Wisconsin Administrative Code › Department of Workforce Development › DWD 80-81 - Worker's Compensation › Chapter DWD 81 - Worker's compensation treatment guidelines › Section DWD 81.06 - Low back pain

Current through June 24, 2024
(1) DIAGNOSTIC PROCEDURES FOR THE EVALUATION
				OF LOW BACK PAIN.
(a) A health care provider
				shall determine the nature of the low back condition before initiating
				treatment.
(b) A health care
				provider shall perform and document an appropriate history and physical
				examination. Based on the history and physical examination the health care
				provider shall assign the patient at each visit to the appropriate clinical
				category under subds. 1. to 4. The health care provider shall document the
				diagnosis in the medical record. For the purposes of subds. 2.and 3.,
				"radicular pain" means pain radiating distal to the knee, or pain conforming to
				a dermatomal distribution, and accompanied by anatomically congruent motor
				weakness, or reflex changes. This section does not apply to fractures of the
				lumbar spine, or low back pain due to an infectious, immunologic, metabolic,
				endocrine, neurologic, visceral, or neoplastic disease process.
1. Regional low back pain, includes referred
				pain to the leg above the knee unless it conforms to an L2, L3, or L4
				dermatomal distribution and is accompanied by anatomically congruent motor
				weakness or reflex changes. Regional low back pain includes the diagnoses of
				lumbar, lumbosacral, or sacroiliac strain, sprain, myofascial syndrome,
				musculoligamentous injury, soft tissue injury, spondylosis, and other diagnoses
				for pain believed to originate in the discs, ligaments, muscles, or other soft
				tissues of the lumbar spine or sacroiliac joints and that effects the
				lumbosacral region, with or without referral to the buttocks or leg, or both
				above the knee, including ICD-9-CM codes 720 to 720.9, 721, 721.3, 721.5 to
				721.90, 722, 722.3, 722.32, 722.5, 722.51, 722.52, 722.6, 722.9, 722.90,
				722.93, 724.2, 724.5, 724.6, 724.8, 724.9, 732.0, 737 to 737.9, 738.4, 738.5,
				739.2 to 739.4, 756.1 to 756.19, 847.2 to 847.9, 922.3, 926.1, 926.11, and
				926.12.
2. Radicular pain, with or
				without regional low back pain, with static or no neurologic deficit. This
				includes the diagnoses of sciatica; lumbar or lumbosacral radiculopathy,
				radiculitis, or neuritis; displacement or herniation of intervertebral disc
				with myelopathy, radiculopathy, radiculitis, or neuritis; spinal stenosis with
				myelopathy, radiculopathy, radiculitis, or neuritis; and any other diagnoses
				for pain in the leg below the knee believed to originate with irritation of a
				nerve root in the lumbar spine, including ICD-9-CM codes 721.4, 721.42 721.91,
				722.1, 722.10, 722.2, 722.7, 722.73, 724.0, 724.00, 724.02, 724.09, 724.3,
				724.4, and 724.9. In these cases, neurologic findings on history and physical
				examination are either absent or do not show progressive
				deterioration.
3. Radicular pain,
				with or without regional low back pain, with progressive neurologic deficit.
				This includes the same diagnoses as subd. 2., except this subdivision applies
				when there is a history of progressive deterioration in the neurologic symptoms
				and physical findings which include worsening sensory loss, increasing muscle
				weakness, or progressive reflex changes.
4. Cauda equina syndrome, which is a syndrome
				characterized by anesthesia in the buttocks, genitalia, or thigh and
				accompanied by disturbed bowel and bladder function, including ICD-9-CM codes
				344.6, 344.60, and 344.61.
(c) A health care provider may not order
				laboratory tests in the evaluation of a patient with regional low back pain,
				radicular pain, or cauda equina syndrome, except for any of the following:
1. When a patient's history, age, or
				examination suggests infection, metabolic-endocrinologic disorders, tumorous
				conditions, systemic musculoskeletal disorders, such as rheumatoid arthritis or
				ankylosing spondylitis.
2. To
				evaluate potential adverse side effects of medications.
3. As part of a preoperative
				evaluation.
(d)
				Laboratory tests may be ordered any time a health care provider suspects any of
				the conditions in par. (c), if the health care provider justifies the need for
				the tests ordered with clear documentation of the indications.
(e) Medical imaging evaluation of the
				lumbosacral spine shall be based on the findings of the history and physical
				examination and may not be ordered before a health care provider's clinical
				evaluation of the patient. Medical imaging may not be performed as a routine
				procedure and shall comply with all of the guidelines in s.
