WCB - Workers' Compensation Board - Alberta

Injury reporting and invoicing

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Low back pain (acute) - L2.1

* Based on the Clinical Practice Guideline produced by the Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, December, 1994

Definition of condition: Activity intolerance due to lower back or back-related leg symptoms of less than 3 months duration.

Issue statement: "Low back problems rank high among the reasons for physician office visits and are costly in terms of medical treatment, lost productivity, and non-monetary costs such as diminished ability to perform or enjoy usual activities." Traditional treatment focused care exclusively on the pain while new guidelines focus care towards helping individuals improve activity tolerance through mobilization and conditioning exercise.

WCB-Alberta position

Work relationship criteria

Back pain has a multifactorial etiology with risk factors that have a high prevalence in the general asymptomatic population. This makes it hard to predict who will and who will not get back pain from doing a given job.

In 90% of persons with acute back pain, strains account for 60-70% of occurrences.

A clear relationship between an incident and/or occupational activities and the onset of low back pain should be able to be established in the majority of cases.

As stated in the AHCPR guideline, the approach to a new episode in a patient with recurrent low back pain is similar to that for a new acute episode. Each new episode should be treated as a new acute injury as they can occur regardless of a pre-existing condition or previous injury.

Clinical criteria

A complete history and physical examination is sufficient to assess the patient with acute or recurrent limitation due to low back symptoms of less than 4 weeks duration. This initial assessment should identify radiculopathy or nerve root irritation and may raise suspicion of possible serious underlying spinal conditions such as fractures, tumor, infection, cauda equina syndrome, pelvic or abdominal pathology.

A thorough history of occupational and non-occupational (domestic, recreational and social) activities is required in the Workers Compensation setting to establish work relationship.

Physical examination as a minimum should include :

General observation of the patient
A regional back exam
Neurologic screening (includes testing for muscle strength, circumferential measurements, reflexes, sensory examination)
Testing for sciatic nerve root tension (includes straight leg raising test, crossover pain, and sitting knee extension)
Inconsistent findings

See Algorithm 1 for procedural guidance for initial evaluation of acute low back problem.

Diagnostic criteria

In the absence of signs of more serious or specific conditions, there is no need for special studies since 90% of patients will recover spontaneously within 4 weeks. Plain x-rays are not recommended for routine evaluation of patients with acute low back pain within the first month of symptoms.

Recommended medical management

Initial care should focus on education and assurance, activity alterations and patient comfort (symptom control). Functional recovery with minimum disruption of daily activities is the goal rather than simply alleviation of symptoms. The patient's perception of activity limitations is useful for education and management purposes.

Education

If no serious condition is identified on the initial assessment, patients should be assured that there is "no hint of a dangerous problem" and that "a rapid recovery can be expected". Gradual return to normal activities should be emphasized through progressive therapeutic exercises to prevent deconditioning. (See physical methods of treatment / activity alteration.)

Activity alteration

Undue back irritation and debilitation from inactivity can be avoided through physician recommendations for alternate activity with or without physiotherapy intervention. Prolonged bed rest has potential debilitating effects and its efficacy in the treatment of low back pain is unproven. A maximum of two days of bed rest is generally recommended, with two to four days of bed rest reserved only for patients with the most severe limitations (due primarily to leg pain).

Avoidance of undue back irritation:

minimize stress of lifting by keeping lifted object close to body at the level of the navel
avoid twisting, bending and reaching while lifting
avoid prolonged sitting and change position often
a soft support at the small of back, armrests to support body weight and slight recline in chair back may make sitting more comfortable
vigorous trunk conditioning exercises such as abdominal crunches and push up extensions are not recommended during the first few weeks of symptoms

Avoidance of debilitation:

aerobic (endurance) conditioning exercise such as walking, stationary biking, swimming and even light jogging may be recommended
incremental, gradually increased regimen of aerobic exercise up to 20 to 30 minutes daily) can usually start within 2 weeks of symptoms
early return to work (with or without modified duties) should be encouraged

Patient comfort - symptom control

Drugs and physical methods

Nonprescription analgesics will provide sufficient pain relief for most patients with acute low back symptoms. If treatment response is inadequate, as evidenced by continued symptoms and activity limitations, prescribed pharmaceutical or physical methods may be added.

From AHCPR guidelines:

Table 2. Symptom control methods
	Recommended
Nonprescription analgesics
Acetaminophen (safest) (no inflammatory properties) NSAIDs (Aspirin ¹, Ibuprofen ¹)
Prescribed pharmaceutical methods	Prescribed physical methods
Nonspecific low back symptoms and/or sciatica	Nonspecific low back symptoms	sciatica
Other NSAIDs ¹	Manipulation(in place of medication or a shorter trial if combined with NSAIDs)
	Options
Muscle relaxants ^2,3,4	Physical agents and modalities ²(heat or cold modalities for home programs only)	Manipulation (in place of medication or a shorter trial if combined with NSAIDs)
Opioids ^2,3,4	Shoe insoles ² (if lower limb length difference 2cm )	Physical agents andmodalities ²(heat or cold modalities for home programs only) Few days' rest ⁴Shoe insoles ²

Not recommended:

manipulation after 4 weeks if no symptomatic and functional improvement
traction
physical modalities such as massage, diathermy, ultrasound, cutaneous laser treatment, biofeedback, and transcutaneous electrical nerve stimulation (TENS)
Invasive techniques such as acupuncture and injection procedures (trigger point injections, injection of facet joints, injection of steroids, lidocaine, or opioids in epidural space) as they have no proven benefit in the treatment of low back symptoms.
Other miscellaneous therapies such as low back corsets and back belts

Suggested physiotherapy/chiropractic intervention

Physical intervention by physiotherapists and chiropractors should be minimal and generally be restricted to the acute phase (first month) of injury. Emphasis should be on individualized education (stressing the importance of maintenance of daily aerobic activity, postural correction and proper body mechanics), one-on-one demonstration of trunkal exercise techniques when tolerated (approximately 2 weeks post date of accident), reinforcement of these techniques and manual therapy (if applicable). Ongoing treatment after this acute phase is not supported by medical research.

Reassessment

Patients should be reassessed if there is no improvement in activity tolerance due to low back pain and/or back-related leg symptoms.

Disability after eight weeks may be organic or functional and further evaluation should begin with a medical reassessment including a history and re-examination. On-going symptoms may be more related to a pre-existing condition or non-medical factors than to the work-related injury and therefore medical reassessment is critical. At this point it is important to define whether prolonged symptomatology is related to :

organic, physical effect of the work injury or non-work related activity
pre-existing pathology
functional, psycho-social issues
a combination of the above

Fitness to work criteria

Complete work cessation should be avoided, if possible, through the use of modified work.

Time loss from work is variable - many may not lose any time from work or may return to full activities any time during the first 6 to 8 weeks.

Modified work and activity restrictions may be recommended for a short defined period of time only, depending on work requirements (no benefit to the recovery process has been documented beyond 3 months). Any restrictions are intended to allow for spontaneous recovery or time to build activity tolerance through exercise and should be re-evaluated every 1 - 3 weeks.

Reasonable starting points for activity depend on the patient's age, general health, and safe limits of sitting, standing, walking or lifting. It is important to note that even moderately heavy unassisted lifting may exacerbate back symptoms.