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Glossary of WCB Terms

Substantive changes in Proposed Medical Treatment Guidelines
January 19, 2010 revision

All Guides | Low Back (LB)/Cervical Spine(C-Spine) | Shoulder | Knee

Note: the language in italics is the new language

All Guides

  1. General Principles-Revisions
    1. #9-Surgical Interventions
      [Basis: Comments received-The original language which stated that surgery should not be performed solely for pain relief runs counter to our first principle as stated in the General Guiding Principles: "Medical care and treatment required as a result of a work-related injury should be focused on restoring functional ability required to meet the patient's daily and work activities and return to work, while striving to restore the patient's health to its pre-injury status in so far as is feasible." AND Under 7. POSITIVE PATIENT RESPONSE, we state: "Subjective reports of pain and function should be considered and given relative weight when the pain has anatomic and physiologic correlation." It is not clear what this statement would mean if we denied surgical intervention when the pain is severe and disabling and there is an operative procedure that could relieve it.]
      • Contemplation of surgery should be within the context of expected functional outcome. 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 imaging and other diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with positive identification of pathologic condition(s). For surgery to be performed to treat severe pain, there should be clear correlation between the pain symptoms and objective evidence of its cause.
    2. #10-Diagnostic Imaging and Testing Procedures
      [Basis: Comments and self-evident based on comments]
      • When a diagnostic procedure, in conjunction with clinical information, provides sufficient information to establish an accurate diagnosis, a second diagnostic procedure will be redundant if it is performed only for diagnostic purposes. At the same time, a subsequent diagnostic procedure (that may be a repeat of the same procedure, when the rehabilitation physician, radiologist or surgeon documents the study was of inadequate quality to make a diagnosis) can be a complementary diagnostic procedure if the first or preceding procedures, in conjunction with clinical information, cannot provide an accurate diagnosis. It is recognized that repeat imaging studies and other tests may be warranted by the clinical course and to follow the progress of treatment in some cases. It may be of value to repeat diagnostic procedures (e.g. imaging studies) during the course of care to reassess or stage the pathology when there is progression of symptoms or findings, prior to surgical interventions and therapeutic injections when warranted, and post-operatively to follow the healing process. Regarding CT examinations, it must be recognized that repeat procedures result in an increase in cumulative radiation dose and associated risks.
  2. Red Flags section added/revised in all Guides. See individual Guide sections.
  3. Follow-up Diagnostic Imaging/Testing:
    Revised language added to LB and revised in all Guides, except as noted.
    • One diagnostic imaging procedure may provide the same or distinctive information as does another procedure. Therefore, prudent choice of a single diagnostic procedure, a complement of procedures, or a sequence of procedures will optimize diagnostic accuracy, and maximize cost effectiveness (by avoiding redundancy), and minimize potential adverse effects to patients.

      All imaging procedures have a degree of specificity and sensitivity for various diagnoses. No isolated imaging test can assure a correct diagnosis. Clinical information obtained by history taking and physical examination should form the basis for selecting an imaging procedure and interpreting its results.

      This sentence in LB and C-Spine only: [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 be redundant if it is performed only for diagnostic purposes. At the same time, a subsequent diagnostic procedure (that may be a repeat of the same procedure, when the rehabilitation physician, radiologist or surgeon documents that the study was of inadequate quality to make a diagnosis) 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.

      It is recognized that repeat imaging studies and other tests may be warranted by the clinical course and to follow the progress of treatment in some cases. It may be of value to repeat diagnostic procedures (e.g. imaging studies) during the course of care to reassess or stage the pathology when there is progression of symptoms or findings, prior to surgical interventions and therapeutic injections when warranted, and post-operatively to follow the healing process. Regarding CT examinations, it must be recognized that repeat procedures result in an increase in cumulative radiation dose and associated risks.
  4. Electrodiagnostic Studies (primarily in Low Back, C-Spine, but also mentioned in Knee and Shoulder). EDS in all Guidelines will have the following language added.
    [Basis: Comments-The professional and accrediting organizations for EDS (see especially the American Association of Neuromuscular & Electrodiagnostic Medicine) agree that only neurologists and physiatrists receive sufficient training during their residency programs to assure competence in the performance and interpretation of EDS.]
    • EDS include needle EMG, peripheral nerve conduction studies (NCS) and motor and sensory evoked potentials. Needle EMG is usually what substantiates the diagnosis of radiculopathy or spinal stenosis in patients with back pain and/or radiculopathy problems. Needle EMG can help determine if radiculopathy is acute or chronic. NCS are done in addition to needle EMG to rule out other potential causes for the symptoms, (co-morbidity or alternate diagnosis involving peripheral nerves) and to confirm radiculopathy. It is recommended and preferred that EDS in the out-patient setting be performed and interpreted by physicians board-certified in Neurology or Physical Medicine and Rehabilitation.
  5. Therapeutic Procedures-Non-operative: Medications
    1. Acetaminophen (Tylenol)-revised
      [Basis: Changed to comply with FDA recommendations.]

