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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

Low Back (LB)/Cervical Spine(C-Spine)

  1. General Summary of Recommendations removed from LB.
  2. Introduction containing the following items has been added to the LB.
    [Basis: To bring LB closer in approach, format and style to other Guides]
    • Introduction
      • History Taking and Physical Examination
      • History taking and physical examination 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 consistent with each other, the objective clinical findings have greater weight. The medical records should reasonably document the following:
      • History of Present Illness
        • A detailed history, taken in temporal proximity to the time of injury, should primarily guide evaluation and treatment. The history should include:
          • 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 work body postures, frequency during the workday and lifting/push/pull requirements should be included in the absence of a known specific incident.
          • 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 pain).
          • The use of an accepted pain assessment tool, (e.g. the Visual Analog Scale [VAS]) is highly recommended, especially during the first two weeks following injury, to assure that all work-related symptoms, including pain, are being addressed.
          • Presence and distribution of lower extremity numbness, paresthesias, or weakness, especially if precipitated or worsened by coughing or sneezing.
          • Alteration in bowel, bladder or sexual function.
          • Prior occupational and non-occupational injuries to the same area including specific prior treatment, history of specific prior motor vehicle accidents, chronic or recurrent symptoms, and any functional limitations.
          • History of emotional and/or psychological reactions to the current injury/illness
          • Ability to perform job duties and activities of daily living
      • Past History
        • Comprehensive past medical history.
        • Review of systems includes symptoms of rheumatologic, neurologic, endocrine, neoplastic, infectious, and other systemic diseases.
        • Smoking history.
        • Vocational and recreational pursuits.
        • History of depression, anxiety, or other psychiatric illness.
      • 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 tests or job information is required.
      • Red Flags section
        • Certain findings, "red flags," raise suspicion of potentially serious and urgent medical conditions. Assessment (history and physical examination) should include evaluation for red flags. In the low back, these findings or indicators may include: acute fractures, dislocations, infection, tumor, progressive neurologic deficit or cauda equina syndrome, and extra spinal disorders. Further evaluation/consultation or urgent/emergent intervention may be indicated and the Low Back Guidelines incorporate changes in clinical management triggered by the presence of "red flags".
      • Imaging/Anatomical Tests
        • Imaging studies should not be routinely performed without indications.
        • Physicians should be aware that "abnormal" findings on x-rays, magnetic resonance images, and other diagnostic tests are frequently seen by age 40 even in asymptomatic individuals. Bulging discs continue to increase after that point and by approximately age 60, will be encountered in a majority of patients. This requires that a careful history and physical examination be conducted by a physician in order to correlate historical, clinical, and imaging findings prior to diagnosing and attributing a patient's complaints to the finding on imaging. The focus of treatment should be improving symptoms and function, and not the correction of abnormalities on imaging studies.
      • Laboratory Testing
        • Laboratory tests are rarely indicated at the time of initial evaluation, unless there is a suspicion of systemic illness, infection, neoplasia or underlying rheumatologic disorder, connective tissue disorder, or other findings based on history and/or physical examination. Laboratory tests can provide useful diagnostic information. Tests include, but are not limited to:
          • Complete Blood Count (CBC)
            • Complete blood count (CBC) with differential can detect infection, blood dyscrasias, and medication side effects.
          • Rheumatologic, Infection or Connective Tissue Disorder
            • Erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), anti-nuclear antigen (ANA), human leukocyte antigen (HLA), and C-reactive protein (CRP), among others, can be used to detect evidence of a rheumatologic, infection, or connective tissue disorder.
          • Metabolic Bone Disease
            • Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease.
          • Liver and Kidney Function
            • Liver and kidney function may be performed for prolonged anti-inflammatory use or other medications requiring monitoring.
          • Follow-up Diagnostic Imaging and Testing Procedures
            • 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.
        • 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.
  3. Other Tests/Procedures:
    1. Discography
      • LB revised
        • Discography, whether performed as a solitary test or when paired with imaging (e.g., MRI), is not recommended for acute, subacute, chronic LBP or radicular pain syndromes. Improvement in surgical outcomes has not been shown to follow the use of discography, and there is evidence that performing discography on normal discs is associated with an enhanced risk of degenerative changes in those discs in later years.
      • C-Spine revised:
        • Provocation Discography: Not Recommended. Improvement in surgical outcomes has not been shown to follow the use of discography, and there is evidence that performing discography on normal discs is associated with an enhanced risk of degenerative changes in those discs in later years.
    2. CT/MRI Discography in LB revised
      • Recommendations: See Lumbar Discography above.
  4. Therapeutic Procedures-Non-operative: Medications
    1. Anti-Seizure Drugs: 2nd Gabapentin recommendation revised.
      • Gabapentin may be considered for the treatment of severe neurogenic claudication from spinal stenosis or chronic radicular pain syndromes with limited walking distance.
    2. Opioids: The following language added to LB
      • Narcotics should be primarily reserved for the treatment of severe back pain. In mild-to-moderate cases of 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. This medication has physically addictive properties and withdrawal symptoms may follow abrupt discontinuation.
      • 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.
