Rule 17, exhibit 9 Chronic Pain Disorder Medical Treatment Guidelines Revised: December 27, 2011 Effective: February 14, 2012



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PATIENT EDUCATION Patients should be educated on their specific injury, assessment findings, and plan of treatment and encouraged to take an active role in establishing functional outcome goals. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of prolonging the beneficial effects of rehabilitation, as well as facilitating self-management of symptoms and prevention of secondary disability.

In some cases, educational intervention combined with exercises may achieve results comparable to surgical intervention for patients who have undergone previous surgery. There is some evidence that, for patients who had undergone previous surgery for disc herniation and continued to experience low back pain for at least one year, educational lectures and materials provided to the patients in conjunction with exercise programs yield similar results as indicated by Oswestry Disability scores to patients who had undergone posterolateral low back fusion. It should be noted that the rehabilitation program included individual and group discussions targeted to assuring patients that participation in ordinary activities would not cause harm. Treatment period was 25 hours per week for three weeks (Brox JI 2010).

Patient education is an interactive process that provides an environment where the patient not only acquires knowledge but also gains an understanding of the application of that knowledge. Therefore, patients should be able to describe and/or will need to be educated on:

a. The treatment plan;

b. Indications for and potential side effects of medications;

c. Their home exercise program;

d. Expected results of treatment;

e. Tests to be performed, the reasons for them and their results;

f. Activity restrictions and return-to-work status;

g. Home management for exacerbations of pain;

h. Procedures for seeking care for exacerbations after office hours;

i. Home self-maintenance program;

j. Patient responsibility to communicate with all medical providers and the employer;

k. Patient responsibility to keep appointments;

l. The importance of taking medications exactly as prescribed; and

m. Basic physiology related to patient’s diagnosis.

Educational efforts should also target family and other support persons, the case manager, the insurer, and the employer as indicated to optimize the understanding of the patient and the outcome. Professional translators should be provided for non-English speaking patients to assure optimum communication. All education, teaching, and instruction given to the patient should be documented in the medical record.

Effects of education weaken over time; continuing patient education sessions will be required to maximize the patient’s function. The effectiveness of educational efforts can be enhanced through attention to the learning style and receptivity of the patient. Written educational materials may reinforce and prolong the impact of verbal educational efforts. Overall, patient education should emphasize health and wellness, return-to-work and return to a productive life.



  • Time to Produce Effect: Varies with individual patient.

  • Frequency: At each visit.

PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION

Psychosocial treatment is a well-established therapeutic and diagnostic intervention with selected use in acute pain problems, and more widespread use in sub-acute and chronic pain populations. Psychosocial treatment is recommended as an important component in the total management of a patient with chronic pain and should be implemented as soon as the problem is identified. 

If a diagnosis consistent with the standards of the American Psychiatric Association Diagnostic Statistical Manual of Mental Disorders has been determined, the patient should be evaluated for the potential need for psychiatric medications. Use of any medication to treat a diagnosed condition may be ordered by the authorized treating physician or by the consulting psychiatrist. Visits for management of psychiatric medications are medical in nature and are not a component of psychosocial treatment. Therefore, separate visits for medication management may be necessary, depending upon the patient and medications selected.

Psychosocial interventions include psychotherapeutic treatments for mental health conditions, as well as behavioral medicine treatments for patients without psychiatric conditions, but who may need to make major life changes in order to cope with pain or adjust to disability. Examples of these treatments include cognitive behavioral therapy, relaxation training, mindfulness training, and sleep hygiene training.

The screening or diagnostic workup should have clarified and distinguished between pre-existing, aggravated, and/or purely causative psychological conditions. Therapeutic and diagnostic modalities include, but are not limited to, individual counseling, and group therapy. Treatment can occur within an individualized model, a multi-disciplinary model, or within a structured pain management program. 

A psychologist with a PhD, PsyD, EdD credentials, or a Psychiatric MD/DO may perform psychosocial treatments. Other licensed mental health providers or licensed health care providers with training in cognitive behavior therapy (CBT), or certified as CBT therapists working in consultation with a PhD, PsyD, EdD, or Psychiatric MD/DO; and with experience in treating chronic pain disorders in injured workers may also perform treatment.

Cognitive behavioral therapy (CBT) refers to a group of psychological therapies that are sometimes referred to by more specific names, such as Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy. Variations of CBT methods can be used to treat a variety of conditions, including chronic pain, depression, anxiety, phobias and PTSD. For patients with multiple diagnoses, more than one type of CBT might be needed. The CBT used in research studies is often “manualized CBT”, meaning that the treatment follows a specific protocol in a manual (Thorn 2004). In clinical settings, CBT may involve the use of standardized materials, but is also commonly adapted by a psychologist or psychiatrist to the patient’s unique circumstances. If the CBT is being performed by a non-mental health professional, a manual approach would be strongly recommended. CBT must be distinguished from neuropsychological therapies used to teach compensatory strategies to brain injured patients, which are also called “cognitive therapy.”

