks following symptom onset.
Duration
0-8 weeks
Goal of Intervention
Symptom control to facilitate rapid recovery and return to normal occupational/social activities before deconditioning or psychosocial barriers occur.
Description
This intervention is generally performed in the acute phase following symptom onset or recurrence, when little or no deconditioning has occurred due to inactivity. This phase of care may be used for any level of severity of symptoms, according to the clinical indicators. Successful treatment leading to maximum medical improvement is accomplished in 60%-80% of spinal disorders with this phase of care, generally requiring very limited intervention.
Clinical or Behavioral Indicators (May include, but not limited to):
- Brief history of acute injury with early positive response to treatment (i.e., early symptomatic
relief)
- No urgent surgical indicators on physical examination
(i.e., progressive neurological deficit or incapacitating pain)
- No significant structural pathology suggesting
surgical solutions
- Acute recurrence or exacerbation after prior episode
- Immediate post-operative patient
Assessments
History and physical examination, including neurological evaluation. Physical and/or functional capacity evaluations may be necessary to assess work tolerance before intervention and return to work release.
Types of Intervention
(if clinically indicated and not previously unsuccessful)
Pharmacologic Pain Control Methods
- Opioids
- Muscle relaxants (tranquilizers)
- Hypnotics
- Non-steroidal anti-inflammatory drugs (NSAIDs)
Non-Pharmacologic Pain Control Methods
- Activity modification
- Manual therapy
- Passive modality procedures
- Injections (epidural steroid, facet, sacroiliac)
- Transcutaneous Electrical Nerve Stimulation
Education
- Back school
- Ergonomics instruction
- Home exercise
Therapeutic Exercise
- Positional exercises (various methods)
- Home exercise instruction
- Return to limited activity (with comparison to job and daily living demands)
Mental Health
- Pain and symptom control techniques
- Behavioral techniques
Expected Outcome
Return to normal occupational/social activities and/or maximum medical improvement.
Resumption of Activities of Daily Living
This initial phase of specialized care assumes a mild level of severity, allowing return to usual work and recreational activities within 0-8 weeks, with or without modified or transitional activity return.
Failure to Respond
Documented failure to respond at any time to treatment may require additional diagnostic tests and/or treatment consistent with greater level of severity.
- Secondary Phase of Specialized Care (Non-Operative Interventions)
These therapeutic procedures are generally applied if symptoms persist into a post-acute phase. The overriding principle is to restore function and prevent deconditioning, emphasizing supervised exercise (see "Secondary Phase of Specialized Care").
Secondary Phase of Specialized Care
Time from Symptom Onset
Post-acute time frames since symptom onset, usually between 1-6 months following initial incident. May include recurrence or post-surgical care.
Duration
0-8 weeks beyond initial phase of specialized care.
Description
This intervention is the first stage of rehabilitation for those individuals who have not returned to productivity through the normal healing process. It is designed to facilitate return to productivity before chronic impairment. It is individualized, time-limited and of limited intensity. It is designed to prevent chronic impairment.
Goal of Intervention
Preventing progressive physical deconditioning and appearance of psychosocial barriers to functional recovery, employing a reactivation process, generally associated with the post-acute or early post-operative periods.
Clinical or Behavioral Indicators (may include, but not limited to)
- History of injury or disorder with partial response
to early initial treatment (persistent symptoms and limitation of activities
of daily living)
- Physical examination suggestive of early
deconditioning (loss of motion and/or strength with limitation of activities
of daily living)
- No urgent surgical indicators on physical examination (i.e., progressive neurological deficit or
incapacitating pain)
- Evidence of limited mental health/psychosocial barriers impeding progress
Assessments
The type of assessments utilized in this phase of treatment depend on the level of severity associated with the diagnosis. Physical and/or functional capacity evaluations may be necessary to assess work tolerance before intervention and return to work release. Mental health evaluation to identify psychosocial barriers or the need for behavioral pain management may be appropriate. Documentation is required to substantiate the need for further diagnostic testing (imaging, electrodiagnostic studies, etc.).