        • Optimum Duration: 3 to 7 days.
        • Maximum Duration: 2 weeks. Use beyond two weeks is acceptable in appropriate cases.
        • Any use beyond the maximum should be documented and justified based on the diagnosis and/or invasive procedures.
    3. Tramadol revised and separated from Opioids in LB. Same language in C-Spine.
      • Recommendations:
        • 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 oxidase (MAO) inhibitors, SSRIs, and tricyclic antidepressants.
        • Maximum Duration: 2 weeks. Use beyond 2 weeks is acceptable in appropriate cases.
        • This medication has physically addictive properties and withdrawal symptoms may follow abrupt discontinuation. It is not recommended for those with prior opioid addiction.
  5. Therapeutic Procedures-Non-operative: Neuroflexotherapy LB-revised.
    • Recommendations:
      • Neuroreflexotherapy is not recommended for treatment of acute, sub-acute, or radicular pain; or for moderate to severe chronic LBP.
  6. Therapeutic Procedures: Operative
    1. Cervical Discectomy in C-Spine revised
      • Post-Operative Therapy: 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 is appropriate, once fusion is solid and without complication. New techniques in cervical fusion with instrumentation may permit more rapid referral to a rehabilitation program, and the decision regarding timing should be left to the surgeon. 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.
    2. Spinal Fusion
      1. Degenerative Disc Disease in LB revised
        [Basis: Literature review (2009 publications)]
        • Lumbar fusion is recommended as a treatment for Degenerative Disc Disease/"Discogenic Back Pain"/"Black Disc Disease" without instability in selected patients for whom non-surgical management has failed to relieve symptoms and improve function. If available, an intensive Functional Rehabilitation Program should be tried first.
      2. Anterior or Posterior Decompression with Fusion: C-Spine revisions
        [Basis: Comments from the orthopedists' society that this recommendation is outdated and fails to reflect new techniques in fusion (with instrumentation) that permits immediate post-operative rehabilitation because of modern internal fixation techniques that encourage early mobilization and range of motion. The language of this recommendation will be changed to reflect this].
        • Post-Operative Treatment: 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 range of motion, is appropriate once the fusion is solid and without complication. New techniques in cervical fusion with instrumentation may permit more rapid referral to a rehabilitation program, and the decision regarding timing should be left to the surgeon. 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.
      3. Cervical Laminectomy with or without Foraminotomy or Fusion: C-Spine revisions
        • Post-Operative Therapy: Cervical bracing may be appropriate (usually 6 to 12 weeks with fusion), although newer surgical techniques may not require prolonged immobilization. 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 range of motion is appropriate for most patients once the cervical spine is deemed stable and without complication. Newer surgical techniques may permit earlier referral to a rehabilitation program, and the decision regarding timing should be left to the surgeon. The goals of the therapy program should include instruction in a long-term home-based exercise program.
    3. Cervical Discectomy: C-Spine revisions
      • Post-Operative Therapy: 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 is appropriate, once fusion is solid and without complication. New techniques in cervical fusion with instrumentation may permit more rapid referral to a rehabilitation program, and the decision regarding timing should be left to the surgeon. 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.
    4. Cervical Corpectomy: C-Spine Revisions
      [Basis: Comments from the orthopedists society that "Because of the rigid types of internal fixation utilized today, which may involve both anterior and posterior internal fixation, external immobilization is frequently not necessary, but may be utilized at the discretion of the treating surgeon if bone quality warrants this. Certainly, the statement that halo vest care is required is archaic and has no place in Guidelines in the 21st Century." We will change the language to reflect that instrumental fixation may obviate the need for external immobilization.]
      • Post-Operative Therapy: Dependent upon number of vertebral bodies involved, healing time may be longer than discectomy. Halo vest care has traditionally been required, but new techniques in cervical fusion with instrumentation may permit more rapid mobilization. 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. Newer surgical techniques may permit earlier referral to a rehabilitation program, and the decision regarding timing should be left to the surgeon. The goals of the therapy program should include instruction in a long-term home-based exercise program.
    5. Artificial Disc Insertion: Revised in LB and C-Spine
      [Basis: Literature review (2009 publications). The FDA in 2004 has approved use of artificial discs and has issued criteria that should be met by potential recipients: It should be noted that we now permit cervical arthroplasty for similar indications, but have denied it for lumbar conditions. We will change the recommendation to indicate that artificial disc insertion should be permitted for lumbar degenerative disc disease at one or two levels with radiculopathy that is unresponsive to conservative management]
      1. Artificial Disc insertion: LB revisions
        • Artificial disc replacement is recommended as treatment for lumbar degenerative disc disease at one or two levels with radiculopathy that is unresponsive to conservative management.
        • The following criteria must be met:
          1. Skeletally mature patient without renal failure, severe diabetes, osteoporosis, severe spondylosis, severe facet pathology, lumbar instability, localized fracture, or localized or systemic infections.
            AND
          2. Single-level disc degeneration of L3 to S1 confirmed by imaging studies such as CT or MRI, with one of the following diagnoses:
            • Herniated disc; or
            • Osteophyte formation; or
            • Loss of disc height

            AND
          3. The patient must present with symptoms, which must correspond with the planned level of disc replacement:
            • Intractable radiculopathy (nerve root compression) and/or myelopathy (functional disturbance or pathological change in the spinal cord) causing radicular pain in the lower extremity; or
            • Functional and/or neurological deficit.

