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## Complete Summary

#### GUIDELINE TITLE

Pain (chronic).

#### BIBLIOGRAPHIC SOURCE(S)

Work Loss Data Institute. Pain (chronic). Corpus Christi (TX): Work Loss
Data Institute; 2007 Jul 5. 372 p. \[458 references\]

#### GUIDELINE STATUS

**Note**: This guideline has been updated. The National Guideline
Clearinghouse (NGC) is working to update this summary.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory information
has been released.

-   [June 15, 2005, COX-2 Selective (includes Bextra, Celebrex, and
    Vioxx) and Non-Selective Non-Steroidal Anti-Inflammatory Drugs
    (NSAIDs)](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#NSAID):
    Labeling revised to include a boxed warning and a Medication Guide,
    highlighting the potential for increased risk of cardiovascular (CV)
    events and life-threatening gastrointestinal (GI) bleeding.

-   [April 7, 2005, Bextra (valdecoxib), Cox-2 inhibitors, Celebrex
    (celecoxib), Non-steroidal anti-inflammatory drugs (NSAIDS)
    (prescription and OTC, including ibuprofen and
    naproxen](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#BEXTRA):
    Bextra (valdecoxib) withdrawn from the market and labels for other
    Cox-2 inhibitors and NSAIDS revised to include a boxed warning and a
    Medication Guide, highlighting the potential for increased risk of
    cardiovascular (CV) events and life-threatening gastrointestinal
    (GI) bleeding.

**Additional Notices**

-   [May 2, 2007, Antidepressant
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant):
    Update to the existing black box warning on the prescribing
    information on all antidepressant medications to include warnings
    about the increased risks of suicidal thinking and behavior in young
    adults ages 18 to 24 years old during the first one to two months of
    treatment.

-   [October 17, 2005, Cymbalta (duloxetine
    hydrochloride)](http://www.fda.gov/medwatch/safety/2005/safety05.htm#Cymbalta):
    Healthcare professionals notified of revision to the
    PRECAUTIONS/Hepatotoxicity section of the prescribing information to
    include precaution against using in patients with chronic liver
    disease.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Work-related chronic pain

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Neurology\
Physical Medicine and Rehabilitation

#### INTENDED USERS

Advanced Practice Nurses\
Health Care Providers\
Health Plans\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To offer evidence-based step-by-step decision protocols for the
assessment and treatment of workers\' compensation conditions

#### TARGET POPULATION

Workers with work-related chronic pain

#### INTERVENTIONS AND PRACTICES CONSIDERED

The following interventions/procedures were considered and recommended
as indicated in the original guideline document:

1.  Acupuncture

2.  Anticonvulsants/antiepileptic drugs for chronic neuropathic pain

3.  Antidepressants as first line option for neuropathic pain

4.  Antidepressants for non-neuropathic pain

5.  Anti-inflammatory medications (e.g., nonsteroidal anti-inflammatory
    drugs \[NSAIDs\], Celebrex)

6.  Behavioral interventions

7.  Boswellia Serrata Resin (Frankincense)

8.  Capsaicin (topical) in patients who have not responded or are
    intolerant to other treatments

9.  Cod liver oil

10. Complex regional pain syndrome (CRPS) (medications, prevention,
    spinal cord stimulators, sympathetic and epidural blocks, treatment
    \[see original guideline document for hierarchy of options\])