It should be remembered that most clinical trials on CBT exclude subjects who have significant psychiatric diagnoses. Consequently, the selection of patients for CBT should include the following considerations. CBT is instructive and structured, using an educational model with homework to teach inductive rational thinking. Because of this educational model, a certain level of literacy is assumed for most CBT protocols. Patients who lack the cognitive and educational abilities required by a CBT protocol are unlikely to be successful. Further, given the highly structured nature of CBT, it is more effective when a patient’s circumstances are relatively stable. For example, if a patient is about to be evicted, is actively suicidal, or coming to sessions intoxicated, these matters will generally preempt CBT treatment for pain, and require other types of psychotherapeutic response. Conversely, literate patients whose circumstances are relatively stable, but catastrophize or cope poorly with pain or disability are often good candidates for CBT for pain. Similarly, literate patients whose circumstances are relatively stable, but who exhibit unfounded medical phobias are often good candidates for CBT for anxiety.

There is good evidence that psychological interventions, especially CBT, are superior to no psychological intervention for chronic low back pain, and that self-regulatory interventions such as biofeedback and relaxation training may be equally effective (Hoffman BM 2007). There is good evidence that 6 sessions of 1.5 hour group therapy focused on CBT skills improved function and alleviated pain in uncomplicated subacute and chronic low back pain patients (Lamb SE 2010). There is some evidence that CBT provided in seven two-hour small group sessions can reduce the severity of insomnia in chronic pain patients (Currie SR 2000). A Cochrane meta-analysis grouped very heterogenous behavioral interventions and concluded that there is good evidence that CBT may reduce pain and disability but the effect size was uncertain (Eccleston C [Cochrane] 2009). In total, the evidence clearly supports cognitive behavioral therapy and it should be offered to all chronic pain patents without other serious issues, as discussed above.

CBT is often combined with active therapy in an interdisciplinary program formal or informal. It must be coordinated with a psychologist or psychiatrist. Cognitive behavioral therapy can be done in a small group or individually and the usual number of treatments varies between 8 and16 sessions.

Before CBT is done, the patient must have a full psychological evaluation. The CBT program must be done under the supervision of a PhD, PsyD, EdD, or Psychiatric MD/DO.

Psychological DSM Axis I disorders are common in chronic pain. One study demonstrated that the majority of patients who had failed other therapy and participated in a functional restoration program also suffered from major depression. However, in a program which included CBT and other psychological counseling the success rate for return to work was similar for those with and without a DSM IV diagnosis. This study further strengthens the argument for having some psychological intervention included in all chronic pain treatment plans (Gatchel RJ 1994).

For all psychological/psychiatric interventions, an assessment and treatment plan with measurable behavioral goals, time frames, and specific interventions planned, must be provided to the treating physician prior to initiating treatment. A status report must be provided to the authorized treating physician every two weeks during initial more frequent treatment and monthly thereafter. The report should provide documentation of progress towards functional recovery and discussion of the psychosocial issues affecting the patient’s ability to participate in treatment. The report should also address pertinent issues such as pre-existing, aggravated, and/or causative, as well as project realistic functional prognosis. 

i. Cognitive Behavioral Therapy (CBT) or similar treatment:


  • Time to Produce Effect: 6 to 8 1-2 hour session, group or individual, 1 hour individual or two-hour group.

  • Maximum Duration: 16 sessions.

NOTE: Before CBT is done, the patient must have a full psychological evaluation. The CBT program must be done under the supervision of a PhD, PsyD, EdD, or Psychiatric MD/DO.

ii. Other psychological/psychiatric interventions:



  • Time to Produce Effect: 6 to 8 weeks.

  • Frequency: 1 to 2 times weekly for the first 2 weeks (excluding hospitalization, if required), decreasing to 1 time per week for the second month. Thereafter, 2 to 4 times monthly with the exception of exacerbations which may require increased frequency of visits. Not to include visits for medication management

 Optimum Duration: 2 to 6 months.

 Maximum: 6 months. Not to include visits for medication management. For select patients, longer supervised psychological/psychiatric treatment may be required, especially if there are ongoing medical procedures or complications. If counseling beyond 6 months is indicated, the management of psychosocial risks or functional progress must be documented. Treatment plan/progress must show severity.

RESTRICTION OF ACTIVITIES Continuation of normal daily activities is the recommendation for chronic pain patients since immobility will negatively affect rehabilitation. Prolonged immobility results in a wide range of deleterious effects, such as a reduction in aerobic capacity and conditioning, loss of muscle strength and flexibility, increased segmental stiffness, promotion of bone demineralization, impaired disc nutrition, and the facilitation of the illness role.

