This is the current release of the guideline.

The American College of Occupational and Environmental Medicine (ACOEM) reviews the literature periodically to identify any major changes in the evidence-base by content area. Subsequent updates of the guidelines will be a full review of previous recommendations. The Panels will review new evidence and revise recommendations at least every 3 years.

Chronic pain conditions including:

• Complex regional pain syndrome (CRPS)
• Neuropathic pain (focus on radicular pain and peripheral neuropathic pain)
• Trigger points/myofascial pain
• Osteoarthritis (OA)
• Chronic persistent pain (CPP)
• Chronic non-specific pain syndrome (CNSPS)

Adults with chronic pain 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. Patient education
3. Occupational therapy/programs
4. Appliances and skilled non-medical therapies
5. Exercise
6. Medications
7. Injection and infusion therapies

The following databases were searched from 1966 to 2008:

• The National Library of Medicine's MEDLARS Database (Medline) (www.nlm.nih.gov )
• The Cochrane Central Register of Controlled Trials
• CINAHL (nursing, allied health, physical therapy, occupational therapy, social services)
• EMBASE
• PEDro
• EMB Online (www.bmjjournals.com )
• TRIP Database (www.tripdatabase.com )

The following inclusion/exclusion criteria were used:

Original data from high- or moderate-quality randomized controlled clinical trials or cross-over trials are relied upon to develop the guidelines. The authors excluded case studies of individual patients or non-controlled groups of patients, studies that are not peer-reviewed, and other guidelines. 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. However, aside from Cochrane reviews, these reviews, other studies, and other guidelines were not relied upon for purposes of the development of this document's guidance on treatments. In conclusion, the authors only include high- and moderate-quality randomized controlled clinical trials or cross-over trials.

Not stated

Strength of Evidence Ratings

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

B: Moderate evidence-base: At least one high-quality study or multiple moderate-quality studies** 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.

*For 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.

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

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.

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.

See the "Availability of Companion Documents" field for more information on the formulation of recommendations.

Published cost analyses were reviewed.

External Peer Review

American College of Occupational and Environmental Medicine's (ACOEM) conducts external peer review of the ACOEM Occupational Medicine Practice Guidelines (Guidelines) to 1) assure that all relevant high-quality scientific literature has been found, 2) assure that the important evidence from the scientific literature relevant to the Guidelines has been accurately interpreted, 3) solicit opinions on whether the findings and recommendation statements are appropriate and consistent with the evidence, and 4) obtain general information on the Guidelines' conclusions and presentation from external topic experts. A more detailed explanation of the external peer review process is included in Attachment 13 of the "Methodology for the Update of the Occupational Medicine Practice Guidelines, 2nd edition" (see the "Availability of Companion Documents" field). These experts review the methodology used as well as summaries of the critically appraised evidence and the recommendations in each area. The Guidelines list the names of all peer reviewers, along with their affiliations for those not desiring anonymity. The Panels review the comments received from the external peer reviewers and make any final modifications to the Guidelines.

Stakeholder Input

In order to understand the needs and preferences of those individuals and organizations who use or are affected by the use of clinical practice guidelines in workplace settings and in the workers' compensation system, ACOEM solicits input from the following stakeholders: clinicians, health-care systems, workers/patients, employers, utilization reviewers, case managers, insurers and third party administrators, attorneys, regulators and policy makers. ACOEM solicits input from these stakeholders by various formal and informal mechanisms on an ongoing basis during the Guidelines development and implementation process. Specific processes and formats for soliciting input from stakeholders is further described in Attachment 15 of the "Methodology for the Update of the Occupational Medicine Practice Guidelines, 2nd edition" (see the "Availability of Companion Documents" field).

Pilot Testing

The Guidelines are pilot tested by having clinicians, utilization review managers, case managers, state workers' compensation systems, etc., use or comment on use of the Guidelines in their daily practice or management activities to determine if they are clear, easy to use and generally useful. Pilot testers will not be asked if they think the recommendations or process for development were appropriate. The Guidelines may be modified based on the feedback received from pilot testing, if the suggestions increase usability.