11. Curcumin (turmeric)

12. Cyclobenzaprine (Flexeril®)

13. Detoxification

14. Duloxetine (Cymbalta®)

15. Education of patient and family

16. Electrodiagnostic testing (electromyography \[EMG\] and nerve
    conduction studies \[NCS\])

17. Epidural steroid injections (ESIs)

18. Evoked potential studies

19. Exercise

20. Functional restoration programs (FRP)

21. Gabapentin for neuropathic pain

22. Glucosamine (and chondroitin sulfate)

23. Green tea

24. Herbal medicines

25. Home health services

26. Implantable drug-delivery systems (IDDSs) (see original guideline
    document for specific indications)

27. Intrathecal drug delivery systems

28. Lumbar sympathetic block

29. Medications for acute pain (analgesics)

30. Methadone for moderate to severe pain

31. Multi-disciplinary pain programs/chronic pain programs

32. Muscle relaxants

33. Nonprescription medications (acetaminophen, nonsteroidal
    anti-inflammatory drugs \[NSAIDs\])

34. Number needed to treat as a measure of absolute risk in evaluating
    drug therapies

35. Obtaining pain treatment agreement prior to initiating opioid
    therapy

36. Opioids for severe cases including cancer pain

37. Opioids: dealing with misuse & addiction, screening for misuse,
    screening for risk of addiction (tests) and dependence vs.
    addiction, psychological intervention

38. Phentolamine infusion test

39. Physical therapy/occupational therapy

40. Psychological evaluations

41. Psychological treatment

42. Pycnogenol (maritime pine bark)

43. Return to work

44. Salicylate topicals

45. Screening for comorbid psychiatric disorders and diabetic neuropathy

46. Spinal cord stimulators (SCS)

47. Stellate ganglion block

48. Topical analgesics

49. Transcutaneous electrical nerve stimulation (TENS) for acute
    postoperative pain

50. Trigger point injections for myofascial pain syndrome only

51. Uncaria Tomentosa (Cat\'s Claw)

52. Venlafaxine

53. Weaning of medications

54. White willow bark

55. Yoga

The following interventions/procedures are under study and are not
specifically recommended:

1.  Autonomic test battery

2.  Chronic pain programs (early intervention, intensity, opioids)

3.  Clonidine, intrathecal

4.  Complex regional pain syndrome (CRPS), diagnostic criteria

5.  Facet blocks

6.  Functional imaging of brain responses to pain

7.  H-wave stimulation (devices)

8.  Injection with anesthetics and/or steroids

9.  Intravenous regional sympathetic blocks (for reflex sympathetic
    dystrophy \[RSD\], nerve blocks)

10. Ketamine

11. Massage therapy

12. Milnacipran

13. Neuromuscular electrical stimulation (NMES devices)

14. Neuroreflexotherapy

15. Percutaneous electrical nerve stimulation (PENS)

16. Testosterone replacement

The following interventions were considered, but are not recommended:

1.  Actiq® (oral transmucosal fentanyl citrate) for musculoskeletal
    pain.

2.  Barbiturate-containing analgesic agents

3.  Benzodiazepines for long-term use

4.  Biofeedback

5.  Botulinum toxin (Botox) for mechanical neck and back disorders

6.  Cannabinoids

7.  Complex regional pain syndrome, sympathectomy

8.  Current perception threshold (CPT) testing/sensory nerve conduction
    threshold (sNCT) device

9.  Electroceutical therapy (bioelectric nerve block)

10. Galvanic stimulation

11. Interferential current stimulation (ICS)

12. Low level laser therapy (LLLT)

13. Magnet therapy

14. Manual therapy and manipulation

15. Microcurrent electrical stimulation (MENS devices)

16. Nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with
    previous ulcer disease and cyclooxygenase-2 inhibitors in patients
    with cardiovascular risk