Immobility may range from bed rest to the continued use of orthoses, such as cervical collars and lumbar support braces. While these interventions may have been ordered in the acute phase, the provider should be aware of their impact on the patient’s ability to adequately comply with and successfully complete rehabilitation. There is strong evidence against the use of bed rest in acute low pain back cases without neurologic symptoms (Malmivaara A 1995; Hagen EM 2000).

Patients should be educated to the detrimental effects of immobility versus the efficacious use of limited rest periods. Adequate rest allows the patient to comply with active treatment and benefit from the rehabilitation program. In addition, complete work cessation should be avoided, if possible, since it often further aggravates the pain presentation and promotes disability. Modified return-to-work is almost always more efficacious and rarely contraindicated in the vast majority of injured workers with chronic pain.

RETURN-TO-WORK, and/or work-related activities whenever possible is one of the major components in chronic pain management and rehabilitation. There is some evidence that an integrated care program including workplace interventions and graded activity teaching that pain need not limit activity, is effective in returning patients with chronic low back pain to work, even with minimal reduction of pain (Lambeek LC 2010). Return-to-work is a subject that should be addressed by each workers’ compensation provider at the first meeting with the injured employee, and be updated at each additional visit. A return-to-work format should be part of a company’s health plan, knowing that return-to-work can decrease anxiety, reduce the possibility of depression, and reconnect the worker with society.

Because a prolonged period of time off work will decrease the likelihood of return to work, the first weeks of treatment are crucial in preventing and/or reversing chronicity and disability mindset. In complex cases, experienced nurse case managers may be required to assist in return-to-work. Other services, including psychological evaluation and/or treatment, jobsite analysis, and vocational assistance may be employed.

The following should be considered when attempting to return an injured worker with chronic pain to work.

Job History Interview: The authorized treating physician should perform a job history interview at the time of the initial evaluation and before any plan of treatment is established. Documentation should include the workers’ job demands, stressors, duties of current job, and duties of job at the time of the initial injury. In addition, cognitive and social issues should be identified and treatment of these issues should be incorporated into the plan of care.

Coordination of Care: Management of the case is a significant part of return-to-work and may be the responsibility of the authorized treating physician, occupational health nurse, risk manager, or others. Case management is a method of communication between the primary provider, referral providers, insurer, employer, and employee. Because case management may be coordinated by a variety of professionals, the case manager should be identified in the medical record.

Communication: is essential between the patient, authorized treating physician, employer, and insurer. Employers should be contacted to verify employment status, job duties and demands, and policies regarding injured workers. In addition, availability of temporary and permanent restrictions, for what duration, as well as other placement options should be discussed and documented. All communications in the absence of the patient are required to be documented and made available to the patient.

Establishment of Return-To-Work Status: Return-to-work for persons with chronic pain should be thought of as therapeutic, assuming that work is not likely to aggravate the basic problem or increase the discomfort. In most cases of chronic pain, the worker may not be currently working or even employed. The goal of return-to-work would be to implement a plan of care to return the worker to any level of employment with the current employer or to return them to any type of new employment.

Establishment of Activity Level Restrictions: A formal job description for the injured/ill employee who is employed is necessary to identify physical demands at work and assist in the creation of modified duty. A jobsite evaluation may be utilized to identify tasks such as pushing, pulling, lifting, reaching above shoulder level, grasping, pinching, sitting, standing, posture, ambulatory distance and terrain, and if applicable, environment for temperature, air flow, noise and the number of hours that may be worked per day. Due to the lack of predictability regarding exacerbation of symptoms affecting function, an extended, occupationally focused functional capacity evaluation may be necessary to determine the patient’s tolerance for job type tasks over a continuing period of time. Functional Capacity Evaluations should usually take place for 8 hours. Between one and three days after the evaluation, there should be a follow-up evaluation by the treating therapist and/or the authorized treating physician to assess the patient’s status. When prescribing the FCE, the physician must assess the probability of return to work against the potential for exacerbation of the work related condition. Work restrictions assigned by the authorized treating physician may be temporary or permanent. The case manager should continue to seek out modified work until restrictions become less cumbersome or as the worker’s condition improves or deteriorates.

Rehabilitation and Return-To-Work: As part of rehabilitation, every attempt should be made to simulate work activities so that the authorized treating physician may promote adequate job performance. The use of ergonomic or adaptive equipment, therapeutic breaks, and interventional modalities at work may be necessary to maintain employment.