Review by the Guideline Methodology Committee (GMC) and the ACOEM Board of Directors

During the entire evidence-based product development process, the GMC will work with the Panels, editors and research staff to ensure that the evidence-based product methodology is being followed, both in the literature evaluation process and development of conclusion and recommendation statements. The Board of Directors has an opportunity to comment on the Guidelines during the external review period. Their comments are reviewed by the Panel and any necessary changes are made to the Guidelines.

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.

Each chapter of the American College of Occupational and Environmental Medicine (ACOEM) Guidelines contains the mainstays of treatment, including chronic pain management, for various specific disorders. This chapter does not supersede that specific guidance. All chapters include analyses of numerous interventions, whether or not U.S. Food and Drug Administration (FDA)-approved. For non–FDA-approved interventions, recommendations are based on the available evidence; however, this is not an endorsement of their use. In addition, many of the medications recommended are utilized off-label. (For example, anti-epileptic agents have been used off-label since the 1960s to treat chronic pain.) The following is a general summary of the recommendations contained in this chapter:

Evaluation and Diagnostic Issues

• In all cases, the body part that is injured should be carefully evaluated with a history, physical examination, and focused diagnostic testing (see specific chapter guidance in the original guideline document). A complete physical is recommended, since pain can be referred from remote organs or anatomical segments (e.g., gallbladder to shoulder or hip joint to knee pain).
• Treatment "failures" are often due to lack of follow-through on initial recommendations for return to function, and can be identified through the patient history.
• The first focus of the initial chronic pain examination or consultation of a patient with chronic pain should be the detection of conditions that are readily remediable or "red flags" for potential alternate conditions.
• Judicious use of diagnostic testing for the initial chronic pain examination or consultation to search for a specific remediable cause may be appropriate.
• Pain is a subjective experience for which there is no objective measure. However, verbal reports of pain can be assessed with regard to compatibility with objective medical findings, and the patient's behavior. This includes consistency of findings with those expected for the condition, consistency of findings during observations within one appointment, and between appointments.
• Repeated diagnostic testing in the absence of indicators for a specifically targeted, remediable cause is not indicated as it focuses the patient on finding an anatomic abnormality, rather than focusing on maintaining and increasing functional outcomes.
• In cases where the chronic pain condition is associated with a substantial compromise of the patient's function and the cause is not apparent, a consultation to confirm the diagnosis and management plan is often appropriate and reassuring to the patient and family. Pain medicine specialists, musculoskeletal disorders experts and other experts in the body part injured (e.g., orthopedic surgeon, neurosurgeon, neurologist, physiatrist and others) as well as behavioral health experts (e.g., pain psychologist, psychiatrist) are all potential consultants for these patients, particularly for purposes of diagnostic confirmation.

Patient Education Issues

• Reassurance that chronic pain is common, in the absence of specific disorders has a good prognosis, and does not cause (or have to cause) severe debility is important for all providers to communicate to the patient. Clinicians providing encouragement that chronic pain is common and manageable are believed to have better outcomes with more effective use of resources, including having more satisfied patients and fewer patients on disability. Reassurance should be tailored to the individual's unique perceptions and lifestyle.
• Patients should be encouraged to maintain as high a level of function at work and resume activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
• Rest, bed rest, and disuse of body parts are not recommended for the routine management of chronic pain conditions as they cause further disability rather than assist in returning the patient to a functional status. The patient may need education to explain these common misconceptions and to address the accompanying fears that are frequently present.
• If the patient has been accurately diagnosed and adequately treated, continuing primary foci on pain ratings and symptoms is counterproductive. Treatment must of necessity focus on increasing function and supplementing the functional restoration plan with appropriate, judicious use of medications and other modalities.
• The patient's cultural background should be considered, including possible language barriers.

Occupational Issues

• All patients should be encouraged to return to normal activity or work as soon as possible. Modified duty is most appropriately utilized when the job demands substantially exceed the patient's capabilities. For those patients on modified or light duty, a plan to return to normal job activities should be specified.
• Non-physical factors (such as psychosocial, workplace, or socioeconomic problems) should be particularly addressed in cases of delayed recovery or delayed return to work.
• Patients should be encouraged to accept responsibility and learn necessary coping skills for managing their recovery rather than expecting the provider to supply an easy or complete "cure." Taking an active role in the recovery process is paramount if the person with pain is to return to work. This 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.
• Participatory ergonomics and return-to-work programs may assist in identifying job attributes that may be perceived barriers to a successful return to work.