17. Nucleoplasty

18. Opioids for chronic pain or as first-line therapy for neuropathic
    pain

19. Opioids for first-line therapy for osteoarthritis

20. Oral morphine as primary treatment

21. Percutaneous neuromodulation therapy (PNT)

22. Power mobility devices

23. Prolotherapy/sclerotherapy

24. Pulsed radiofrequency treatment (PRF)

25. Rapid detox

26. Sclerotherapy (prolotherapy)

27. Sympathetic therapy

28. TENS as primary therapy for chronic pain

29. Therapeutic ultrasound

30. Thermography (not recommended except possibly for CRPS)

31. Vioxx (withdrawn from the U.S. and worldwide market)

32. Ziconotide (Prialt)

#### MAJOR OUTCOMES CONSIDERED

Adverse effects of medications

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Work Loss Data Institute (WLDI) conducted a comprehensive medical
literature review (now ongoing) with preference given to high quality
systematic reviews, meta-analyses, and clinical trials published since
1993, plus existing nationally recognized treatment guidelines from the
leading specialty societies. WLDI primarily searched MEDLINE and the
Cochrane Library. In addition, WLDI also reviewed other relevant
treatment guidelines, including those in the National Guideline
Clearinghouse, as well as state guidelines and proprietary guidelines
maintained in the WLDI guideline library. These guidelines were also
used to suggest references or search terms that may otherwise have been
missed. In addition, WLDI also searched other databases, including MD
Consult, eMedicine, CINAHL, and conference proceedings in occupational
health (i.e. American College of Occupational and Environmental medicine
\[ACOEM\]) and disability evaluation (i.e. American Academy of
Disability Evaluating Physicians \[AADEP\], American Board of
Independent Medical Examiners \[ABIME\]). Search terms and questions
were diagnosis, treatment, symptom, sign, and/or body-part driven,
generated based on new or previously indexed existing evidence,
treatment parameters and experience.

In searching the medical literature, answers to the following questions
were sought: (1) If the diagnostic criteria for a given condition have
changed since 1993, what are the new diagnostic criteria? (2) What
occupational exposures or activities are associated causally with the
condition? (3) What are the most effective methods and approaches for
the early identification and diagnosis of the condition? (4) What
historical information, clinical examination findings or ancillary test
results (such as laboratory or x-ray studies) are of value in
determining whether a condition was caused by the patient\'s employment?
(5) What are the most effective methods and approaches for treating the
condition? (6) What are the specific indications, if any, for surgery as
a means of treating the condition? (7) What are the relative benefits
and harms of the various surgical and non-surgical interventions that
may be used to treat the condition?  (8) What is the relationship, if
any, between a patient\'s age, gender, socioeconomic status and/or
racial or ethnic grouping and specific treatment outcomes for the
condition? (9) What instruments or techniques, if any, accurately assess
functional limitations in an individual with the condition? (10) What is
the natural history of the disorder? (11) Prior to treatment, what are
the typical functional limitations for an individual with the condition?
(12) Following treatment, what are the typical functional limitations
for an individual with the condition? (13) Following treatment, what are
the most cost-effective methods for preventing the recurrence of signs
or symptoms of the condition, and how does this vary depending upon
patient-specific matters such as underlying health problems?

**Criteria for Selecting the Evidence**

Preference was given to evidence that met the following criteria: (1)
The article was written in the English language, and the article had any
of the following attributes: (2) It was a systematic review of the
relevant medical literature, or (3) The article reported a controlled
trial -- randomized or controlled, or (4) The article reports a cohort
study, whether prospective or retrospective, or (5) The article reports
a case control series involving at least 25 subjects, in which the
assessment of outcome was determined by a person or entity independent
from the persons or institution that performed the intervention the
outcome of which is being assessed.

More information about the selection of evidence is available in
\"Appendix. ODG Treatment in Workers\' Comp. Methodology description
using the AGREE instrument\" (see \"Availability of Companion
Documents\" field).

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Ranking by Type of Evidence**

1.  Systematic Review/Meta-Analysis

2.  Controlled Trial-Randomized (RCT) or Controlled

3.  Cohort Study-Prospective or Retrospective

4.  Case Control Series

5.  Unstructured Review

6.  Nationally Recognized Treatment Guideline (from
    [www.guideline.gov](http://www.guideline.gov/))

7.  State Treatment Guideline

8.  Other Treatment Guideline

9.  Textbook

10. Conference Proceedings/Presentation Slides

**Ranking by Quality within Type of Evidence**

a.  High Quality

b.  Medium Quality

c.  Low Quality

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The Work Loss Data Institute (WLDI) reviewed each article that was
relevant to answering the question at issue, with priority given to
those that met the following criteria: (1) The article was written in
the English language, and the article had any of the following
attributes: (2) It was a systematic review of the relevant medical
literature, or (3) The article reported a controlled trial -- randomized
or controlled, or (4) The article reported a cohort study, whether
prospective or retrospective, or (5) The article reported a case control
series involving at least 25 subjects, in which the assessment of
outcome was determined by a person or entity independent from the
persons or institution that performed the intervention the outcome of
which is being assessed.