Vocational Assistance: Formal vocational rehabilitation is a generally accepted intervention and can assist disabled persons to return to viable employment. Assisting patients to identify vocational goals will facilitate medical recovery and aid in the maintenance of MMI by 1) increasing motivation towards treatment and 2) alleviating the patient’s emotional distress. Chronic pain patients will benefit most if vocational assistance is provided during the interdisciplinary rehabilitation phase of treatment. To assess the patient’s vocational capacity, a vocational assessment utilizing the information from occupational and physical therapy assessments may be utilized to identify rehabilitation program goals, as well as optimize both patient motivation and utilization of rehabilitation resources. This may be extremely helpful in decreasing the patient’s fear regarding an inability to earn a living which can add to their anxiety and depression.

Recommendations to employers and employees of small businesses: employees of small businesses who are diagnosed with chronic pain may not be able to perform any jobs for which openings exist. Temporary employees may fill those slots while the employee functionally improves. Some small businesses hire other workers and if the injured employee returns to the job, the supervisor/owner may have an extra employee. To avoid this, it is suggested that case managers be accessed through their payer or third party administrator. Case managers may assist with resolution of these problems, as well as assist in finding modified job tasks, or find jobs with reduced hours, etc., depending upon company philosophy and employee needs.

Recommendations to Employers and Employees of mid-sized and Large Businesses – Employers are encouraged by the Division to identify modified work within the company that may be available to injured workers with chronic pain who are returning to work with temporary or permanent restrictions. To assist with temporary or permanent placement of the injured worker, it is suggested that a program be implemented that allows the case manager to access descriptions of all jobs within the organization.

THERAPY—ACTIVE The following active therapies are widely used and accepted methods of care for a variety of work-related injuries. Active therapy is based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range-of-motion, and can alleviate discomfort. All active therapy plans should be made directly with patients in the interest of achieving long-term individualized goals.

Active therapy requires an internal effort by the individual to complete a specific exercise or task. This form of therapy requires supervision from a therapist or medical provider such as verbal, visual, and/or tactile instruction(s). Active therapy is intended to promote independence and self-reliance in managing the physical pain as well as to improve the functional status in regard to the specific diagnosis and general conditioning and well-being. At times, a provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is predominately executed by the patient. Therapy in this section should not be merely a repeat of previous therapy but should focus specifically on the individual goals and abilities of the patient with chronic pain.

The goal of active therapy is to teach the patient exercises that they can perform regularly on their own. Patients should be instructed to continue active therapies at home as an extension of the treatment process in order to maintain improvement levels. Follow-up visits to reinforce and monitor progress and proper technique are recommended. Home exercise can include exercise with or without mechanical assistance or resistance and functional activities with assistive devices.

The following active therapies are listed in alphabetical order:

Activities of Daily Living (ADL): instruction, active-assisted training, and/or adaptation of activities or equipment to improve a person's capacity in normal daily activities such as self-care, work re-integration training, homemaking, and driving.



  • Time to Produce Effect: 4 to 5 treatments.

  • Frequency: 3 to 5 times per week.

  • Optimum Duration: 4 to 6 weeks.

  • Maximum Duration: 6 weeks.

Aquatic Therapy: is a well-accepted treatment which consists of the therapeutic use of aquatic immersion for therapeutic exercise to promote strengthening, core stabilization, endurance, range-of-motion, flexibility, body mechanics, and pain management. Aquatic therapy is the implementation of active therapeutic procedures (individual or group) in a swimming or therapeutic pool heated to 88 to 92 degrees. The water provides a buoyancy force that lessens the amount of force of gravity applied to the body, and the pool should be large enough to allow full extremity range of motion and full erect posture. The decreased gravity effect allows the patient to have a mechanical advantage and more likely have a successful trial of therapeutic exercise. Indications are for individuals who may not tolerate active land-based or full weight-bearing therapeutic procedures or who require augmentation of other therapy. The therapy may be indicated for individuals who:

  • Cannot tolerate active land-based or full-weight bearing therapeutic procedures;

  • Require increased support in the presence of proprioceptive deficit;

  • Are at risk of compression fracture due to decreased bone density;

  • Have symptoms that are exacerbated in a dry environment;

  • Have a higher probability of meeting active therapeutic goals than in a dry environment.

The pool should be large enough to allow full extremity range-of-motion and fully erect posture. Aquatic vests, belts and other devices can be used to provide stability, balance, buoyancy, and resistance.

  • Time to Produce Effect: 4 to 5 treatments.

  • Frequency: 3 to 5 times per week.

  • Optimum Duration: 4 to 6 weeks.

  • Maximum Duration: 6 weeks.

A self-directed program is recommended after the supervised aquatics program has been established, or, alternatively a transition to a self-directed dry environment exercise program.

Functional Activities: are well-established interventions which involve the use of therapeutic activity to enhance mobility, body mechanics, employability, coordination, and sensory motor integration.



  • Time to Produce Effect: 4 to 5 treatments.