Appliances and Skilled Non-medical Therapies

• Slings, splints, and other appliances are contraindicated in managing chronic pain in the absence of focal neurological or structural deficits as they may reinforce pain and illness behaviors.
• Ice, heat, ultrasound, and other similar modalities are rarely indicated in the clinical setting. Heat and ice may be considered as a part of self care to be used at home if their use provides the patient with temporary relief of symptoms, though the physician should be aware that these may also reinforce pain and illness behaviors in persons with chronic non-malignant pain.
• There is no evidence to support prolonged and repetitive use of skilled non-medical therapies (massage, electrical therapies, manipulation, acupuncture, etc.) and, in the absence of documentation of functional improvement, they are not indicated in managing patients with chronic pain. These interventions tend to draw attention towards numbers of appointments and adding or trying more passive modalities, instead of focusing on and benchmarking increases in activity levels. Their use may be briefly indicated in conjunction with the introduction of an active conditioning program that includes both aerobic and strengthening components for treatment of referred patients found to have significant debility and deconditioning.
• Judicious short-term use of skilled non-medical therapies may be indicated for significant exacerbations of underlying chronic pain conditions when there has been documented improvement following such treatments. Such exacerbations may be analogous to acute pain episodes; however, in the patient with chronic pain, such exacerbations are also believed to entail risk of sliding into reduced functional status. Physicians who recommend these therapeutic approaches should be aware that they may detrimentally draw the focus away from increasing function and reinforce pain behavior and disability. A transition back to active treatment modalities and self care should be reinforced to the patient at that first visit to establish clear expectations.

Exercise Issues

• Graded exercises to assist in achieving a return to maximal function are indicated. Aerobic and strengthening exercises appear most helpful for the rehabilitation of most chronic pain conditions.
• Stretching or flexibility exercises may be important components to treat some patients' injuries. They are important where there is a significant reduction in range of motion and where restoration of range of motion is required to enable engagement in strengthening and functional activities. In general, stretching exercises can be taught by therapists, but should be performed by patients repeatedly, with limited numbers of repetitions to achieve most rapid gains in flexibility. Where there is either minimal or no reduction in range of motion, however, strengthening and aerobic exercise should be emphasized.

Medications

• Although there is considerable overlap between types of pain, the physician should seek to identify whether chronic non-malignant pain is due to a specific diagnosis and/or thought to be primarily nociceptive, neuropathic, or of unclear etiology. Treatment options for these divergent types of commonly encountered pain have some differences—e.g., there is evidence that pain patients with neuropathic conditions may respond to anti-convulsant medications, whereas patients with nociceptive or chronic non-malignant pain do not. When evidence clearly indicates that specific medications are particularly effective in managing a given diagnosis or type of pain, they should be used preferentially. When the response to a medication has been suboptimal, consideration should be given to discontinuing it either before or immediately after adding a different agent.
• If an intervention is ineffective, it is better to stop it and try a different intervention (e.g., rather than switch to a different non-steroidal anti-inflammatory drug [NSAID], consider manipulation, exercise, and/or a different class of medications).
• Opioid use in the setting of chronic, non-malignant, or neuropathic pain is controversial. Opioids used in higher doses tend to have a greater adverse effect profile. A potential for abuse or addiction does exist, especially with inappropriate use; systemic effects also are apparent over time in many patients for whom opioids are prescribed. Patients on opioids should be routinely monitored for signs of impairment, particularly those who are working in safety sensitive positions (including those who have to drive to and from work). However, while there is population-based evidence of approximately doubled crash risk continuing at 2 weeks into opioid treatment, there is also literature that suggests there may not be elevated accident risk among those who are accustomed to opioid use and are on stable doses of medication.
• Use of opioids in patients with chronic pain should be reserved for those with improved functional outcomes attributable to their use, in the context of an overall approach to pain management that also includes non-opioid analgesics, adjuvant therapies, psychological support, and active treatments (e.g., exercise).