Especially when articles on a specific topic that met the above criteria
were limited in number and quality, WLDI also reviewed other articles
that did not meet the above criteria, but all evidence was ranked
alphanumerically (see the Rating Scheme of the Strength of Evidence
field) so that the quality of evidence could be clearly determined when
making decisions about what to recommend in the Guidelines.. Articles
with a Ranking by Type of Evidence of Case Reports and Case Series were
not used in the evidence base for the Guidelines. These articles were
not included because of their low quality (i.e., they tend to be
anecdotal descriptions of what happened with no attempt to control for
variables that might effect outcome). Not all the evidence provided by
WLDI was eventually listed in the bibliography of the published
Guidelines. Only the higher quality references were listed. The criteria
for inclusion was a final ranking of 1a to 4b (the original inclusion
criteria suggested the methodology subgroup), or if the Ranking by Type
of Evidence was 5 to 10, the quality ranking should be an \"a.\"

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

The guideline developers reviewed published cost analyses.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Prior to publication, select organizations and individuals making up a
cross-section of medical specialties and typical end-users externally
reviewed the guideline.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note**: This guideline has been updated. The National Guideline
Clearinghouse (NGC) is working to update this summary. The
recommendations that follow are based on the previous version of the
guideline.

**Note from the National Guideline Clearinghouse (NGC)**: For the Work
Loss Data Institute\'s \"Disclaimer: limitations of scope\" statement,
refer to the \"Qualifying Statements\" field in this summary or see the
original guideline document.

**Introduction**

Pain has been classified in multiple ways. One common methodology is to
temporally classify the condition according to duration, with the most
common categories given as acute and chronic. Acute pain is a sign of
real or impending tissue damage and usually disappears with healing. It
is the normal predicted physiologic response and is usually of short
duration. Chronic pain, a common and expensive problem in occupational
and disability medicine, has been defined by multiple different time
durations (generally from 6 weeks to 3 months after the onset of
symptoms). It has also been defined as pain that persists for at least
30 days beyond the usual course of an illness. Chronic pain is a
condition that ultimately adversely affects the patient\'s well being,
level of function and quality of life. This chapter of Official
Disability Guidelines (ODG) *Treatment* focuses on chronic pain.

Pain has also been classified according to presumed neurophysiologic
mechanisms. There is no real consistency to this type of classification,
but texts on pain suggest that pain is either of somatic/nociceptive
origin, or a non-nociceptive origin; the latter commonly classified as
neuropathic and/or idiopathic/psychogenic. (Definition: somatic pain is
a pain arising in the body tissues typically associated with injury or
trauma, and nociceptive pain is a normal and expected pain response to
injury.) Nociceptive pain is not necessarily synonymous with acute pain.
Examples of chronic pain conditions that have been classified as
nociceptive include arthritis and other degenerative conditions such as
rotator cuff disease.

Pain has also been described as an experience rather than a sensation.
Chronic pain may occur without obvious tissue damage, and psychological
components have a substantial impact on its development and chronicity.
Pain societies have recognized that psychological input to pain may
include components of cognitive, behavioral, emotional, and certain
predisposing factors (such as childhood trauma or abuse), as well as a
potential role of traumatic stress. In addition, in workers\'
compensation cases and other cases involving personal injury, the \"sick
role\" is further reinforced by the promise that compensation
(indemnification) may play in the process. Additionally, there is an
increasing emphasis on the role psychiatric co-morbidities such as
anxiety disorder, bipolar disease and addictive disease may play in the
pathogenesis of the condition.

**Initial Evaluation for Chronic Pain**

**History**

1.  Determine the chief complaint.

2.  Determine if there was a specific incident that caused or triggered
    the onset of pain or if pain was insidious in onset.

