• Hegmann KT, ed. Low back disorders. In: Glass LS, editor(s). Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers. 2nd ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2007. p. 366. [1310 references]

This is the current release of the guideline.

This guideline updates a previous version: Low back complaints. In: Glass LS, editor(s). Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers. 2nd ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. p. 286-326.

The ACOEM Guidelines are currently being updated on a 3-year rolling process.

Low back disorders

Diagnosis
Evaluation
Management
Treatment

Family Practice
Internal Medicine
Orthopedic Surgery
Physical Medicine and Rehabilitation
Preventive Medicine
Surgery

Advanced Practice Nurses
Physician Assistants
Physicians
Utilization Management

• To update the 2004 American College of Occupational and Environmental Medicine's (ACOEM's) Guidelines on Low Back Complaints
• To help improve or restore the health of those workers who incur occupationally related illnesses or injuries
• To present essential evidence-based information to address the injured worker's functional impairment and safely return him or her to work

Adults with potentially work-related low back disorders seen in primary care settings

Note from the National Guideline Clearinghouse (NGC): The following general clinical measures were considered. Refer to the "Major Recommendations" section of this summary and the original guideline document for information regarding which specific interventions and practices under these general headings are recommended, optional, or not recommended by the American College of Occupational and Environmental Medicine.

1. Diagnostic testing
2. Medications
3. Orthotics and immobilization
4. Physical treatment methods
5. Activity modification and exercise
6. Injections
7. Surgical considerations
8. Rehabilitation/behavioral/education

Missed work days

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

Note from the National Guideline Clearinghouse (NGC): The American College of Occupational and Environmental Medicine contracted the Work Loss Data Institute to provide medical library research services.

Disability-Duration Data

This edition includes disability-duration data that have been extracted from National Health Interview Survey data. Only data from interviews with individuals without workers' compensation claims has been included.

2007 Update

Under the ACOEM new methodology, the process begins with the systematic identification of high-quality original research studies on a topic. References are identified from a number of national and international databases of original research. Additional references are identified through an exhaustive "hand search" of the literature by trained health science researchers.

Not stated

Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)

Strength of Evidence Ratings

A: Strong evidence-base: Two or more high-quality studies.¹

B: Moderate evidence-base: At least one high-quality study or multiple moderate-quality studies² relevant to the topic and the working population.

C: Limited evidence-base: At least one study of moderate quality.

I: Insufficient evidence: Evidence is insufficient or irreconcilable.

¹For therapy and prevention, randomized controlled trials (RCTs) with narrow confidence intervals and minimal heterogeneity.

For diagnosis and screening, cross sectional studies using independent gold standards.

For prognosis, etiology or harms, prospective cohort studies with minimal heterogeneity.

²For therapy and prevention, a well-conducted review of cohort studies.

For prognosis, etiology or harms, a well-conducted review of retrospective cohort studies or untreated control arms of RCTs.

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Contributors reviewed at least one chapter each and reviewed the relevant medical literature that had been published since the creation of the original Guidelines in 1997.

2007 Update

As part of the update process, American College of Occupational and Environmental Medicine (ACOEM) adopted a new more meticulous strength-of-evidence rating methodology. The enhanced methodology incorporates the highest scientific standards for reviewing evidence-based literature, thus ensuring the most rigorous, reproducible, and transparent occupational health guidelines available.

Studies are graded for actual design and for execution of that design and the subsequent analyses of results. Evidence with the highest available ranking—e.g., all randomized controlled trials (RCTs) or randomized crossover trials for treatment studies—is selected. Each article that meets inclusion criteria is reviewed and critically appraised.

As an example, RCTs that meet inclusion criteria are scored on 11 criteria. Each criterion is scored 0.0, 0.5, or 1.0. These individual ratings are summed up, resulting in an overall rating that ranges from 0 to 11.

The rating for each article is then converted into a quality grade—low quality (0-3.5), moderate quality (4.0-7.5), or high quality (8.0-11.0).

While literature searches also seek systematic reviews and meta-analyses, on critical appraisal very few of these secondary studies are truly systematic as the term is used in the evidence-based medicine literature. Most typically, there are errors in analyses or interpretation. For this reason, ACOEM relies primarily on the original literature as the source for its evidence syntheses and recommendations.