Injection and Infusion Therapies

• While injection and infusion therapies are widely used in the management of patients with chronic pain, there is generally no high-quality literature demonstrating efficacy and no evidence of long-term pain relief or demonstrable increases in function in the literature (usually case series) that does promote their use. Hence, while they may have an occasional role in the management of carefully selected patients, their indiscriminate use is not recommended.
• Furthermore, when the decision is made to employ injection or infusion therapies as an adjunct to patient care, the goal should be to use the temporary decrease in pain that they afford to initiate reductions in use of opioid medications, or encourage performance of exercises that previously may not have been tolerated and functional activities that were not possible before the procedure. Documentation of objective, quantifiable benefit as a consequence of their use must be provided, and repeated interventions in the absence of this documentation would not be warranted.

Other Issues

• The majority of those with chronic pain do not seek professional health care, and are able to control symptoms with simple modalities such as over-the-counter medications, a heating pad, exercise and other remedies. Even those who have had complicated courses (e.g., complex treatment, litigation, etc.) can reach a state of self-management and coping with pain. The empowerment of patients to independently manage their pain as early as possible should be encouraged.
• Patients using over-the-counter medications for management of chronic pain should be educated and assessed for potential adverse effects, as those are most likely to occur among chronic medication users.
• Significant psychological factors are nearly always present as etiologic influences and/or sequelae when pain of non-malignant origin becomes chronic as per the biopsychosocial model (see Basic Principles in the original guideline document). Evaluation and management of these factors by the primary treating physician is recommended. When recovery is excessively delayed or psychological/psychiatric treatment by the primary physician is ineffective, consideration should be given to obtaining a comprehensive psychological evaluation. Fear of further injury or missing a diagnosis also needs to be addressed if the person with pain is to progress.
• Focusing the treatment plan primarily on psychological issues is generally difficult for the person with pain to become engaged. More often they become defensive and deny that there is any psychological component. Mind and body can be blended together in a comprehensive pain program by ensuring the person with pain understands the connection. Even compliance with some of the off-label medications such as anti-depressants and anti-convulsants needs to be carefully explained to ensure the patient clearly understands the multiple purposes of these treatments.
• Fibromyalgia is a disorder which typically has significant psychological components, particularly depression and other affective problems, that is reviewed in Appendix 2 in the original guideline document for completeness although it is not an occupational disorder. Despite the underlying psychological components, treatment should consist primarily of progressive aerobic exercises, potentially combined with strengthening exercises, and anti-depressants. This is the only major pain disorder for which selective serotonin reuptake inhibitor (SSRI) anti-depressants are effective (which provides additional indirect evidence that it is a different disorder than other chronic pain conditions), although both the tricyclic anti-depressants and dual serotonin/norepinephrine reuptake inhibiting anti-depressants are also effective.
• Patient involvement in litigation or workers' compensation claims has been shown to be associated with poorer clinical outcomes, including delayed return to work, poorer satisfaction with treatment, and worse surgical outcomes. There are marked differences from state to state with regards to whether patients typically retain attorneys for workers' compensation. Accordingly, whether a patient is involved in litigation over workers' compensation may or may not raise concerns about possible advocagenic influences on the patient's clinical course and prognosis. It is recommended that these local cultural factors be taken into account when attempting to discern potential influences on pain complaints, treatment responsiveness, and disability.

Summary Tables: Recommendations and Evidence

Table 1 is a summary of the Evidence-based Practice Chronic Pain Panel's recommendations for diagnostic and other testing for chronic pain conditions and Table 2 is a summary of recommendations for managing chronic pain conditions. These recommendations are based on critically appraised higher quality research evidence and on expert consensus observing First Principles when higher quality evidence was unavailable or inconsistent. 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 the original guideline document in 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 Diagnostic and Other Testing for Chronic Pain Conditions

Table 2: Summary of Recommendations for Managing Chronic Pain Conditions

Definitions:

Strength of Evidence Ratings

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

B: Moderate evidence-base: At least one high-quality study or multiple moderate-quality studies** 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.

