La. Admin. Code tit. 40 § I-2017

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-2017 - Initial Diagnostic Procedures

A. The OWCA recommends the following diagnostic procedures be considered, at least initially, the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Standard procedures, that should be utilized when initially diagnosing a work-related low back pain complaint, are listed below.

1. History-taking and physical examination (Hx and PE) are generally accepted, well-established and widely used procedures that establish the foundation/basis for and dictates subsequent stages of diagnostic and therapeutic procedures. List of medications patient is taking should be included in every history, including over the counter medicines as well as supplements. When findings of clinical evaluations and those of other diagnostic procedures are not complementing each other, the objective clinical findings should have preference. The medical records should reasonably document the following.

a. History of Present Injury-a detailed history, taken in temporal proximity to the time of injury should primarily guide evaluation and treatment. The history should include pertinent positive and negative information regarding the following:

i. mechanism of injury. This includes details of symptom onset and progression. The mechanism of injury should include a detailed description of the incident and the position of the body before, during, and at the end of the incident. Inclusion of normal work body postures, frequency during the workday, and lifting/push/pull requirements should be included in the absence of a known specific incident;

ii. location of pain, nature of symptoms, and alleviating/exacerbating factors (e.g., sitting tolerance). The history should include both the primary and secondary complaints (e.g., primary low back pain, secondary hip, groin). The use of a patient completed pain drawing, such as Visual Analog Scale (VAS), is highly recommended, especially during the first two weeks following injury to assure that all work related symptoms are addressed;

iii. presence and distribution of lower extremity numbness, paresthesias, or weakness, especially if precipitated by coughing or sneezing;

iv. alteration in bowel, bladder, or sexual function; and for female patients, alteration in their menstrual cycle;

v. any treatment for current injuries or results;

vi. ability to perform job duties and activities of daily living.

b. Past History

i. past medical history includes neoplasm, gout, arthritis, hypertension, kidney stones, and diabetes;

ii. review of systems includes symptoms of rheumatologic, neurologic, endocrine, neoplastic, infectious, and other systemic diseases;

iii. smoking history;

iv. vocational and recreational pursuits;

v. history of depression, anxiety, or other psychiatric illness; and

vi. prior occupational and non-occupational injuries to the same area including specific prior treatment, chronic or recurrent symptoms, and any functional limitations; specific history regarding prior motor vehicle accidents may be helpful.

c. Physical Examination-should include accepted tests and exam techniques applicable to the area being examined, including:

i. general and visual inspection, including posture, stance, balance and gait;

ii. palpation of spinous processes, facets, and pelvis; and muscles noting myofascial tightness, tenderness and trigger points

iii. lumbar range of motion, and quality of motion, and presence of muscle spasm. Motion evaluation of specific joints may be indicated;

iv. examination of thoracic spine and pelvis;

v. nerve tension testing;

vi. sensory and motor examination of the lower extremities with specific nerve root focus;

vii. deep tendon reflexes with or without Babinski's;

viii. if applicable to injury, anal sphincter tone and/or perianal sensation; and

ix. if applicable, abdominal examination, vascular examination, circumferential lower extremity measurements, or evaluation of hip or other lower extremity abnormalities;

x. if applicable, Waddell Signs, which include five categories of clinical signs tenderness; superficial and non-anatomic, pain with simulation: axial loading and rotation; regional findings: sensory and motor, inconsistent with nerve root patterns; distraction/inconsistency in straight leg raising findings, and over-reaction to physical examination maneuvers. Significance may be attached to positive findings in three out of five of these categories, but not to isolated findings. Waddell advocates considering Waddell's signs prior to recommending a surgical procedure. These signs should be measured routinely to identify patients requiring further assessment (i.e., biopsychosocial) prior to undergoing back surgery.

(a). It is generally agreed that Waddell Signs are associated with decreased functional performance and greater subjective pain levels, though they provide no information on the etiology of pain. Waddell Signs cannot be used to predict or diagnose malingering. Their presence of three out of five signs may most appropriately be viewed as a "yellow flag", or screening test, alerting clinicians to those patients who require a more comprehensive approach to their assessment and care plan. Therefore, if three out of five Waddell Signs are positive in a patient with subacute or chronic back pain, a psychosocial evaluation should be part of the total evaluation of the patient. Refer to Personality/Psychological/Psychosocial Evaluation.

d. Relationship to Work. This includes a statement of the probability that the illness or injury is work-related. If further information is necessary to determine work relatedness, the physician should clearly state what additional diagnostic studies or job information is required.

2. Radiographic imaging of the lumbosacral spine is a generally accepted, well-established and widely used diagnostic procedure when specific indications based on history and/or physical examination are present. There is some evidence that early radiographic imaging without clear indications is associated with prolonged care, but no difference in functional outcomes. Therefore, it should not be routinely performed without indications. The mechanism of injury and specific indications for the radiograph should be listed on the request form to aid the radiologist and x-ray technician. Suggested indications include:

a. history of significant trauma, especially blunt trauma or fall from a height; greater than one meter; high impact motor vehicle accident, rollover, ejection, bicycle, or recreational vehicle collision; seatbelt use;

b. age over 55 years;

c. unexplained or persistent low back pain for at least 6 weeks or pain that is worse with rest;

d. localized pain, fever, constitutional symptoms, or history or exam suggestive of intravenous drug abuse, prolonged steroid use, or osteomyelitis;

e. suspected lesion in the lumbosacral spine due to systemic illness such as a rheumatic/rheumatoid disorder or endocrinopathy. Suspected lesions may require special views;

f. past medical history suggestive of pre-existing spinal disease, osteoporosis, spinal instrumentation, or cancer; and

g. prior to high-velocity/low amplitude manipulation or Grade IV to V mobilization.

3. Laboratory Testing. Laboratory tests are generally accepted, well-established and widely used procedures. They are, however, rarely indicated at the time of initial evaluation, unless there is suspicion of systemic illness, infection, neoplasia, or underlying rheumatologic disorder, connective tissue disorder, or based on history and/or physical examination. Laboratory tests can provide useful diagnostic information. Tests include, but are not limited to:

a. complete blood count (CBC) with differential can detect infection, blood dyscrasias, and medication side effects;

b. erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), antinuclear antigen (ANA), human leukocyte antigen (HLA), and C-reactive protein (CRP), can be used to detect evidence of a rheumatologic, infectious, or connective tissue disorder;

c. serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease;

d. urinalysis for bacteria (usually with culture and sensitivity), calcium, phosphorus, hydroxyproline, or hematuria; and

e. liver and kidney function may be performed for prolonged anti-inflammatory use or other medications requiring monitoring.

La. Admin. Code tit. 40, § I-2017

Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation Administration, LR 37:1656 (June 2011), amended by the Louisiana Workforce Commission, Office of Workers Compensation, LR 40:1136 (June 2014), Amended LR 461245 (9/1/2020).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.