Acceptable studies are abstracted into evidence tables that include details of study methods, outcomes, and statistical analyses. Research staff then use the tables to grade the strength of evidence in order to draft specific clinical practice recommendations that will be combined into collective evidence-based guidelines. Evidence is drawn almost entirely from original research studies.

Expert Consensus

In reviewing or revising recommendations, the expert Panels review the articles, evidence tables, and strength-of-evidence ratings (A, B, C, or I). Panels discuss recommendations for diagnosis or treatment based on the critically appraised body of evidence using a "best evidence" approach. In addition to critically appraised evidence, "first principles" of medical logic and ethics are observed in formulating recommendations:

• Imaging or testing should generally be done to confirm a clinical impression.
• Tests should affect the course of treatment.
• Treatments should improve on the natural history of the disorder, which in many cases is recovery without treatment.
• Invasive treatment should be preceded by adequate conservative treatment and may be performed if conservative treatment does not improve the health problem.
• The more invasive and permanent, the more caution should be exerted in considering invasive tests or treatments and the stronger should be the evidence of efficacy.
• The more costly the test or intervention, the more caution should be generally exerted prior to ordering the test or treatment and the stronger should be the evidence of efficacy.
• Testing/treatment decisions should be a collaboration between the clinician and patient with full disclosure of benefits and risks.
• Treatment should not create dependence or functional disability.

Health benefits, side effects, and risks are explicitly considered and discussed in formulating recommendations. Benefits should significantly exceed risks. Each recommendation specifies the clinical problem to which it relates and is linked to the relevant higher quality available evidence. Consensus recommendations, following the first principles above, are formulated when there is either a lack of quality evidence or the available evidence substantially conflicts.

The American College of Occupational and Environmental Medicine (ACOEM) evidence-based recommendations are explicitly classified as follows:

* "Appropriate" means meeting screening or preventive method entry criteria without contraindications, or having the appropriate diagnosis, indication, time frame, prior conservative testing or treatment, and lack of contraindications for the specific test or treatment.

** For example, would include acetaminophen, and self-administered cold or heat treatments. Excludes all interventional treatments, manual adjustment, and prescriptions medications. Aggregate and individual harms and costs are considered.

Published cost analyses were reviewed.

External Peer Review
Internal Peer Review

Following the chapter and literature review, participants provided written or verbal comments to the American College of Occupational and Environmental Medicine's Practice Guidelines Committee.

Verbal comments were in the form of participation in multi-specialty conference calls, during which the issues raised in each chapter were extensively discussed. Draft chapters were prepared and distributed by the American College of Occupational and Environmental Medicine to all chapter reviewers. Follow-up multi-specialty teleconferences were then held as appropriate, during which time the draft was again reviewed.

2007 Update

Specialty society and society representatives (listed in the original guideline document) served as external reviewers of the low back chapter.

Definitions for the strength of evidence ratings (A, B, C, and I) and the criteria for evidence-based recommendations are presented at the end of the "Major Recommendations" field.