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

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

• Chronic pain management
• Management of complex regional pain syndrome (CRPS)
• Management of trigger points/myofascial pain
• Management of neuropathic pain
• Management of fibromyalgia

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

Appropriate evaluation and treatment of patients with chronic pain

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.

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

American College of Occupational and Environmental Medicine

American College of Occupational and Environmental Medicine's Evidence-based Practice Chronic Pain Panel

Panel Members: Gerald M. Aronoff, MD, DABPM; Daniel Bruns, PsyD; Jeffrey L. Cole, MD; Penney Cowan; Steven D. Feinberg, MD, MPH (Chronic Pain Chapter Associate Editor); Corey D. Fox, PhD, ABPP; Jill Galper, PT, MEd; Elizabeth Genovese, MD, MBA, FACOEM (Chronic Pain Chapter Associate Editor and Lead Chair); Lee S. Glass, MD, JD; Scott Haldeman, MD, DC, PhD, FRCP(C), FAAN, FCCS; Jeffrey S. Harris, MD, MPH, MBA, FACOEM (Methodology Committee Consultant); Kurt T. Hegmann, MD, MPH, FACOEM (Editor-in-Chief); Wilhelmina C. Korevaar, MD, MMM (Chronic Pain Chapter Associate Editor and Associate Chair); James E. Lessenger, MD, FACOEM; Steven Mandel, MD; Tom G. Mayer, MD; Kathryn L. Mueller, MD, MPH, FACOEM (Chronic Pain Chapter Associate Editor and Associate Chair); Albert J. Osbahr III, MD, MSCM, FACOEM; Russell Travis, MD; April Hazard Vallerand, PhD, RN, FAAN; Pamela A. Warren, PhD; Janet S. Weiss, MD; Thomas Winters, MD, FACOEM

Gerald M. Aronoff, MD, DABPM (Panel Member)

Adjunct Associate Professor, Duke University Medical Center, Department of Psychiatry, Pain Evaluation & Treatment Service; Medical Director, Carolina Pain Associates, PA & North American Pain and Disability Group

National, Regional, Local Committee Affiliations—Past President, North Carolina Pain Society; Past President, American Academy of Pain Medicine; Past President, New England Pain Association, Eastern Pain Association, NC Pain Society; Past Chairman, American Pain Society's Committee on Pain Centers; Past member of the Commission Accreditation of Rehabilitation (CARF) National Advisory Committee for Pain; Past pain consultant to FDA, Arthritis Advisory Committee; Past Chairman, American Academy of Pain Medicine's End of Life Task Force; Advisory Board, National Pain Foundation

Guidelines Related Professional Activities—Pain consultant to the Federation of State Medical Boards; Consensus Panel to develop guidelines for the use of controlled substances for chronic pain; Task Force to develop national guidelines for management of non-malignant pain in the elderly; Chairman, AADEP Task Force to Develop Guidelines for CRPS (RSD) Impairment and Disability Issues (2002); Co-Chairman, AADEP Task Force to develop Guidelines for Fibromyalgia Syndrome: A Consensus Report on Fibromyalgia Impairment and Disability (1999); Reviewer, Pain Chapter, AMA Guides to the Evaluation of Permanent Impairment, 6th Edition

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—Multiple speaker bureaus; educational 'think tanks'

Daniel Bruns, PsyD (Panel Member)

Principal, Health Psychology Associates PC, 3D Assessments LLC

National, Regional, Local Committee Affiliations—Chairperson, Clinical Health Services Council: American Psychological Association Division of Health Psychology; Board Member, American Psychological Association's Division of Health Psychology

Guidelines Related Professional Activities—Member, State of Colorado Workers' Compensation Task Force for Evidence-Based Medicine Guidelines (Psychiatric Disability, Chronic Pain, CRPS); State of Colorado Workers' Compensation Advisory Panels for Evidence-Based Guidelines for Low Back/Neck Injury, TBI; Reviewer for AMA Guide to Impairment Ratings; Reviewer, Pain Medicine Journal

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—Author of 3 published psychological tests for injured patients and their test manuals, and receive royalties for them: The Battery for Health Improvement 2 (BHI 2), the Brief Battery for Health Improvement 2 (BBHI 2), and the Comprehensive Pain Scale (CPS).