3.  Determine the severity and specific anatomic location of the pain
    (including radiation patterns).

4.  Determine if the pain has remained localized, or if it become more
    multifocal/generalized.

5.  Determine the character of pain including the following:

    a.  Quality of pain (by descriptions such as aching, dull, sharp,
        allodynia, burning, electric, dysesthesia, paresthesias, and or
        neuralgia)

    b.  Continuous or intermittent

    c.  Associated neurological factors (weakness, numbness, balance
        problems)

    d.  Factors that exacerbate or relieve

    e.  Effect of activity, body position

    f.  Effect of stress

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6.  Determine previous tests and results.

7.  Determine the effect of previous treatment including medications.

8.  Assess the ability of the patient to perform functions such as
    walking, lifting, sitting, and standing including job-related
    limitations.

9.  Assess for evidence of substance abuse in the patient in the past or
    currently (including alcohol, smoking, or illicit drugs). A family
    history should also be ascertained.

10. Examine for evidence of concordant depression, anxiety, other mood
    disturbance, sleep disturbance, or eating disturbance.

11. Assess the effect that pain has had on quality of life in regards to
    social and family interactions and sexual function.

12. Assess for involvement of litigation or evidence of secondary gain.

13. Assess the patient\'s goals of treatment.

**Physical Examination**

1.  Assess vital signs, weight, and body mass index. Assess pain using
    an instrument such as the visual analog scale (VAS), and
    functionality.

2.  Observe appearance, attitude and behavior (such as response on
    examination maneuvers), and gait.

3.  Observe for musculoskeletal defects: deformity, atrophy, masses or
    lesions, signs of trauma, alignment of spine, range of motion.
    Determine muscle strength, and evaluate for evidence of myofascial
    dysfunction.

4.  Assess neurologic status: mental status sensory examination
    (including hyperalgesia, hyperpathia, paresthesias, dysesthesias,
    allodynia, hypesthesia, hyperesthesia), muscle stretch reflexes.

5.  Assess pain-exacerbating maneuvers.

6.  Assess for Waddell\'s signs and inconsistencies in the above
    examination.

**Begin an Assessment of the Presumed Chronic Pain Mechanism Based on
the History and Physical**

The Institute for Clinical Systems Improvement (ICSI) has differentiated
distinct biological mechanisms that contribute to chronic pain. Each
patient may have multiple and/or overlapping contributors. The criteria
and suggested treatment of specific conditions listed are given in the
Procedure Summary of the original guideline document.

*Neuropathic Pain*: Defined as \"pain initiated or caused by a primary
lesion or dysfunction of the nervous system.\" Neuropathic pain can be
classified according to several methodologies. The first includes a
classification into categories of peripheral, central, or a
controversial category that includes \"dysfunction of the nervous
system.\" An alternative mechanism is to classify neuropathies
associated with pain into the following: 1) mononeuropathies, either
traumatic or from other causes; 2) polyneuropathies, with etiologies
including metabolic, nutritional, drugs, toxins, hereditary, malignant,
infective, or an \"other\" category. See the Procedure Summary in the
original guideline document for recommendations concerning the use of
various treatments and, in particular, medications such as
antidepressants and anticonvulsants (e.g., gabapentin \[Neurontin®\])
for neuropathic pain.

*Muscle Pain*: Includes fibromyalgia and myofascial pain.

*Inflammatory Pain*: This type of pain mechanism is commonly associated
with acute pain (postoperative pain and acute tissue injury). An example
of chronic inflammatory pain includes arthritis.

*Mechanical Pain*: Examples of chronic conditions include etiologies
that create pressure or stretching, resulting in pain including
fracture, dislocation. Another chronic pain example would include
compression of tissue by bony structures.

*Psychological*: In addition to the ICSI mechanisms, it is suggested in
guidelines (such as the Chronic Pain Disorder Medical Treatment
Guidelines, 2003) to also evaluate for psychological contributors.
Specific examples of psychological contributors/comorbidities that are
either associated with or contribute to chronic pain include depression,
anxiety, personality disorders somatization, and post-traumatic stress.
The possibility of the contribution of underlying substance abuse
problems must also be assessed. Specific guidelines for both suggested
and required psychological testing for specific treatment interventions
are included in the Procedure Summaries of the original guideline
document. Descriptions of specific standardized psychological tests are
provided in \"Psychological Tests Commonly Used in the Assessment of
Chronic Pain Patients.\"

*Secondary Gain Issues*: Issues such as indemnity and current litigation
may have impact on resolution of pain. Some authors also suggest even
more important social contributors including the primary loss of
physical health and functioning, as well as secondary losses such as
loss of financial stability and relationships (both on a personal and
work-related level).