      In the LB, acetaminophen was separated from NSAIDs and the following added. In the other Guidelines, modifications were made. All guidelines now have the following language.
      • 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 when the recommended daily dose is exceeded or in patients who chronically use alcohol. Patients may not realize that many over-the-counter preparations may contain acetaminophen. The total daily dose of acetaminophen should not exceed 4 grams per 24-hour period from all sources, including narcotic-acetaminophen combination preparations. Patients who consume three or more alcoholic drinks per day are at greater risk for liver toxicity, and consideration should be given to the use of other analgesics or limiting the acetaminophen dose to 2 grams per 24-hour period from all sources. Monitoring liver function via blood testing for use beyond 10 days is advisable.
        • Recommendations:
          • Acetaminophen is a reasonable alternative to NSAIDs, although evidence suggests it is modestly less efficacious.
          • Acetaminophen is recommended for treatment of LBP with or without radicular symptoms, particularly for those with contraindications for NSAIDs.
            • Optimum Duration: 7 to 10 days
            • Maximum Duration: Chronic use as indicated on a case-by-case basis.
    2. NSAIDs-revised: language in all Guidelines modified to read as below.
      [Basis: changed to comply with FDA recommendations.]
      • 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 patient 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 have an increased risk of serious cardiovascular thrombotic events, myocardial infarction, stroke, which can be fatal and increased risk of serious adverse GI events including bleeding, ulceration and perforation of the stomach and intestines.
      • Generally, older generation (COX-1, non-selective) NSAIDs are recommended as first-line medications. Second-line medications should generally include one of the other COX-1 medications. While COX-2 selective agents generally have been recommended as either third- or fourth-line medications to use when there is a risk of gastrointestinal complications, misoprostol, sucralfate, histamine 2 blockers and proton pump inhibitors are also gastro-protective. COX-2 selective agents may still be used for those with contraindications to other medications, especially those with a history of gastrointestinal bleeding or past history of peptic ulcer disease.
      • Selective COX-2 inhibitors should be used with great caution in patients with ischemic heart disease and/or stroke and avoided in patients with risk factors for coronary heart disease. Patients with known cardiovascular disease or multiple risk factors for cardiovascular disease should have the risks and benefits of NSAID therapy for pain discussed. In these patients, it appears to be safest to use acetaminophen or aspirin as the first-line therapy. If needed, NSAIDs that are non-selective are preferred over COX-2 specific drugs. Even a relative lack of COX-2 selectivity does not completely eliminate the risk of cardiovascular events, and in that regard, all drugs in the NSAID spectrum should only be prescribed after thorough consideration of risk benefit balance. Patients who receive COX-2 inhibitors should take the lowest effective dose for the shortest time necessary to control symptoms. In patients receiving low-dose aspirin for primary or secondary cardiovascular disease prevention, to minimize the potential for the NSAID to counteract the beneficial effects of aspirin, aspirin should be taken 2 hours before or at least 8 hours after the NSAID. (Antman 07).
        • Recommendations:
          • NSAIDs are recommended for the treatment of acute, subacute, chronic, or post-operative LBP. Over-the counter (OTC) agents may suffice and may be tried first.
            • Frequency/Duration: In most acute LBP patients, scheduled dosage, rather than as needed, is generally preferable. As needed (PRN) prescriptions may be reasonable for mild, moderate or chronic LBP. Discontinuation: Resolution of symptoms, lack of efficacy, or development of adverse effects that necessitate discontinuation.
            • NSAIDs are recommended for treatment of acute or chronic radicular pain syndromes, including sciatica.
            • Frequency/Duration: In acute radicular pain syndromes, scheduled dosage, rather than as needed, is generally preferable. PRN prescriptions may be reasonable for mild, moderate, or chronic radicular pain.
            • Discontinuation: Resolution of symptoms, lack of efficacy, or development of adverse effects that necessitate discontinuation. It should be noted that resolution of radicular symptoms generally takes significantly longer than does resolution of acute LBP.
      • Those patients at substantially increased risk for gastrointestinal bleeding, who also have indications for NSAIDs, should be considered for concomitant prescriptions of cytoprotective medications, particularly if longer term treatment is contemplated.
      • Individuals considered being at elevated risk include history of prior gastrointestinal bleeding, elderly, diabetics, and cigarette smokers. There are four commonly used cytoprotective classes of drugs: misoprostol, sucralfate, histamine type 2 receptor blockers (famotidine, ranitidine, cimetadine, etc.), and proton pump inhibitors (esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole). There is not believed to be substantial differences in efficacy for prevention of gastrointestinal bleeding. There also are combination products of NSAIDs/misoprostol (e.g., arthrotec).
        • Frequency/Duration: Frequency as recommended.
        • Discontinuation: Intolerance, development of adverse effects, or discontinuation of the NSAID.