Jeffrey L. Cole, MD (Panel Member)

Director, Electrodiagnostic Service and Musculoskeletal Rehabilitation, Kessler Institute for Rehabilitation, Department of Physical Medicine & Rehabilitation; Physiatrist, Physical Medicine & Rehabilitation Consultant, PC; Nassau University Medical Center, Department of Physical Medicine & Rehabilitation; Attending Physician, Consultant and former Director of Interventional Pain Management, Department of PM&R; Attending and Consultant, Board Certified, Physiatric Interventional Pain Management; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, UMDNJ; Clinical Associate Professor, Department of Medicine, NYCOM; Diplomate and Fellow, American Academy of Physical Medicine and Rehabilitation

National, Regional, Local Committee Affiliations—Member, Program Planning Committee, American Academy of Physical Medicine and Rehabilitation; Past President, American Society for Clinical Potentials; Vice Chairman, Committee on Physical Medicine and Rehabilitation, Medical Society of the State of New York; Member, Physiatric Association of Spine, Sports and Occupational Rehabilitation; Member, Institute of Electrical and Electronics Engineers.

Guidelines Related Professional Activities—None

Research Grants/Other Support—New Jersey Commission on Spinal Cord Research

Financial/Non-Financial Conflict of Interest—Consultations: health care and business organizations, hospitals

Penney Cowan (Panel Member)

Founder & Executive Director, American Chronic Pain Association

National, Regional, Local Committee Affiliations—Member, Pain Care Forum; Member, IMMPACT II, III, IV, V, VI, VII (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials) Steering Committee; Member, International Neuropathic Pain Network Steering Committee; Member, Northern California Pain Initiative; Member, Evidence-based Medicine Working Group; Member, Alliance for Better Medicine (CA); Member, AgrAbility Project; Member, Chronic Pain Network Steering Committee; Member, American Academy of Pain Medicine's Medical School Curriculum Advisory Board for TOPMED (Topics in Medical Education)

Guidelines Related Professional Activities—Panel Member, American College of Physicians and American Pain Society's Clinical Practice Guidelines for Low Back Pain; Member, Chronic Pain Panel of the Practice Guidelines Coalition

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Steven D. Feinberg, MD, MPH (Chronic Pain Chapter Associate Editor and Panel Member)

Adjunct Clinical Professor, Department of Anesthesia, Stanford University School of Medicine; Pain Program Consultant, Bay Area Pain & Wellness Center Functional Restoration Program; Medical Director, Cedaron Software

National, Regional, Local Committee Affiliations—Past Member and President, Board of Directors, American Academy of Pain Medicine; Past Member and President, Board of Directors of the California Society of Industrial Medicine and Surgery; Member, Board of Directors (Medical Advisor), American Chronic Pain Association; Member, Board of Directors, California Academy of Pain Medicine

Guidelines Related Professional Activities—Member, Pain Chapter Team, AMA Guides to the Evaluation of Permanent Impairment, 6th Edition

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Corey D. Fox, PhD, ABPP (Panel Member)

Principal, Healthcare Consulting Associates

National, Regional, Local Committee Affiliations—Member, Medical Advisory Board, Collaborative for Excellence in Occupational Medicine; Past Member, Advisory Committee, UniMed Direct, LLC; Past Member, Editorial Board, American Pain Society Bulletin; Past Member, Managed Care Committee, American Pain Society

Guidelines Related Professional Activities—Chair, American Pain Society's Committee to develop guidelines on pain management in managed care; developed guidelines on chronic pain for a workers' compensation carrier and a group health plan; Member, CARF International Advisory Committee for Standards

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—Consultations: health care and business organizations, hospitals, health plans and insurers, government agencies regarding health and disability management, guidelines and standards, clinical programs, utilization review, accreditation, staff and program development, and evaluation

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, FACOEM (Chronic Pain Chapter Associate Editor and Lead Chair)

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—Consultations: Client companies are often interested in guidelines

Lee S. Glass, MD, JD (Panel Member)

Associate Medical Director, State of Washington's Department of Labor and Industries