Types of Intervention (if clinically indicated and not previously unsuccessful):
Medication Modification
- Decrease Use of Narcotics, Tranquilizers
- Antidepressant (for analgesia, sedation, mood)
Non-Pharmacologic Pain Control
- Progressive Activity Resumption
- Decreased Use of Passive Modalities for Pain Control
Only
- Injection Procedures (epidural steroids, facet joint,
sacroiliac joint, or selective nerve root blocks)
- Manual Therapy
- Facet Joint Neurotomy
Education
- Emphasis on Post-Acute Issues
- Overcoming Inactivity
Therapeutic Exercise
- Progressive Strengthening
- Aerobic Conditioning
- Functional Reconditioning
- Concurrent Home Programs
- Aquatic Rehabilitation
Mental Health Intervention
- Pharmacologic Intervention
- Behavioral Techniques
Uni- or Interdisciplinary Programs (limited intensity with consultative medical, educational, occupational and/or psychological assistance)
- Outpatient Medical Rehabilitation
- Work Conditioning
- Work Hardening
Expected Outcome
Return to normal occupational/social activities and/or maximum medical improvement.
Resumption of Activities of Daily Living
This secondary phase of specialized care is associated with a moderate level of severity consistent with the patient expected to be released to full activities or minimally modified/transitional activity resumption lasting no more than 3 months. Treatment response to initial and/or secondary interventions should result in nearly full recovery with the exception of possible limitations restricting some heavy job or recreational demands, even after completion of a transitional work return and achievement of maximum medical improvement. (The health provider should assure the patient an opportunity to reach the highest possible functional level, eliminating all possible temporary impairment, before determining maximum medical improvement.)
Failure to Respond
Documented failure to respond may require additional diagnostic tests and/or treatments consistent with greater severity. Consider referral for mental health evaluation/assessment.
- Tertiary Phase of Specialized Care (Non-Operative Interventions)
This is the treatment phase for those refractory to all other interventions. This is generally a medically-directed, interdisciplinary approach to reduce chronic pain and minimize permanent disability, emphasizing therapeutic exercise, education and mental health interventions (see "Tertiary Phase of Specialized Care").
Tertiary Phase of Specialized Care
Time from Symptom Onset
The chronic phase of symptoms and/or disability following symptom onset or recurrence beginning after an anticipated healing period, usually not before 3-6 months following symptom onset. Occasionally tertiary care may be indicated if a greater level of severity is identified in the post-acute phase of the condition.
Duration
0-10 weeks beyond secondary phase of treatment.
Goal of Intervention
To represent the final phase of non-operative or post-operative treatment for severe cases, with the goal of giving patients an opportunity to actively cooperate in programs designed to achieve return to productivity. Full return to work or recreational activities may not always be possible and may necessitate the introduction of vocational rehabilitation services following completion of medical rehabilitation.
Description
The tertiary phase of care involves medically-directed interdisciplinary, individualized and intensive services designed for patients already demonstrating physical and psychosocial changes consistent with chronic pain and disability of marked severity. In general, differentiation from secondary treatment includes medical direction, intensity of services, severity of injury, individualized programmatic protocols with integration of physician, mental health and disability or pain management services and specificity of physical/psychosocial assessment, with all interdisciplinary team members.
Clinical or Behavioral Indicators (may include, but not limited to):
- Documented history of persistent failure to respond
to non-operative and/or operative treatment, which surpasses the usual healing
period of more than 4-6 months post-injury and/or post-surgery, or special
cases with severe mental health issues which last more than 2 months without
response to initial or secondary treatment
- History of significant psychosocial disturbance
(i.e., substance abuse, affective disorders, psychiatric conditions)
- Inhibition of physical functioning producing failure
to match physical capacities to daily living requirements, as evidenced by
pain sensitivity, non-organic signs, fear producing physical inhibition or
limited response to reactivation treatment, as documented by quantitative
physical and/or functional capacity testing
- Heavy or repetitive job demands with inability to
match physical capacity to work requirement after presumed adequate treatment
causing inability to sustain uninterrupted work or recreation. This situation
would be evidenced by a patient unable to transition to acceptable full or
modified duty or significant episodes of recurrent lost time from work or
recreation after presumed maximum medical improvement. The inability to match
the patient’s skills to any available job may necessitate vocational
rehabilitation following maximum medical improvement
- Patients who cannot tolerate initial or secondary
phases of care
- Psychiatric illness or mental health disturbance likely to preclude success in initial or secondary care designed for milder levels of severity
Assessments
Usual history and physical examination should be accompanied by mental health assessment, physical capacity evaluation of the injured region(s) or joint(s) and/or functional capacity evaluation of whole-body performance. The specific testing chosen and the need for serial assessments may be individualized to the specific patient or programmatic protocols, based on documentation of effective outcomes of return to work, lower risk of recurrent disability and decreased future medical utilization.