**Determine the Need for Specific Diagnostic Studies**

Specific recommendations for diagnostic tests are given in the Procedure
Summaries of the original guideline document for both the Pain Chapter
and specific body-part chapters.

**General Treatment Management**

Specific recommendations for each condition are given in the Procedure
Summaries of the original guideline document for both the Pain Chapter
and specific body-part chapters. General management suggestions as
suggested by ICSI also include the following:

1.  Develop a written plan of care that addresses the patient\'s
    personal goals, sleep, physical activity, stress management, and
    recommendations to improve pain control.

2.  Provide adequate information to the patient, including opportunities
    for education on their condition.

3.  Include the patient in the treatment plan.

4.  Acknowledge that the treatment team recognizes that their pain is
    considered as \"real.\"

5.  Provide all patients with an exercise and fitness program.

6.  Consider the use of a cognitive behavioral program when indicated.

7.  Schedule routine appointments to avoid the incidence of visits
    secondary to increased pain.

8.  Stress self-management by the patient.

9.  Enlist family and friends to both support the patient and reinforce
    gains.

10. Assist in return to work.

11. Assist in appropriate attainment of entitlements.

At a certain point in the course of care, there are two general
treatment options for claimants with chronic pain. One is medication,
and the second is cognitive therapy/pain management programs. See the
Procedure Summary in the original guideline document for more details
and links to the medical evidence.

*Medication Issues*: (See also Medications in the Procedure Summary of
the original guideline document for links to specific choices)

Non-neuropathic pain is generally treated with analgesics and
anti-inflammatories. First-line treatment for neuropathic pain requires
treatment with medications that influence the various transmitters
involved in the underlying pain pathology, with opioids reserved for
refractory pain. When considering opioids for either type of pain,
discussion should include duration of treatment and when to discontinue
their use (as occasionally suggested as \"detoxification\" by many
reviewers). This area of opioid treatment remains extremely
controversial, and research remains ongoing. It is generally felt that
\"detoxification\" should not be proposed without offering another
treatment solution, although alternative options also remain
controversial.

Anticonvulsants are also currently suggested medications for
neuropathically related chronic pain. When dealing with neuropathic
pain, and in particular, neuropathic pain of possible spinal origin,
treatment issues are confounded due to the presence of underlying
non-work-related conditions that also can present with neuropathic pain
such as impaired glucose tolerance/type 2 diabetes (i.e. diabetic
peripheral neuropathy) and/or aging (possible neurogenic claudication
secondary to spinal stenosis). The question often arises as to the
actual indication of the use of anti-convulsant medication in these
instances, and their compensability in regards to the work-related
injury. These questions include how the medications should be prescribed
and how outcomes should be recorded. Antidepressants have also been
indicated for both neuropathic and non-neuropathic pain. Not only do
compensability issues arise for this class of medications in regards to
the underlying issues of etiologies of neuropathy, but also in regards
to their use for pre-existing conditions of depression and anxiety.
Needless to say, the issues involved with medication for chronic pain
are controversial, and current literature addressing the above issues is
included in the Procedure Summary in the original guideline document.

**Note**: In workers\' compensation cases, providers may need to shift
focus from a \"cure and relieve\" strategy to a \"functional
restoration\" paradigm. Too much attention may be focused on the
\"pain\" and not enough on functional restoration and gain that
encourages \"coping\" strategies and the desirable outcome of
\"working\" with pain. Also consider the possibility of patients
developing \"Wounded Worker Syndrome,\" a chronic pain condition
characterized by failure of an injured worker to respond to conventional
healthcare measures, and prolonged disability with continued absence
from the workplace. The main contributor of this condition may be the
healthcare system itself, which reinforces the \"sickness\" role of the
injured worker and provides many misguided interventions due to a lack
of adequate assessment of underlying psychosocial factors.