General Summary of Recommendations

• The initial assessment of patients with low back problems focuses on detecting indications of potentially serious disease, termed "red flags" (i.e., fever or major trauma).
• In the absence of red flags, imaging and other tests are not recommended in the first 4 to 6 weeks of low back symptoms as they almost never result in a meaningful change in clinical management. Nonprescription medication or an appropriately selected nonsteroidal anti-inflammatory drug (NSAID), appropriate adjustment of physical activity if needed, and the use of thermal modalities such as heat and/or cryotherapies can safely relieve discomfort.
• In the absence of red flags, primary care and occupational physicians or other health care professionals can effectively manage low back problems conservatively.
• At the first visit, the physician should assure the patient that low back pain (LBP) is normal, has an excellent prognosis and, in most cases, is not debilitating on a long-term basis. Patients with elevated fear avoidance beliefs may require additional instructions and interventions to be reassured of this prognosis. Theoretically, this reassurance has the potential to avoid increasing the probability of the patient developing chronic pain syndrome.
• To avoid undue back irritation and debilitation from inactivity, some activity or job modification may be helpful in the acute period. However, bed rest is not recommended for essentially all LBP and radiculopathy patients other than those with unstable fractures or cauda equina syndrome with pending neurological catastrophe. Maintaining ordinary activity, as tolerated, leads to the most rapid recovery.
• All patients should be encouraged to return to work as soon as possible as evidence suggests this leads to the best outcomes. This process may be facilitated with modified duty particularly if job demands exceed patient capabilities. Full-duty work is a reasonable option for patients with low physical job demands and the ability to control such demands (e.g., alternate their posture) as well as for those with less severe presentations.
• Aerobic exercise has the best evidence of efficacy among the exercise regimens, whether for acute, subacute, or chronic LBP patients.
• Non-specific stretching is not recommended as it is not helpful for treatment of LBP. However, specific types of stretching exercises appear helpful (e.g., directional and slump stretching). Strengthening exercises, including lumbar stabilization exercises, are recommended, but not until the acute period of LBP has subsided.
• There is evidence of efficacy for manipulation for treatment of non-specific LBP, particularly for those patients who test positive for the Clinical Prediction Rule.
• Many invasive and noninvasive therapies are intended to cure or manage LBP, but no strong evidence exists that they accomplish this as successfully as therapies that focus on restoring functional ability without focusing on pain. In those cases, the traditional medical model of "curing" the patient does not work well. Furthermore, patients should be aware that returning to normal activities most often aids functional recovery.
• Patients should be encouraged to accept responsibility for managing their recovery rather than expecting the provider to provide an easy "cure." This process will promote using activity rather than pain as a guide, and it will make the treatment goal of return to occupational and non-occupational activities more obvious.
• If symptoms persist without improvement, further evaluation is recommended.
• Within the first 3 months of low back symptoms, only patients with evidence of severe spinal disease or severe debilitating symptoms and physiologic evidence of specific nerve root compromise confirmed by appropriate imaging studies, can be expected to potentially benefit from surgery.
• Quality evidence exists indicating that patient outcomes are not adversely affected by delaying surgery for weeks or a few months and continued conservative care is encouraged in patients with stable or improving deficits who desire to avoid surgery. However, patients with severe or progressive deficits that are not improving at 4 to 6 weeks may benefit from earlier surgical intervention.
• Nonphysical factors (such as psychiatric, psychosocial, workplace, or socioeconomic problems) should be investigated and addressed in cases of delayed recovery or delayed return to work.
• Physicians can greatly improve patient response to back symptoms by providing assurance, encouraging activity, and emphasizing that more than 90% of LBP complaints resolve without any specific therapies. While patients may be looking for a clear-cut diagnosis for their LBP, the risk to them of a suggested "cure" for this assumed diagnosis, resulting in failed expectations, may be worse than their symptoms.
• Physicians should be aware that "abnormal" findings on x-rays, magnetic resonance images, and other diagnostic tests are so common they are normal by age 40. Bulging discs continue to increase after age 40, and by age 60 will be encountered in 80% of patients. This requires that a careful history and physical examination be conducted by a skilled physician in order to correlate historical, clinical, and imaging findings prior to assigning the finding on imaging to a patient's complaints. It is recommended that physicians unable to make those correlations, and thus properly educate patients about these complex issues, should defer ordering imaging studies to a qualified consultant in musculoskeletal disorders. Without proper education on prevalence, treatment, and prognosis, patients may become fixated on "fixing" their abnormality (which may in fact be a completely normal condition) and thus iatrogenically increase their risk of developing chronic pain.
• Significant abnormalities in hip range-of-motion may increase the probability of back disorders.

Summary Tables: Recommendations and Evidence

The following summary tables contain the recommendations of the Evidence-based Practice Spine Panel. These recommendations are based on critically appraised higher quality research evidence or, when higher quality evidence was unavailable or inconsistent, on expert consensus observing the First Principles of Clinical Logic as required in the American College of Occupational and Environmental Medicine (ACOEM) Methodology. Table 1 is a summary of the recommendations by treatment (i.e., medications). Table 2 is a summary by low back disorder. The reader is cautioned to utilize the more detailed indications, specific appropriate diagnoses, temporal sequencing, preceding testing or conservative treatment, and contraindications that are elaborated in more detail for each test or treatment in the body of this Guideline when using these recommendations in clinical practice or medical management. These recommendations are not simple "yes/no" criteria.