  • Frequency: 3 to 5 times per week.

  • Optimum Duration: 4 to 6 weeks.

  • Maximum Duration: 6 weeks.

Functional Electrical Stimulation: is an accepted treatment in which the application of electrical current to elicit involuntary or assisted contractions of atrophied and/or impaired muscles. Indications include muscle atrophy, weakness, and sluggish muscle contraction secondary to pain, injury, neuromuscular dysfunction, peripheral nerve lesion, or radicular symptoms. This modality may be prescribed for use at home when patients have demonstrated knowledge of how to self-administer and are in an independent exercise program.

  • Time to Produce Effect: 2 to 6 treatments.

  • Frequency: 3 times per week.

  • Optimum Duration: 8 weeks.

  • Maximum Duration: 8 weeks. If beneficial, provide with home unit.

Spinal Stabilization: is a generally well-accepted treatment. The goal of this therapeutic program is to strengthen the spine in its neural and anatomic position. The stabilization is dynamic which allows whole body movements while maintaining a stabilized spine. It is the ability to move and function normally through postures and activities without creating undue vertebral stress.

  • Time to Produce Effect: 4 to 8 treatments.

  • Frequency: 3 to 5 times per week.

  • Optimum Duration: 4 to 8 weeks.

  • Maximum Duration: 8 weeks.

Neuromuscular Re-education: is a generally accepted treatment. It is the skilled application of exercise with manual, mechanical, or electrical facilitation to enhance strength; movement patterns, neuromuscular response, proprioception, kinesthetic sense, coordination; education of movement, balance and posture. Indications include the need to promote neuromuscular responses through carefully timed proprioceptive stimuli, to elicit and improve motor activity in patterns similar to normal neurologically developed sequences, and improve neuromotor response with independent control.

  • Time to Produce Effect: 2 to 6 treatments.

  • Frequency: 3 times per week.

  • Optimum Duration: 4 to 8 weeks.

  • Maximum Duration: 8 weeks.

Therapeutic Exercise: with or without mechanical assistance or resistance, may include isoinertial, isotonic, isometric and isokinetic types of exercises. Indications include the need for cardiovascular fitness, reduced edema, improved muscle strength; improved connective tissue strength and integrity, increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle recruitment, improved proprioception, and coordination, and increased range of motion are used to promote normal movement patterns. May also include alternative/complementary exercise movement therapy (with oversight of a physician or appropriate healthcare professional).

There is some evidence that Iyengar yoga, which avoids back bending, results in improved function and decreased chronic mechanical low back pain for up to 6 months. One quarter of the participants dropped out. Instruction occurred 2 times per week for 24 weeks and was coupled with home exercise (Williams K 2009). Yoga may be an option for motivated patients. 48 sessions is the maximum expected duration and time to effect is 8.

There is some evidence that intensive exercise coupled with cognitive behavioral therapy is as effect for chronic un-operated low back pain as posterolateral fusion (Brox JI 2010).

There is good evidence that exercise alone or part of a multi-disciplinary program results in decreased disability for workers with non-acute low back pain (Oesch P 2010).

Therapeutic exercise programs should be tissue specific to the injury and address general functional deficits as identified in the diagnosis and clinical assessment. Patients should be instructed in and receive a home exercise program that is progressed as their functional status improves. Upon discharge, the patient would be independent in the performance of the home exercise program and would have been educated in the importance of continuing such a program. Educational goals would be to maintain or further improve function and to minimize the risk for aggravation of symptoms in the future.


  • Time to Produce Effect: 2 to 6 treatments.

  • Frequency: 3 to 5 times per week.

  • Optimum Duration: 4 to 8 weeks and concurrent with an active daily home exercise program.

  • Maximum Duration: 8 to 12 weeks of therapist oversight. Home exercise should continue indefinitely.

Work Conditioning: These programs are work-related, outcome-focused, individualized treatment programs. Objectives of the program include, but are not limited to, improvement of cardiopulmonary and neuromusculoskeletal functions (strength, endurance, movement, flexibility, stability, and motor control functions), patient education, and symptom relief. The goal is for patients to gain full- or optimal-function and return to work. The service may include the time-limited use of modalities, both active and passive, in conjunction with therapeutic exercise, functional activities, general conditioning body mechanics, and lifting techniques re-training.

These programs are usually initiated once re-conditioning has been completed but may be offered at any time throughout the recovery phase. It should be initiated when imminent return of a patient to modified- or full-duty is not an option, but the prognosis for returning the patient to work at completion of the program is at least fair to good.



  • Length of Visit: 1 to 2 hours per day.

  • Frequency: 2 to 5 visits per week.

  • Optimum Duration: 2 to 4 weeks.

  • Maximum Duration: 6 weeks. Participation in a program beyond 6 weeks must be documented with respect to need and the ability to facilitate positive symptomatic and functional gains.