**ODG Return-To-Work Pathways for Selected Generalized Pain Syndromes**

(See body-part chapters for disability duration information for pain
that is the result of conditions in specific body parts, such as low
back, neck or extremity pain)

+-----------------------------------------------------------------------+
| **ODG Return-To-Work Pathways**                                       |
|                                                                       |
| **Myalgia and Myositis, Unspecified** *(Muscle Pain or Inflammation)* |
| (see the original guideline document for International Classification |
| of Diseases, Ninth Revision \[ICD-9\] codes for this and other        |
| diagnoses)                                                            |
|                                                                       |
| Moderate pain: 0 days                                                 |
|                                                                       |
| Debilitating pain, with hospitalization, modified work: 14 days       |
|                                                                       |
| Debilitating pain, with hospitalization, regular work: 42 days        |
|                                                                       |
| Myofascial pain syndrome, trigger point injection: 1 to 7 days        |
|                                                                       |
| Myofascial pain syndrome, acupuncture: 7 to 21 days                   |
|                                                                       |
| Myofascial pain syndrome, physical therapy: 14 to 21 days             |
|                                                                       |
| Fibromyalgia: Controversial and self-perpetuating diagnosis - see     |
| related conditions and return to regular activities as soon as        |
| possible                                                              |
|                                                                       |
| **Reflex Sympathetic Dystrophy** *(including complex regional pain    |
| syndrome \[CRPS\]-I)*                                                 |
|                                                                       |
| *Note: this is a controversial diagnosis*                             |
|                                                                       |
| Sympathetic nerve block: 3 to 7 days                                  |
|                                                                       |
| Complex regional pain syndrome (CRPS-I), early stage: 28 to 84 days   |
|                                                                       |
| Complex regional pain syndrome (CRPS-I), late stage: 210 days to      |
| indefinite                                                            |
|                                                                       |
| Late stage reflex sympathetic dystrophy (RSD) (CRPS-I): 365 days to   |
| indefinite                                                            |
|                                                                       |
| **Causalgia of Upper Limb** *(including CRPS-II)*                     |
|                                                                       |
| *Note: this is a controversial diagnosis*                             |
|                                                                       |
| Medical treatment: 0 days                                             |
|                                                                       |
| Sympathetic nerve block: 2 days                                       |
|                                                                       |
| Complex regional pain syndrome (CRPS-II): 28 to 84 days               |
|                                                                       |
| **Causalgia of Lower Limb** *(including CRPS-II)*                     |
|                                                                       |
| *Note: this is a controversial diagnosis*                             |
|                                                                       |
| Medical treatment: 0 days                                             |
|                                                                       |
| Sympathetic nerve block: 2 days                                       |
|                                                                       |
| Complex regional pain syndrome (CRPS-II): 28 to 84 days               |
|                                                                       |
| **Mononeuritis of Unspecified Site** *(including CRPS-II)*            |
|                                                                       |
| *Note: this is a controversial diagnosis*                             |
|                                                                       |
| Sympathetic nerve block: 3 to 7 days                                  |
|                                                                       |
| Complex regional pain syndrome (CRPS-II), early stage: 28 to 84 days  |
|                                                                       |
| Complex regional pain syndrome (CRPS-II), late stage: 210 days to     |
| indefinite                                                            |
+-----------------------------------------------------------------------+

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

During the comprehensive medical literature review, preference was given
to high quality systematic reviews, meta-analyses, and clinical trials
over the past ten years, plus existing nationally recognized treatment
guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure
Summary (see the original guideline document), which provides a concise
synopsis of effectiveness, if any, of each treatment method based on
existing medical evidence. Each summary and subsequent recommendation is
hyper-linked into the studies on which they are based, in abstract form,
which have been ranked, highlighted and indexed.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

These guidelines unite evidence-based protocols for medical treatment
with normative expectations for disability duration. They also bridge
the interests of the many professional groups involved in diagnosing and
treating pain.