Types of Intervention (if clinically indicated and not previously unsuccessful):
Interdisciplinary Programs (medically directed, intensive, time limited with all therapists on-site)
- Chronic pain management
- Functional restoration
- Pharmacologic interventions
- Behavioral techniques
Pharmacologic Pain Control
- Further efforts to decrease use of habituating medication
Non-Pharmacologic Pain Control Techniques
- Injection procedures (to facilitate active treatment)
- Epidural blocks
- Facet or sacroiliac joint injections
- Trigger point injections
- Selective nerve root blocks
- Facet joint neurotomy
- Transcutaneous Electrical Nerve Stimulation
- Limited passive modalities (to facilitate active treatment)
Mental Health Interventions
- Behavioral techniques
- Pharmacologic techniques
Job Site Analysis
Expected Outcome
Should be the last remaining medical option before maximum medical improvement.
Resumption of Activities of Daily Living
Tertiary care represents treatment for marked level of severity, which would allow return to productivity within 2-4 months, with or without a transitional period of modified activity (not to exceed 4 months). Treatment response to tertiary interventions will ultimately allow return to full (or permanently modified) work. There will likely be some limitation restricting medium-to-heavy work or recreational performance, accompanied by some permanent impairment, but with the patient always able to reach maximum medical improvement following completion of surgical and/or tertiary non-operative interventions. [Non-compliance or abandonment of secondary or tertiary care (which requires patient's active cooperation) result in maximum medical improvement by default.] Other outcomes include vocational rehabilitation or voluntary decision to discontinue work or recreational activities.
Failure to Respond
Documented failure to respond at any time to treatment may require additional diagnostic tests and/or treatment consistent with greater levels of severity. Consider mental health evaluation.
- Surgical Intervention
All operative interventions should be based on positive correlation of clinical findings, diagnostic tests, response to non-operative treatment and doctor-patient discussion of treatment options and expected outcomes. A comprehensive assimilation of these factors should be based on a specific diagnosis with positive identification of pathologic condition(s). Optimum outcomes with surgical intervention usually require appropriate application of pre-operative care and post-operative rehabilitation (see "Surgical Intervention", below).
Surgical Intervention
Time from Symptom Onset
- Unless surgery is emergent or urgent, initial
surgical intervention is best delayed 2-4 months for a trial of non-operative
interventions
- Subsequent procedures for initial surgical failure will be determined by clinical findings
Duration
Time from initial surgical procedure to initiation of post-operative rehabilitation (or full activity resumption) depends on surgical procedure.
The time to healing period ranges from 2-16 weeks for initial procedures and longer for secondary.
Goal of Intervention
Correction of appropriately-diagnosed anatomic condition. Facilitate post-operative rehabilitation to the highest possible functional outcome.
Clinical or Behavioral Indicators (May include, but not limited to):
- Documented history of failure to respond to initial and/or secondary treatment with symptoms suggestive of surgically treatable lesion (i.e., persistent leg pain, limitation of activities of daily living or perceived weakness)
- Physical examination findings consistent with surgically treatable lesion (i.e., positive
straight leg raise, hypesthesia, weakness or loss of motion)
- Structural diagnostic testing, (i.e., magnetic resonance imaging, computed tomography, myelogram) consistent with a surgically treatable lesion noted on the above diagnostics. Surgery would not occur except on objective findings of structural defects
Expected Outcome
- Return to normal occupational/social activities
and/or recreation
- Maximum medical improvement after appropriate post-operative care
Resumption of Activities of Daily Living
- Initial surgical intervention implies a level of
severity, which should allow return to modified work within 6-12 weeks
post-operatively based on job demands, usually after a post-operative
rehabilitation intervention
- Subsequent procedures for failure of initial surgery
may require up to 6 months to resume activities of daily living
- There may be limitations restricting medium-to-heavy work or recreational demands accompanied by some permanent impairment
Failure to Respond
Documented failure to respond to treatment at any time may require additional diagnostic tests and/or treatment consistent with greater levels of severity. Failure to respond may indicate a need for mental health evaluation. Patients declining to participate in appropriate surgical intervention and/or alternative non-operative treatment requiring active cooperation, may be determined to have reached maximum medical improvement by default.
