The guidelines set forth by the New York State Workers Compensation Board offer general principles to aid healthcare professionals in addressing injuries affecting the mid and low back. These directives support physicians and healthcare practitioners in determining appropriate measures for comprehensive care when dealing with injuries in these specific areas.
Healthcare professionals specializing in mid and low back injuries can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about suitable approaches for their patients.
It is crucial to emphasize that these guidelines are not meant to replace clinical judgment or professional expertise. The ultimate decision regarding the management of mid and low back injuries should involve collaboration between the patient and their healthcare provider.
Introduction to Mid and Lower Back Injury
History Taking and Physical Examination
The process of taking a patient’s history and conducting a physical examination forms the cornerstone for subsequent diagnostic and therapeutic procedures. If the results from clinical evaluations and other diagnostic procedures do not align, greater weight is given to the objective clinical findings. It is imperative that medical records thoroughly and reasonably document the following:
History of Present Illness
When conducting a detailed history, it is crucial to focus on the temporal proximity to the time of injury, as this will primarily guide the evaluation and subsequent treatment. The comprehensive history should encompass the following aspects:
Mechanism of Injury: This involves obtaining detailed information about the symptom onset and progression, including a thorough description of the incident. It is crucial to understand the body’s position before, during, and at the end of the incident. In cases where there isn’t a specific incident, it becomes important to include details about work body postures, their frequency during the workday, and lifting/pushing/pulling requirements.
Location of Pain, Nature of Symptoms, and Alleviating/Exacerbating Factors: The history should delve into the specifics of the pain’s location, the nature of symptoms, and factors that either alleviate or exacerbate the condition, such as sitting tolerance. Both primary and secondary complaints should be addressed, for example, primary back pain with secondary hip or groin pain.
The Use of an Accepted Pain Assessment Tool: Employing a recognized pain assessment tool, like the Visual Analog Scale (VAS), is highly recommended, especially within the initial two weeks post-injury. This ensures that all work-related symptoms, including pain, are adequately addressed.
Presence and Distribution of Lower Extremity Symptoms: Special attention should be given to the presence and distribution of lower extremity numbness, paresthesias, or weakness, particularly if they are precipitated or worsened by coughing or sneezing.
Alterations in Bowel, Bladder, or Sexual Function: The history-taking process should also explore any alterations in bowel, bladder, or sexual function, as these can be indicative of underlying issues related to the injury.
Past injuries, both work-related and non-occupational, to the same region, should be explored. This includes details about prior treatments, any history of specific motor vehicle accidents, and chronic or recurring symptoms. A thorough review of any previous spinal imaging studies is essential.
Consideration should be given to the individual’s emotional and psychological responses related to the current injury or illness.
The ability to carry out job duties and engage in everyday activities is a crucial aspect that needs to be examined.
Past History
Gathering a comprehensive past medical history is an important step.
A thorough review of systems should cover various elements, including signs or symptoms related to constitutional health, eyes, ears, nose, mouth, and throat, cardiovascular system, respiratory system, gastrointestinal system, genitourinary system, musculoskeletal system, integumentary/breast, neurological system, psychiatric aspects, endocrine system, and hematologic/lymphatic system, as well as allergic/immunologic responses. Depending on the specific condition under consideration and clinical judgment, the scope and emphasis of this review can be adjusted on a case-by-case basis.
An exploration of smoking history is essential to gain a comprehensive understanding.
Examining vocational and recreational pursuits provides valuable insights into an individual’s daily activities.
It’s important to delve into the history of depression, anxiety, or any other psychiatric illness for a holistic perspective.
Physical Examination
Guided by the patient’s medical history, the examination should encompass accepted tests and techniques relevant to the specific area under consideration:
Conducting a check on vital signs is a fundamental aspect of the examination.
A general inspection is crucial, encompassing an evaluation of posture, stance, and gait.
Visual inspection aids in a comprehensive assessment.
Palpation, involving a tactile examination, is an essential part of the process.
Evaluating lumbar range of motion, assessing the quality of motion, and identifying muscle spasms are integral components. Specific joint motion assessments may be required.
Examining the thoracic spine and pelvis provides a more complete understanding.
Nerve tension testing, including the Lasegue Test (Straight Leg Raise test), is a valuable part of the examination. A positive result is typically considered when elevation falls between 25 and 60 degrees, with precise degrees always being reported.
Examining the sensory and motor functions of the lower extremities with a specific focus on nerve roots is a key part of the assessment.
Evaluating deep tendon reflexes provides valuable insights.
In cases where relevant, conducting an abdominal examination, measuring circumferences of the lower extremities, or assessing other abnormalities in the lower extremities is warranted.
A thorough hip examination, encompassing range of motion, pain assessment, and deformity evaluation, is an important aspect.
Conducting a lower extremity vascular examination, including palpation of distal pulses, contributes to a comprehensive assessment.
Spinal Cord Evaluation
When there are indications of a potentially severe injury based on the mechanism of injury, history, or clinical presentation, it is imperative to conduct additional evaluations. A comprehensive neurological examination, aimed at assessing the possibility of spinal cord injury, may involve:
Checking sharp and light touch, deep pressure, temperature, and proprioceptive sensory functions.
Conducting strength testing to evaluate motor functions.
Assessing anal sphincter tone and/or perianal sensation.
Examining the presence of pathological reflexes.
Classifying spinal cord lesions according to the American Spine Injury Association (ASIA) impairment scale is a crucial step in the evaluation process.
Red Flags
Certain findings, commonly referred to as “red flags,” warrant careful consideration as they indicate a potential for serious and urgent medical conditions. The assessment, which encompasses both the patient’s history and physical examination, should specifically focus on identifying these red flags. In the context of mid and low back issues, these concerning indicators may involve acute fractures, dislocations, infections, tumors, progressive neurological deficits, cauda equina syndrome, and extraspinal disorders. The identification of such red flags may necessitate further evaluation, consultation, or even urgent/emergent interventions. The New York Mid and Low Back Injury Guidelines are designed to incorporate adjustments in clinical management in response to the presence of these red flags, ensuring a proactive and tailored approach to patient care.