Work Simulation: is a program where an individual completes specific work-related tasks for a particular job and return to work. Use of this program is appropriate when modified duty can only be partially accommodated in the work place, when modified duty in the work place is unavailable, or when the patient requires more structured supervision. The need for work place simulation should be based upon the results of a functional capacity evaluation and/or jobsite analysis.

  • Length of Visit: 2 to 6 hours per day.

  • Frequency: 2 to 5 visits per week.

  • Optimum Duration: 2 to 4 weeks.

  • Maximum Duration: 6 weeks. Participation in a program beyond 6 weeks must be documented with respect to need and the ability to facilitate positive symptomatic and functional gains.

THERAPY—PASSIVE Most of the following passive therapies and modalities are generally accepted methods of care for a variety of work-related injuries. Passive therapy includes those treatment modalities that do not require energy expenditure on the part of the patient. They are principally effective during the early phases of treatment and are directed at controlling symptoms such as pain, inflammation and swelling and to improve the rate of healing soft tissue injuries. They should be used adjunctively with active therapies such as postural stabilization and exercise programs to help control swelling, pain, and inflammation during the active rehabilitation process. Please refer to Section B. 4. General Guideline Principles, Active Interventions. Passive therapies may be used intermittently as a therapist deems appropriate or regularly if there are specific goals with objectively measured functional improvements during treatment; or if there are episodes of acute pain superimposed upon a chronic pain problem.

On occasion, specific diagnoses and post-surgical conditions may warrant durations of treatment beyond those listed as "maximum.” Factors such as exacerbation of symptoms, re-injury, interrupted continuity of care and co-morbidities may extend durations of care. Having specific goals with objectively measured functional improvement during treatment can support extended durations of care. It is recommended that if after 6 to 8 visits no treatment effect is observed, alternative treatment interventions, further diagnostic studies or further consultations should be pursued.

The following passive therapies are listed in alphabetical order:

Electrical Stimulation (Unattended):

TENS - Electrical stimulation, once applied, requires minimal on-site supervision by the physical or nonphysical provider. Indications include pain, inflammation, muscle spasm, atrophy, decreased circulation, and the need for osteogenic stimulation. A TENS home unit should be purchased if treatment is effective and frequent use is recommended.


  • Time to Produce Effect: 2 to 4 treatments.

  • Frequency: Varies, depending upon indication, between 2 to 3 times per day to 1 time week. A home unit should be purchased if treatment is effective and frequent use is recommended.

  • Optimum and Maximum Duration: 4 treatments for clinic use.

Iontophoresis: is an accepted treatment which consists of the transfer of medication, including, but not limited to, steroidal anti-inflammatories and anesthetics, through the use of electrical stimulation. Indications include pain (lidocaine), inflammation (hydrocortisone, salicylate), edema (mecholyl, hyaluronidase, and salicylate), ischemia (magnesium, mecholyl, and iodine), muscle spasm (magnesium, calcium), calcific deposits (acetate), scars and keloids (chlorine, iodine, acetate).

  • Time to Produce Effect: 1 to 4 treatments.

  • Frequency: 3 times per week with at least 48 hours between treatments.

  • Optimum Duration: 4 to 6 weeks.

  • Maximum Duration: 6 weeks.

 

Manipulation: Manipulative Treatment (not therapy) is defined as the therapeutic application of manually guided forces by an operator to improve physiologic function and/or support homeostasis that has been altered by the injury or occupational disease, and has associated clinical significance.

There is good evidence that a combination of exercise and spinal manipulation is more effective than manipulation alone in relieving chronic neck pain, and that these advantages remain for more than one year after the end of treatment (Bronfort 2001, Evans 2002).

Conversely, there is some evidence that a combination of spinal manipulation and exercise is more effective than exercise alone in reducing pain and improving function of low back pain for one year (Aure 2003).

There is good evidence that spinal manipulation has a small superiority to other common interventions (standard medical care, physiotherapy, and exercise alone) for chronic low back pain, making it comparable to other commonly accepted interventions for this indication (Rubinstein 2011).

The decision to refer a patient for spinal manipulation rather than for other treatments should be made on the basis of patient preference and relative safety, not on an expectation of a greater treatment effect. Manipulation may be indicated in patients who have not had an evaluation for manual medicine, or have not progressed adequately in an exercise program.