#### POTENTIAL HARMS

-   Adverse effects of medications

-   Side effects of implanted catheters for complex regional pain
    syndrome (CRPS) include technical failure and infection.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Tricyclic antidepressants are contraindicated in patients with
    cardiac conduction disturbances and/or decompensation as well as
    those patients with epilepsy.

-   Both cyclooxygenase-2 (Cox-2s) and nonsteroidal anti-inflammatory
    drugs (NSAIDs) are contraindicated in patients with previous ulcer
    disease. Patients with cardiovascular risk should not use Cox-2s.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   **Note from the Work Loss Data Institute**: Disclaimer: limitations
    of scope. See body-part chapters for condition specific information,
    especially the Low Back Chapter. The Pain Chapter is focused on
    chronic pain, and also covers causalgia, complex regional pain
    syndrome (CRPS), myofascial pain, and generalized pain syndromes.
    Users interested in pain that is the result of conditions in
    specific body parts (e.g., low back, neck, or extremity pain),
    should also access those other chapters for management of pain of
    those body parts, although those chapters may refer to the Pain
    Chapter for certain generalized evidence summaries.

-   The Treatment Planning sections outline the most common pathways to
    recovery, but there is no single approach that is right for every
    patient and these protocols do not mention every treatment that may
    be recommended. See the Procedure Summaries (in the original
    guideline document) for complete lists of the various options that
    may be available, along with links to the medical evidence.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Patient Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Work Loss Data Institute. Pain (chronic). Corpus Christi (TX): Work Loss
Data Institute; 2007 Jul 5. 372 p. \[458 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 (revised 2007 Jul 12)

#### GUIDELINE DEVELOPER(S)

Work Loss Data Institute - Public For Profit Organization

#### SOURCE(S) OF FUNDING

Not stated

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Editor-in-Chief, Philip L. Denniston, Jr. and Senior Medical Editor,
Charles W. Kennedy, MD, together pilot the group of approximately 80
members. See the ODG *Treatment in Workers Comp* [Editorial Advisory
Board](http://www.disabilitydurations.com/advisoryboard.htm).

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

There are no conflicts of interest among the guideline development
members.

#### GUIDELINE STATUS

**Note**: This guideline has been updated. The National Guideline
Clearinghouse (NGC) is working to update this summary.

#### GUIDELINE AVAILABILITY

Electronic copies of the updated guideline: Available to subscribers
from the [Work Loss Data Institute Web
site](http://www.odg-disability.com/).

Print copies: Available from the Work Loss Data Institute, 169 Saxony
Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992,
Fax: 760-753-9995; [www.worklossdata.com](http://www.worklossdata.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Background information on the development of the Official Disability
    Guidelines of the Work Loss Data Institute is available from the
    [Work Loss Data Institute Web
    site](http://www.disabilitydurations.com/ODG Treatment in Workers.htm).

-   Appendix. ODG Treatment in Workers\' Comp. Methodology description
    using the AGREE instrument. Available to subscribers from the [Work
    Loss Data Institute Web site](http://www.odg-disability.com/).

#### PATIENT RESOURCES

The following is available:

-   Appendix B. ODG Treatment in Workers\' Comp. Patient information
    resources. 2006.

Electronic copies: Available to subscribers from the [Work Loss Data
Institute Web site](http://www.odg-disability.com/).

Print copies: Available from the Work Loss Data Institute, 169 Saxony
Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992,
Fax: 760-753-9995; [www.worklossdata.com](http://www.worklossdata.com/).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This summary was completed by ECRI on February 2, 2004. The information
was verified by the guideline developer on February 13, 2004. This NGC
summary was updated by ECRI on March 28, 2005. This summary was updated
by ECRI on June 16, 2005, following the U.S. Food and Drug
Administration advisory on COX-2 selective and non-selective
non-steroidal anti-inflammatory drugs (NSAIDs). This NGC summary was
updated by ECRI on January 13, 2006, April 11, 2006, November 13, 2006,
April 2, 2007, and on August 29, 2007. This summary was updated by ECRI
Institute on October 31, 2007, following the U.S. Food and Drug
Administration advisory on Antidepressant drugs.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008