- Palliative Phase of Specialized Care
Some patients complete a full algorithmic approach to treatment of unremitting low back pain (whether or not surgery has been utilized) and reach a medical end point with persistent pain. While the vast majority of patients respond to the phases of care outlined in the unremitting low back pain guidelines (see Sections I through IV), some continue with chronic pain and disability in spite of optimum treatment opportunities. Such patients may become candidates for palliative treatment. Palliative treatment is designed to provide reasonable efforts to control chronic pain, while continuing to strive for the highest functional levels. It is important to note that some patients may prefer to be passive recipients of interventional procedures or medications rather than actively participating in therapeutic exercise, education and mental health interventions designed to produce independence. Care should be carefully targeted in these individuals to prevent excessive, prolonged health care utilization and disability documentation (see "Palliative Phase of Specialized Care or Failed Back Syndrome").
Palliative Phase of Specialized Care or Failed Back Syndrome
Time from Symptom Onset
This final phase of care begins after all reasonable treatments for initial unremitting low back pain (ULBP), both surgical and non-operative, have been attempted and/or have failed to bring about satisfactory abatement of symptoms or administrative maximum medical improvement (MMI) (see the section titled "General Guideline Principles and Terminology" in the original guideline document).
Duration
- Initial phase: 3 months
- Maintenance program-lifelong
Description
The palliative phase of specialized care may involve:
- Medical maintenance procedures to limit severity of
recurrent episodes of pain/disability
- Additional diagnostic and surgical or non-operative
interventions to address recurrent or secondary sequelae of treated initial
unremitting low back pain
- Medical and/or non-medical procedures specifically designed to ameliorate chronic pain or disability
Goal of Intervention
To palliate chronic pain, including efforts to resolve recurrent or secondary mechanical abnormalities after completing treatment for initial unremitting low back pain. Lifelong patient maintenance in a cost-effective structure at maximum functional capacity.
Clinical or Behavioral Indicators (May include, but not limited to):
- Documented history of persistent failure to respond
to prior treatment for initial unremitting low back pain, which surpasses a
medical end point
- Persistent or recurrent psychosocial or psychiatric
disturbance associated with intractable pain and/or disability
- History of persistent or recurrent associated non-medical socio-economic issues resulting in secondary gain disincentives to recovery (e.g., ongoing compensation-related litigation, private or federal long term disability payments, other financial or health benefits tied to disability documentation)
Assessments
Initial program design to determine operative/non-operative/medical/behavioral interventions. Maintenance program established for lifelong cost-effective management. Includes mechanism for management of crisis as well as symptoms. Decreases utilization of emergency services.
Types of Intervention (if clinically indicated and not previously unsuccessful):
Medical Maintenance Procedures for Episodic Pain
- Medications: non-steroidal anti-inflammatory drugs,
psychotropic medications
- Reinstruction in fitness maintenance program,
stretching, thermal modalities for self-care
- Reinstruction in relaxation, coping skills and stress
management techniques
- Reinstruction in behavioral modification
- Injection procedures
- Limited passive modalities (e.g., manipulations)
Severe Recurrence or Episodes
- Trial or repeat of "refresher" secondary or tertiary
phase of specialized care
- Special tests to predict outcome of surgical
intervention (e.g., discography, diagnostic injections, response to spinal
cord stimulation)
- Repeat surgical intervention with post-operative rehabilitation
Non-Medical Socio-Economic Interventions
- Vocational rehabilitation
- Resolution of injury-related permanency awards
- Evaluate effect of compensation (e.g., long term
disability, social security disability income, health/welfare benefits)
Depending on disability documentation of persistent illness behaviors and
projected therapeutic outcomes
- Evaluate effect of previous non-compliance or failure to cooperate with interventions requiring patient’s active participation
Intractable Pain Suppression Procedures
- Transcutaneous Electrical Nerve Stimulation
- Spinal Cord Stimulation
- Denervation procedures
- Analgesic pumps
- Other habituating medication usage
Expected Outcome
- Partial abatement of symptoms
- Partial return to societal productivity
- Minimize dependence on financial/health benefits
requiring documentation on ongoing disability; maximize physical and
functional capacities
- Return to best possible activities of daily living.