            AND
          4. Six weeks of non-operative alternative treatments have failed. These treatments may include physical therapy, medications, braces, chiropractic care, bed rest, spinal injections or exercise programs. Documentation of treatments and failure to improve is required.

            The disc must be approved by the U.S. Food and Drug Administration (FDA). All other artificial disc systems are considered experimental and investigational.

            All other indications, including multilevel degenerative disc disease, are considered experimental and investigational.

            Artificial disc replacement is NOT recommended under the following conditions, since safety and effectiveness of the replacement discs has not been established for patients with:
            • Previous surgical intervention at the involved level;
            • Prior or proposed fusion at an adjacent cervical level;
            • More than one lumbar level requiring artificial disc replacement;
            • Clinically compromised vertebral bodies at the affected level due to current or past trauma (including but not limited to the radiographic appearance of fracture callus, malunion or nonunion).
      2. Artificial Cervical Disc Replacement: C-Spine revisions
        • 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. If cervical disc replacement is to be used, the most current FDA guidelines must be followed.
        • The following criteria must be met:
          1. Skeletally mature patient without renal failure, severe diabetes, osteoporosis, severe spondylosis, severe facet pathology, cervical instability, localized fracture, or localized or systemic infections.

            AND
          2. Single-level disc degeneration of C3 to C7 confirmed by imaging studies such as CT or MRI, with one of the following diagnoses:
            • Herniated disc; or
            • Osteophyte formation; or
            • Loss of disc height

            AND
          3. The patient must present with symptoms, which must correspond with the planned level of disc replacement:
            • Intractable radiculopathy (nerve root compression) and/or myelopathy (functional disturbance or pathological change in the spinal cord) causing radicular pain in the lower extremity; or
            • Functional and/or neurological deficit.

            AND
          4. Six weeks of non operative alternative treatments have failed. These treatments may include physical therapy, medications, braces, chiropractic care, bed rest, spinal injections or exercise programs. Documentation of treatments and failure to improve is required.

            The disc must be approved by the U.S. Food and Drug Administration (FDA). All other artificial disc systems are considered experimental and investigational.

            All other indications, including multilevel degenerative disc disease, are considered experimental and investigational.

            Artificial disc replacement is NOT recommended under the following conditions, since safety and effectiveness of the replacement discs has not been established for patients with:
            • Previous surgical intervention at the involved level;
            • Prior or proposed fusion at an adjacent cervical level;
            • More than one cervical level requiring artificial disc replacement;
            • Clinically compromised vertebral bodies at the affected level due to current or past trauma (including but not limited to the radiographic appearance of fracture callus, malunion or nonunion).
              • Active systemic infection or infection at the operating site;
              • Allergy to titanium, polyurethane, or ethylene oxide residues;
              • Osteoporosis defined as a DEXA bone mineral density T-score equal to or worse than -2.5;
              • Moderate to advanced spondylosis characterized by bridging osteophytes, marked reduction or absence of motion, or collapse of the intervertebral disc space of greater than 50% of its normal height;
              • Marked cervical instability on radiographs (e.g., radiographic signs of subluxation greater than 3.5 mm or angulation of the disc space more than 11 degrees greater than adjacent segments);
              • Significant cervical anatomical deformity or compromised vertebral bodies at the index level (e.g., ankylosing spondylitis, rheumatoid arthritis, or compromise due to current or past trauma);
              • Significant kyphotic deformity or significant reversal of lordosis; or
              • Symptoms necessitating surgical treatment at more than one cervical level.
  7. Vertebroplasty and Kyphoplasty-LB revisions
    [Basis: Literature review.]
    • Vertebroplasty and kyphoplasty may be considered for treatment of select patients with vertebral body compression fractures with associated chronic or severe pain. Patients who have had fractures despite bisphosphonate therapy are particularly appropriate candidates. Recent placebo-controlled studies have questioned the efficacy of vertebroplasty, and the evidence warranting this recommendation will be monitored closely.
  8. Spinal Cord Stimulator-LB revisions
    [Basis: Literature review (2007-2009 publications)]
    • Spinal cord stimulators are recommended for treatment of selected patients with chronic LBP, specifically patients with failed back syndrome, i.e. who have persistent severe and disabling LBP despite having been provided with conventional non-surgical treatments and having undergone surgical treatment that failed to relieve symptoms and improve function. If available, an intensive Functional Rehabilitation Program should be tried before the use of a spinal cord stimulator. No patient can undergo insertion of a spinal cord stimulator before a thorough psychological evaluation indicates that there are no significant psychosocial factors that would predict poor response.