Recommendations are made under the following categories:

• Strongly Recommended, "A" Level
• Moderately Recommended, "B" Level
• Recommended, "C" Level
• Insufficient – Recommended (Consensus-based), "I" Level
• Insufficient – No Recommendation (Consensus-based), "I" Level
• Insufficient – Not Recommended (Consensus-based), "I" Level
• Not Recommended, "C" Level
• Moderately Not Recommended, "B" Level
• Strongly Not Recommended, "A" Level

Table 1: Summary of Recommendations for Evaluating and Managing Low Back Disorders

Table 2: Summary of Recommendations by Low Back Disorders

Definitions:

Strength of Evidence Ratings

A: Strong evidence-base: Two or more high-quality studies.¹

B: Moderate evidence-base: At least one high-quality study or multiple moderate-quality studies² relevant to the topic and the working population.

C: Limited evidence-base: At least one study of moderate quality.

I: Insufficient evidence: Evidence is insufficient or irreconcilable.

¹For therapy and prevention, randomized controlled trials (RCTs) with narrow confidence intervals and minimal heterogeneity. For diagnosis and screening, cross sectional studies using independent gold standards. For prognosis, etiology or harms, prospective cohort studies with minimal heterogeneity.

²For therapy and prevention, a well-conducted review of cohort studies. For prognosis, etiology or harms, a well-conducted review of retrospective cohort studies or untreated control arms of RCTs.

* "Appropriate" means meeting screening or preventive method entry criteria without contraindications, or having the appropriate diagnosis, indication, time frame, prior conservative testing or treatment, and lack of contraindications for the specific test or treatment.

** For example, would include acetaminophen and self-administered cold or heat treatments. Excludes all interventional treatments, manual adjustment, and prescriptions medications. Aggregate and individual harms and costs are considered.

The following clinical algorithms are provided in the original guideline document:

• Master low back algorithm
• Initial evaluation of acute and subacute low back and radicular pain
• Initial and follow-up management of acute and subacute low back and radicular pain
• Evaluation of subacute or slow-to-recover patients with low back pain unimproved or slow to improve (symptoms >4 weeks)
• Surgical considerations for patients with anatomic and physiologic evidence of nerve root compression and persistent low back symptoms
• Further management of subacute low back pain
• Further management of chronic low back pain

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Where there was not quality evidence, guidance represents a consensus of the Evidence-based Practice Spine Panel.

• Improved efficiency of the diagnostic process
• Effective treatment resulting in symptom alleviation and cure

• False-positive or false-negative diagnostic tests
• Risks and complications of surgical procedures and imaging studies (e.g., infection, radiation)
• Side effects of medications and injection therapies

Implanted metallic-ferrous device and significant claustrophobia are contraindications for magnetic resonance imaging (MRI)

• Original data from high- or moderate-quality randomized controlled clinical trials or cross-over trials were relied upon to develop all evidence-based treatment guidance. Many "systematic" reviews, low-quality randomized controlled studies, other studies, and other guidelines for treatments are referenced and reviewed in the Appendix of the original guideline document. Most of these "systematic" reviews or other guidelines are not high-quality reviews and guidelines usually due to one or more errors (e.g., lack of defined methodology, incomplete database searches, lack of exhaustive searches, lack of clearly defined article grading, lack of consideration of the importance of study design, selective use of the studies and inadequate or incorrect interpretation of the studies' results). These errors may render the conclusions invalid. Aside from Cochrane reviews which are nearly always high quality, these reviews, other studies, and other guidelines were not relied upon for purposes of the development of this document's guidance on treatments.
• The American College of Occupational and Environmental Medicine (ACOEM) provides this segment of guidelines for practitioners and notes that decisions to adopt particular courses of actions must be made by trained practitioners on the basis of the available resources and the particular circumstances presented by the individual patient. Accordingly, the ACOEM disclaims responsibility for any injury or damage resulting from actions taken by practitioners after considering these guidelines.

An implementation strategy was not provided.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

• Hegmann KT, ed. Low back disorders. In: Glass LS, editor(s). Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers. 2nd ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2007. p. 366. [1310 references]

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

1997 (revised 2007)

American College of Occupational and Environmental Medicine - Medical Specialty Society

American College of Occupational and Environmental Medicine

American College of Occupational and Environmental Medicine Practice Guidelines Committee