				DWD 81.05(1) and
				(2). A health care provider shall document
				the appropriate indications for any medical imaging studies obtained.
(f) A health care provider may not order
				electromyography and nerve conduction studies for regional low back pain as
				defined in s. DWD 81.06(1) (b) 1. A health care provider may order
				electromyography and nerve conduction studies as a diagnostic tool for
				radicular pain and cauda equina syndrome as defined in s. DWD 81.06(1) (b) 2.
				to 4. after the first 3 weeks of radicular symptoms. Repeat electromyography
				and nerve conduction studies for radicular pain and cauda equina syndrome are
				not necessary unless a new neurologic symptom or progression of existing
				finding has developed that in itself would warrant electrodiagnostic testing.
				Failure to improve with treatment is not an indication for repeat
				testing.
(g) A health care provider
				may not order the use of any of the following procedures or tests for the
				diagnosis of any of the clinical categories in par. (b) 1. to 4.:
1. Surface electromyography or surface
				paraspinal electromyography.
2.
				Thermography.
3.
				Plethysmography.
4. Electronic
				X-ray analysis of plain radiographs.
5. Diagnostic ultrasound of the lumbar
				spine.
6. Somatosensory evoked
				potentials and motor evoked potentials.
(h) A health care provider may not order
				computerized range of motion or strength measuring tests during the period of
				initial nonsurgical management but may order these tests during the period of
				chronic management when used in conjunction with a computerized exercise
				program, work hardening program, or work conditioning program. During the
				period of initial nonsurgical management, computerized range of motion or
				strength testing may be performed but shall be done in conjunction with an
				office visit with a health care provider's evaluation or treatment, or physical
				or occupational therapy evaluation or treatment.
(i) A health care provider may order
				personality or psychosocial evaluations for evaluating patients who continue to
				have problems despite appropriate care. A treating health care provider may
				perform this evaluation or may refer the patient for consultation with another
				health care provider in order to obtain a psychological evaluation. These
				evaluations may be used to assess the patient for a number of psychological
				conditions that may interfere with recovery from the injury. Since more than
				one of these psychological conditions may be present in a given case, the
				health care provider performing the evaluation shall consider all of the
				following:
1. Is symptom magnification
				occurring?
2. Does the patient
				exhibit an emotional reaction to the injury, such as depression, fear, or
				anger, that is interfering with recovery?
3. Are there other personality factors or
				disorders that are interfering with recovery?
4. Is the patient chemically
				dependent?
5. Are there any
				interpersonal conflicts interfering with recovery?
6. Does the patient have a chronic pain
				syndrome or psychogenic pain?
7. In
				cases in which surgery is a possible treatment, are psychological factors
				likely to interfere with the potential benefit of the surgery?
(j) All of the following are
				guidelines for diagnostic analgesic blocks or injection studies and include
				facet joint injection, facet nerve injection, epidural differential spinal
				block, nerve block, and nerve root block:
1.
				These procedures are used to localize the source of pain before surgery and to
				diagnose conditions that fail to respond to initial nonsurgical
				management.
2. These injections are
				invasive and are not necessary when done as diagnostic procedures only, unless
				noninvasive procedures have failed to establish the diagnosis.
3. Selection of patients, choice of
				procedure, and localization of the level of injection may be determined by
				documented clinical findings indicating possible pathologic conditions and the
				source of pain symptoms.
4. These
				blocks and injections may also be used as therapeutic modalities and are
				subject to the guidelines of sub. (5).
(k) Functional capacity assessment or
				evaluation is a comprehensive and objective assessment of a patient's ability
				to perform work tasks. The components of a functional capacity assessment or
				evaluation include neuromusculoskeletal screening, tests of manual material
				handling, assessment of functional mobility, and measurement of postural
				tolerance. A functional capacity assessment or evaluation is an individualized
				testing process and the component tests and measurements are determined by the
				patient's condition and the requested information. Functional capacity
				assessments and evaluations are performed to determine and report a patient's
				physical capacities in general or to determine work tolerance for a specific
				job, task, or work activity.
1. A functional
				capacity assessment or evaluation is not necessary during the period of initial
				nonsurgical management.
2. A
				functional capacity assessment or evaluation is necessary in any of the
				following circumstances:
a. To identify the
				patient's activity restrictions and capabilities.
b. To resolve a question about the patient's
				ability to do a specific job.
3. A functional capacity evaluation may not
				establish baseline performance before treatment or for subsequent assessments
				to evaluate change during or after treatment.
4. A health care provider may direct only one
				completed functional capacity evaluation per injury.
(L) Consultations with other health care
				providers may be initiated at any time by the treating health care provider
				consistent with accepted medical practice.