National, Regional, Local Committee Affiliations—Chair, Coding and Classification Committee, ACOEM; Member, Council on OEM Practice, ACOEM; ACOEM Representative to AMA's Relative Value System Update Committee; Committee on Homeland Security, State of Washington Department of Emergency Management; Disaster Preparedness Task Force, Washington State Medical Association; and Bioterrorism Preparedness and Response Program Advisory Committee, Washington State 's Department of Health

Guidelines Related Professional Activities—Member, APS/ACP Low Back Pain Guideline Project; Immediate Past Chair, Guidelines Committee, ACOEM; Editor, ACOEM's Occupational Medicine Practice Guidelines, 2nd Edition; and Past Associate Editor, APG Insights

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Scott Haldeman, MD, DC, PhD, FRCP(C), FAAN, FCCS (Panel Member)

Clinical Professor, Department of Neurology, UCI; Adjunct Professor, Department of Epidemiology, UCLA School of Public Health

National, Regional, Local Committee Affiliations— Past President and Committee Member, North American Spine Society; President, American Back Society; Chairman, World Federation of Chiropractic Research Council

Guidelines Related Professional Activities— Member, IASP Neuropathic Pain Special Interest Group; Member, State of California Department of Workers' Compensation Medical Evidence Evaluation Advisory Committee; Panel Member, U.S. Department of Health and Human Services, Agency for Health Care Policy and Research's Clinical Practice Guidelines on "Acute Low Back Pain in Adults"; Commission Chairman, Guidelines for Chiropractic Quality Assurance and Practice Parameters; Facilitator, American Academy of Neurology's Assessment: The Neurological Evaluation of Male Sexual Dysfunction. Report of the Therapeutics and Technology Assessment Subcommittee; Practice Guidelines Committee and Guidelines Committee Advisory Panel, North American Spine Society; President, The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders; Associate Editor, Spine; Associate Editor and past Deputy Editor, The Spine Journal; Editorial Board, Journal of Manipulative and Physiological Therapeutics; Editorial Board, Alternative Therapies; Editorial Board, Australian Chiropractic Association; Editorial Board, Journal of the Canadian Chiropractic Association; Editorial Board, The Back Letter; International Advisory Board, Clinical Chiropractic

Research Grants/Other Support—None at present; grants to the Task Force on Neck Pain and Its Associated Disorders

Financial/Non-Financial Conflict of Interest—Financial-private practice/non-financial; multiple positions in organizations and associations

Jeffrey S. Harris, MD, MPH, MBA, FACOEM (Methodology Committee Consultant)

Senior Physician, The Permanente Medical Group; President, J. Harris Associates Inc; Clinical Associate Professor, University of California at San Francisco, University of Utah, and Medical College of Wisconsin

National, Regional, Local Committee Affiliations—Board of Directors, Finance Committee, Policies and Procedures Committee, ACOEM; President and Member, Board of Directors, Collaborative for Excellence in Occupational Medicine (CEOM)

Guidelines Related Professional Activities—Guidelines Methodology Committee and Evidence-Based Practice Committee, ACOEM; Consultant, Evidence-Based Medicine Task Force, ACOEM; Editor, ACOEM Occupational Medicine Practice Guidelines, 1st Edition and Associate Editor, 2nd Edition; Past Chair, Practice Guidelines Committee, ACOEM (1994–1998); Guideline Quality Review Committee and Guideline Medical Editor, The Permanente Federation/Care Management Institute; Reviewer, the Cochrane Collaboration, Musculoskeletal and Low Back Groups and Occupational Medicine Field; Panel Member, American College of Physicians/American Pain Society Low Back Guideline

Research Grants/Other Support—University of California at Davis to CEOM

Financial/Non-Financial Conflicts of Interest—None

Kurt T. Hegmann, MD, MPH, FACOEM (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 2001–2005), 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 (2001–2005), 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 injuries; Clinical: Primary, secondary, and tertiary clinical management of occupational injuries and diseases

Wilhelmina C. Korevaar, MD, MMM (Chronic Pain Chapter Associate Editor and Associate Chair)