Editor-in-Chief: Kurt T. Hegmann, MD, MPH, FACOEM, FACP

Evidence-based Practice Spine Panel Chair: James Talmage, MD

Evidence-based Practice Spine Panel Members: Roger Belcourt, MD, MPH, FACOEM; Jill Galper, PT, Med; Elizabeth Genovese, MD, MBA, FACOEM; Michael Goertz, MD, MPH, FACOEM; James Lessenger, MD, FACOEM; Tom Mayer, MD; Scott Morris, MD, MPH; Kathryn Mueller, MD, MPH, FACOEM; Jack Richman, MD, FACOEM, CCFP, DOHS; Russell Travis, MD; Michael S. Weiss, MD, MPH, FACOEM, FAAPMR, FAANEM

Panel Consultants: Timothy K. Behrens, PhD, CHES; M. Jann Dewitt, PhD; Steven D. Feinberg, MD, MPH; Corey D. Fox, PhD, ABPP; Arun Garg, PhD, CPE; Paul Hooper, DC, MPH, MS; Christy Porucznik, PhD, MSPH; William Tellin, DC, DABCO; Matthew S. Thiese, MSPH, PhD-C

Methodology Committee Consultant: John P. Holland, MD, MPH, FACOEM

Managing Editors: Production: Marianne Dreger, MA; Research: Julie A. Ording, MPH; Editorial Assistant: Debra M. Paddack

Roger Belcourt, MD, MPH (Panel Member)

Assistant Vice President, Pacific Coast Zone, Concentra

National, Regional, Local Committee Affiliations—President, Nevada Health Professional Assistance Foundation; Diversion Committee and Foundation Board Member; Nevada Institutional Review Board; Board of Directors, Western Occupational and Environmental Medical Association (WOEMA); and Chair, 2006 Western Occupational Health Conference

Guidelines Related Professional Activities—None

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Jill Galper, PT, MEd (Panel Member)

Vice President, Clinical Program Development, IMX Medical Management Services

National, Regional, Local Committee Affiliations—Executive Committee, Southeast District, Pennsylvania Physical Therapy Association

Guidelines Related Professional Activities—Affiliate Editor, ACOEM's APG Insights; American Physical Therapy Association (APTA)

Representative for Occupational Medicine Practice Guidelines, 2nd Edition, 2004

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Elizabeth Genovese, MD, MBA (Panel Member)

Medical Director, IMX Medical Management Services; Adjunct Assistant Professor of Medicine, Associated Faculty, University of Pennsylvania School of Medicine

National, Regional, Local Committee Affiliations—Board of Directors, American Academy of Disability Evaluating Physicians; Advisory Committee, Athena Institute for Women's Wellness; Board of Directors, Philadelphia OEMS; Committee on Coding and Classification, ACOEM; Committee on Return to Work, ACOEM; Evidence Based Practice Committee, ACOEM; AMA CPT Advisory Committee, ACOEM Representative; Director, "Musculoskeletal Diagnosis and Treatment" course, ACOEM; Co-Director, "Clinical Guidelines" course, ACOEM

Guidelines Related Professional Activities—Member, Evidence Based Practice Committee, Occupational Medicine Practice Guidelines, 2nd Edition, 2004; Editor, ACOEM's APG Insights; Section Reviewer, AMA Guides to the Evaluation of Permanent Impairment, 6th Edition

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Michael Goertz, MD, MPH (Panel Member)

Department Chair, Occupational Medicine, Park Nicollet Clinic

National, Regional, Local Committee Affiliations—Medical Services Review Board, DOL State of Minnesota

Guidelines Related Professional Activities—Guidelines Panel Member, Disability Prevention/Management, ACOEM; Member, Evidence Based Practice Committee, ACOEM Occupational Medicine Practice Guidelines, 2nd Edition, 2004

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Kurt Hegmann, MD, MPH (Editor-in-Chief)

Associate Professor and Center Director, Rocky Mountain Center for Occupational and Environmental Health, University of Utah

National, Regional, Local Committee Affiliations—Member, Ergonomics Committee (Chair 2001-05), ACOEM; Board of Trustees, American Board of Preventive Medicine (Chair, Examination Committee); and Chair, Federal Motor Carrier Safety Administration's Medical Review Board

Guidelines Related Professional Activities—Chair, Evidence Based Practice Committee (update of 2nd Edition), ACOEM; Member, Council on Scientific Affairs (2001-05), ACOEM

Research Grants/Other Support—NIOSH (CDC) Training grants and research grants primarily on the epidemiology of musculoskeletal disorders (e.g., CTS, shoulder tendinosis, LBP) and truck driver safety; and a grant from the Utah Labor Commission studying cancers among firefighters and police officers