Manipulative treatments may be applied by osteopathic physicians (D.O.), chiropractors (D.C.), properly trained physical therapists (P.T.), properly trained occupational therapists (O.T.), or properly trained medical doctors (M.D.). Some popular and useful techniques include, but are not limited to, high velocity, low amplitude (HVLA), muscle energy (ME), strain-counterstrain (SCS), a balanced ligamentous tension (BLT) and myofascial release (MFR). Under these different types of manipulation exist many subsets of different techniques that can be described as a) direct- a forceful engagement of a restrictive/pathologic barrier, b) indirect- a gentle/non-forceful disengagement of a restrictive/pathologic barrier, c) the patient actively assists in the treatment and d) the patient relaxing, allowing the practitioner to move and balance the body tissues. When the proper diagnosis is made and coupled with the appropriate technique, manipulation has no contraindications and can be applied to all tissues of the body, including muscles, tendons, ligaments, joints, fascia and viscera. Pre-treatment assessment should be performed as part of each manipulative treatment visit to ensure that the correct diagnosis and correct treatment is employed.

Contraindications to HVLA manipulation include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthritides, aortic aneurysm, and signs of progressive neurologic deficits.



  • Time to Produce Effect: 4 to 6 treatments.

  • Frequency: 1 to 2 times per week for the first 2 weeks as indicated by the severity of the condition. Treatment may continue at 1 treatment per week for the next 6 weeks.

  • Optimum Duration: 8 weeks.

  • Maximum Duration: 8 weeks. At week 8, patients should be re-evaluated. Care beyond 8 weeks may be indicated for certain chronic pain patients in whom manipulation is helpful in improving function, decreasing pain and improving quality of life. In these cases, treatment may be continued at one treatment every other week until the patient has reached MMI and maintenance treatments have been determined. Extended durations of care beyond what is considered “maximum” may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with comorbidities. Such care should be re-evaluated and documented on a monthly basis.

Manipulation under General Anesthesia (MUA): refers to manual manipulation of the lumbar spine in combination with the use of a general anesthetic or conscious sedation. It is intended to improve the success of manipulation when pain, muscle spasm, guarding, and fibrosis appear to be limiting its application in patients otherwise suitable for their use. There have been no high quality studies to justify its benefits given the risks of general anesthetic and conscious sedation. It is not recommended.

Manipulation Under Joint Anesthesia (MUJA): refers to manipulation of the lumbar spine in combination with a fluoroscopically guided injection of anesthetic with or without corticosteroid agents into the facet joint at the level being manipulated. There are no controlled clinical trials to support its use. It is not recommended.

Massage—Manual or Mechanical: Massage is manipulation of soft tissue with broad ranging relaxation and circulatory benefits. This may include stimulation of acupuncture points and acupuncture channels (acupressure), application of suction cups and techniques that include pressing, lifting, rubbing, pinching of soft tissues by or with the practitioners’ hands. Indications include edema (peripheral or hard and non-pliable edema), muscle spasm, adhesions, the need to improve peripheral circulation and range-of-motion, or to increase muscle relaxation and flexibility prior to exercise.

There is good evidence that massage therapy in combination with exercise reduces pain and improves function short-term for patients with subacute low back pain (Cherkin DC 2001; Furlan AD 2008; Preyde, 2010).



  • Time to Produce Effect: Immediate.

  • Frequency: 1 to 2 times per week.

  • Optimum Duration: 6 weeks.

  • Maximum Duration: 2 months.

Mobilization (Joint): Is a generally well-accepted treatment. Mobilization is passive movement involving oscillatory motions to the vertebral segment(s). The passive mobility is performed in a graded manner (I, II, III, IV, or V), which depicts the speed and depth of joint motion during the maneuver. It may include skilled manual joint tissue stretching. Indications include the need to improve joint play, segmental alignment, improve intracapsular arthrokinematics, or reduce pain associated with tissue impingement. For Level V mobilization contraindications include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthritides, aortic aneurysm, and signs of progressive neurologic deficits.

  • Time to Produce Effect: 6 to 9 treatments.

  • Frequency: 3 times per week.

  • Optimum Duration: 4 to 6 weeks.

  • Maximum Duration: 6 weeks.

Mobilization (Soft Tissue): Is a generally well-accepted treatment. Mobilization of soft tissue is the skilled application of muscle energy, strain/counter strain, myofascial release, manual trigger point release, and manual therapy techniques designed to improve or normalize movement patterns through the reduction of soft tissue pain and restrictions. These can be interactive with the patient participating or can be with the patient relaxing and letting the practitioner move the body tissues. Indications include muscle spasm around a joint, trigger points, adhesions, and neural compression. Mobilization should be accompanied by active therapy.

  • Time to Produce Effect: 4 to 9 treatments.

  • Frequency: Up to 3 times per week.

  • Optimum Duration: 4 to 6 weeks.

  • Maximum Duration: 6 weeks.