Financial/Non-Financial Conflict of Interest—Honoraria: Teaching honoraria from various courses, mostly ACOEM-related; Consultations: Consulting with companies regarding how to reduce work-related injuries, causation and apportionment of injuries and consultations with unions regarding return to work, work restrictions and work-relatedness on injuries; Clinical: Primary, secondary and tertiary clinical management of occupational injuries and diseases

John P. Holland, MD, MPH (Methodology Committee Consultant)

Principal, Holland Associates, Inc., Seattle, Washington; Clinical Assistant Professor, Department of Environmental and Occupational Health Sciences and Department of Orthopaedics, University of Washington, Seattle

National, Regional, Local Committee Affiliations—Board of Directors (1994-2005), ACOEM; President (2003-04), ACOEM; Chair, Council on External Affairs (2005-06), ACOEM

Guidelines Related Professional Activities—Chair, Practice Guidelines Committee (1998-2000), ACOEM; Chair, Practice Guidelines Steering Committee (2003-06), ACOEM; Methodology Advisory Group and Peer Reviewer (2001-04), Occupational Medicine Practice Guidelines, 2nd Edition, ACOEM; Head, Research Team (1991-94), Clinical Practice Guidelines on Low Back in Adults, AHCPR; Head, Research Team (1998-2002), Clinical Practice Guidelines for Young Children with Developmental Disabilities, New York State Department of Health

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

James Lessenger, MD (Panel Member)

Private Practice; Disability Examiner, Department of Social Services, State of California; Consultant, Toxcenter, Northridge Hospital Medical Center; Consultant, Medical Board of California; Lecturer, Occupational Medicine Residency, University of California, San Francisco

National, Regional, Local Committee Affiliations—Board Member, Benicia Historical Museum; Editorial Board, Journal of Agromedicine; Western Occupational Medicine Association

Guidelines Related Professional Activities—None

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Tom Mayer, MD (Panel Member)

Private Practice: Medical Director, Productive Rehabilitation Institute of Dallas for Ergonomics (PRIDE), Dallas, TX; Clinical Professor of Orthopedic Surgery, University of Texas Southwestern Medical Center

National, Regional, Local Committee Affiliations—Editorial Board and Founding Editor, The Spine Journal; Board of Associate Editors, SPINE; Interdisciplinary Program Work Group, Division of Workers' Compensation/Texas Department of Insurance; International Editorial Board, Isokinetics and Exercise Science; Editorial Board, The Back Letter; Board of Trustees, Dallas Opera Association

Guidelines Related Professional Activities—Musculoskeletal Section Editor and Spine Chapter Author, Executive Editorial Board, 6th Edition, AMA Guides to the Evaluation of Permanent Impairment; Editorial Advisory Board, Official Disability Guidelines (ODG); AMA Guides Newsletter Advisory Board; Co-Chair, North American Spine Society, Spine Treatment Guideline (1996-04); Co-Chairman, Texas Spine Treatment Guideline Work Group (1990-95)

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Scott Morris, MD, MPH (Panel Member)

Area Medical Director, Chicago, Concentra Medical Centers

National, Regional, Local Committee Affiliations—None

Guidelines Related Professional Activities—None

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Kathryn Mueller, MD, MPH (Panel Member)

Medical Director, Colorado Division of Workers Compensation, Colorado Department of Labor; Professor of Surgery, Division of Emergency Medicine and Department of Preventive Medicine, University of Colorado Health Science Center; UCHSC Graduate School Faculty

National, Regional, Local Committee Affiliations—International Association of Injury and Accident Boards and Commissions Committee on Occupational Health and Disability Management; Bylaws Revision Committee, Committee on Workers' Compensation, Committee on Evidence Based Medicine, Steering Committee for Revision of ACOEM Guidelines, ACOEM; Task Force on Chronic Pain, Task Force Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy, Upper Extremity Task Force on Carpal Tunnel, Cumulative Trauma Disorder and Thoracic Outlet Syndrome, Task Force on Lumbar and Cervical Spine and Lower Extremity, Colorado Division of Workers' Compensation; Workers' Compensation Personal Injury and Workers' Compensation Committee, Colorado Medical Society; Preventive Medicine Residency Advisory Committee, Occupational Medicine Residency Advisory Committee, MSPH Policy Committee, MSPH Curriculum Committee, University of Colorado School of Medicine

Guidelines Related Professional Activities—Section Editor, AMA Guides to Evaluation of Permanent Impairment, 6th Edition; LBP Guideline Subcommittee, American Pain Society/American College of Physicians; Guidelines for State of Colorado; Editorial Board, AMA Guides Newsletter; Adviser/Reviewer, Medical Disability Advisor, 3rd Edition

Research Grants/Other Support—NIOSH Training Grant for Occupational Medicine Residencies, University of Colorado Health Sciences Department of Preventive Medicine

Financial/Non-Financial Conflict of Interest—Received less than $2,000 in honorarium for teaching engagements for ACOEM

Jack Richman, MD (Panel Member)

Executive Vice President and Medical Director, AssessMed Inc.; and President, AssessMed Quality Review

National, Regional, Local Committee Affiliations—Chair, Research Committee of the Canadian Institute for the Relief of Pain and Disability (CIRPD)

Guidelines Related Professional Activities—Member, Guidelines Committee, ACOEM (2nd Edition); Ontario Government Occupational Disease Panel for the Workplace Safety and Insurance Board; and Chair, Standards Committee, Canadian Society of Medical Evaluators

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

James B. Talmage, MD (Chair of Panel)

Occupational Health Center LLC, Cookeville, Tennessee

National, Regional, Local Committee Affiliations—Member, Return to Work Committee, ACOEM; Examination Committee, ABIME; Editorial Advisory Board, Tennessee Workers' Comp Reporter; Editorial Board, Tennessee Medicine, Tennessee Medical Association

Guidelines Related Professional Activities—Chair, Spine Panel, Occupational Medicine Practice Guidelines; (update to 2nd Edition); Associate Editor, APG Insights, ACOEM; Associate Editor, AMA Guides Newsletter; Section Editor, Medical Disability Advisor, 3rd, 4th, 5th Editions; Reviewer, Guides to the Evaluation of Permanent Impairment, 5th Ed.

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Russell Travis, MD (Panel Member)

Associate Medical Director, Cardinal Hill Rehabilitation Hospital; Voluntary Faculty, University of Kentucky Physical Medicine and Rehabilitation Department

National, Regional, Local Committee Affiliations—Board of Directors, American Academy of Disability Evaluating Physicians; Task Force on Health Care and Access and Affordability, Commonwealth of Kentucky; Board of Directors, Kentucky Foundation for Medical Care; Committee on Professional Liability Insurance, Committee on National Legislative Activities, Committee on Medical Insurance and Prepayment Plans, Kentucky Medical Association; Regional Translational Research Committee and Co-chair Selection Committee for Endowed Research Chair; Board of Directors, Kentucky Medical Insurance Company; Joint Washington Committee of Neurosurgery; Joint Section on Disorders of the Spine and Peripheral Nerves and Spine Task Force

Guidelines Related Professional Activities—Chapter Work Group, AMA's Guides to the Evaluation of Permanent Impairment, 6th Ed.; Editorial Advisory Board, Official Disability Guidelines, ODG Treatment; Advisory Board, ACOEM's APG Insights

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Michael S. Weiss, MD, MPH (Panel Member)

Medical Director, Occupational Health Services, St. Luke's Regional Medical Center; Assistant Clinical Professor, Department of Rehabilitation Medicine/Department of Environmental and Occupational Medicine, University of Washington School of Medicine; Medical Director, Idaho Power Company; Medical Director, Paradigm Health Corporation; Medical Consultant, Idaho State Insurance Fund

National, Regional, Local Committee Affiliations—Board, Northwest Occupational and Environmental Medical Association; Resident Advisory Committee, University of Washington, Department of Environmental and Occupational Medicine

Guidelines Related Professional Activities—None

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

This is the current release of the guideline.

This guideline updates a previous version: Low back complaints. In: Glass LS, editor(s). Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers. 2nd ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. p. 286-326.

The ACOEM Guidelines are currently being updated on a 3-year rolling process.

None available

None available

This NGC summary was completed by ECRI on May 31, 2006. The information was verified by the guideline developer on November 3, 2006. This summary was updated by ECRI Institute on July 29, 2008. The updated information was verified by the guideline developer on August 7, 2008.

The American College of Occupational and Environmental Medicine, the signator of this license, represent and warrant that they are the publisher of the guidelines and/or possess all rights necessary to grant the license rights to AHRQ and its agents.