Percutaneous Electrical Nerve Stimulation (PENS): Needles are used to deliver low-voltage electrical current under the skin. Theoretically this therapy prevents pain signals traveling through small nerve fibers from reaching the brain, similar to the theory of TENS. There is good evidence that PENS produces improvement of pain and function compared to placebo; however, there is no evidence that the effect is prolonged after the initial 3 week treatment episode (Ghoname, 1999, Hamza 2000). There are no well done studies that show PENS performs better than TENS for chronic pain patients. PENS is more invasive, requires a trained health care provider and has no clear long term effect; therefore it is not generally recommended.

  • Time to Produce Effect: 1 to 4 treatments.

  • Frequency: 2 to 3 times per week.

  • Optimum 9 sessions.

  • Maximum Duration: 12 sessions per year.

Superficial Heat and Cold Therapy (Including Infrared Therapy): is a generally accepted treatment. Superficial heat and cold are thermal agents applied in various manners that lower or raise the body tissue temperature for the reduction of pain, inflammation, and/or effusion resulting from injury or induced by exercise. Includes application of heat just above the surface of the skin at acupuncture points. Indications include acute pain, edema and hemorrhage, need to increase pain threshold, reduce muscle spasm, and promote stretching/flexibility. Cold and heat packs can be used at home as an extension of therapy in the clinic setting.

  • Time to Produce Effect: Immediate.

  • Frequency: 2 to 5 times per week.

  • Optimum Duration: 3 weeks as primary or intermittently as an adjunct to other therapeutic procedures up to 2 months.

  • Maximum Duration: 2 months.

Traction—Manual: are an accepted treatment and an integral part of manual manipulation or joint mobilization. Indications include decreased joint space, muscle spasm around joints, and the need for increased synovial nutrition and response. Manual traction is contraindicated in patients with tumor, infection, fracture, or fracture dislocation.

  • Time to Produce Effect: 1 to 3 sessions.

  • Frequency: 2 to 3 times per week.

  • Optimum/Maximum Duration: 1 month.

Traction—Mechanical: Mechanical traction is indicated for decreased joint space, muscle spasm around joints, and the need for increased synovial nutrition and response. Traction modalities are contraindicated in patients with tumor, infections, fracture, or fracture dislocation. Non-oscillating inversion traction methods are contraindicated in patients with glaucoma or hypertension. There is some evidence that mechanical traction, using specific, instrumented axial distraction technique, is not more effective than active graded therapy without mechanical traction. Therefore, mechanical traction is not recommended for chronic axial spine pain (Schimmel J 2009).

  • Time to Produce Effect: 1 to 3 sessions up to 30 minutes. If response is negative after 3 treatments, discontinue this modality.

  • Frequency: 2 to 3 times per week.

  • Optimum/Maximum Duration: 1 month.

Transcutaneous Electrical Nerve Stimulation (TENS): should include least one instructional session for proper application and use. Indications include muscle spasm, atrophy, and decreased circulation and pain control. Minimal TENS unit parameters should include pulse rate, pulse width and amplitude modulation.

  • Time to Produce Effect: Immediate.

  • Frequency: Variable.

  • Optimum Duration: 3 sessions. If beneficial, provide with home unit.

  • Maximum Duration: 3 sessions. Purchase if effective.

Ultrasound (Including Phonophoresis): is an accepted treatment which uses sonic generators to deliver acoustic energy for therapeutic thermal and/or non-thermal soft tissue effects. Indications include scar tissue, adhesions, collagen fiber and muscle spasm, and the need to extend muscle tissue or accelerate the soft tissue healing. Ultrasound with electrical stimulation is concurrent delivery of electrical energy that involves dispersive electrode placement. Indications include muscle spasm, scar tissue, pain modulation, and muscle facilitation.

Phonophoresis is the transfer of medication to the target tissue to control inflammation and pain through the use of sonic generators. These topical medications include, but are not limited to, steroidal anti-inflammatory and anesthetics.



  • Time to Produce Effect: 6 to 15 treatments.

  • Frequency: 3 times per week.

  • Optimum Duration: 4 to 8 weeks.

  • Maximum Duration: 2 months.

Vertebral Axial Decompression (VAX-D)/DRX, 9000: Motorized traction devices which purport to produce non-surgical disc decompression by creating negative intradiscal pressure in the disc space include devices with the trade names of VAX-D and DRX 9000. There are no good studies to support their use. They are not recommended.
THERAPEUTIC PROCEDURES – OPERATIVE

When considering operative intervention in chronic pain management, the treating physician must carefully consider the inherent risk and benefit of the procedure. All operative intervention should be based on a positive correlation with clinical findings, the clinical course, and diagnostic tests. A comprehensive assessment of these factors should have led to a specific diagnosis with positive identification of the pathologic condition. Operative treatment is indicated when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions.

Surgical procedures are seldom meant to be curative and would be employed in conjunction with other treatment modalities for maximum functional benefit. Functional benefit should be objectively measured and includes the following:

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