President, Wilhelmina C. Korevaar, MD, PC; Medical Director, Employee Disability Program, City of Philadelphia

National, Regional, Local Committee Affiliations—None

Guidelines Related Professional Activities—Member, American Society of Anesthesiologist's Task Force for Chronic Pain Guidelines

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—Private practice: evaluation, diagnosis, and treatment of chronic pain and associated conditions; Consultations: government agencies/programs; Independent contractor: specialist evaluations of chronic pain complaints, diagnosis, treatment, and causality

James E. Lessenger, MD, FACOEM (Panel Member)

Private Practice; Disability Examiner, Department of Social Services, State of California; 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

Steven Mandel, MD (Panel Member)

Clinical Professor of Neurology, Jefferson Medical College

National, Regional, Local Committee Affiliations—AADEP Disability Newsletter; Expert Opinion Editor, Practical Neurology; Editor Health Policy, Pennsylvania Neurological Society; Member, Occupational Health Subcommittee, Philadelphia County Medical Society

Guidelines Related Professional Activities—Developed evidence-based guidelines for laryngeal EMG in most peer-reviewed journals

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Tom G. 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 (1996–2004); Co-Chairman, Texas Spine Treatment Guideline Work Group (1990–1995)

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Kathryn L. Mueller, MD, MPH, FACOEM (Chronic Pain Chapter Associate Editor and Associate Chair)

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; ACOEM: Bylaws Revision Committee, Committee on Workers' Compensation, Committee on Evidence-based Medicine, Steering Committee for Revision of ACOEM Guidelines; Colorado Division of Workers' Compensation: Task Force on Chronic Pain, Task Force on 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; 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 the 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 completed July 1, 2007

Financial/Non-Financial Conflict of Interest—Received less than $2,000 in honorarium for teaching engagements for ACOEM; Consultations: research purposes and impairment rating

Albert J. Osbahr III, MD, MSCM, FACOEM (Panel Member)

Medical Director, Occupational Health, Catawba Valley Medical Center

National, Regional, Local Committee Affiliations—Member, AMA Council of Science and Public Health; Member, NC Medical Society Board; Chair/Member, NCMS Industrial Commission Liaison Committee; Chair/Member, NCMS Public Health Committee

Guidelines Related Professional Activities—Independent Reviewer, ACOEM's Occupational Medicine Practice Guidelines, 2nd Edition

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—Consultations: government agencies and corporations

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—Past President, American Association of Neurological Surgeons; Past President, The Neurological Society of America; Member, Kentucky Medical Licensure Board

Guidelines Related Professional Activities—Chapter Work Group, AMA Guides to the Evaluation of Permanent Impairment, 6th Edition; 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

April Hazard Vallerand, PhD, RN, FAAN (Panel Member)

Associate Professor, Wayne State University College of Nursing

National, Regional, Local Committee Affiliations—Elected Member, Pain and Disparities Special Interest Group Advisory Committee, American Pain Society; Member, Board of Directors, Midwest Pain Society; Member, Scientific Program Committee, Midwest Pain Society; Member, Board of Directors, Michigan Cancer Pain Initiative; Past Member, Board of Directors, American Society of Pain Management Nurses

Guidelines Related Professional Activities—Member, American Pain Society's Panel for development of Guidelines for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis; Member, American Geriatric Society's Panel for development of Guidelines for the Management of Persistent Pain in Older Persons; Reviewer of following journals: Cancer, Expert, Reviews in Neurotherapeutics, Cancer Nursing, Journal of General Internal Medicine, Social Science and Medicine, Journal of American Geriatrics Society, American Journal of Nursing, Journal of Pain

Research Grants/Other Support—Detroit Center/College of Nursing Scholar Award

Financial/Non-Financial Conflict of Interest—Reviewer, American Pain Society's guidelines for use of opioids in chronic nonmalignant pain; Consultations: public agencies, foundations, professional associations, and private enterprises

Pamela A. Warren, PhD (Panel Member)

Clinical Psychologist, Carle Clinic Association; Faculty, College of Education, Department of Counseling Psychology and College of Medicine, Department of Psychiatry, University of Illinois-Urbana, Champaign

National, Regional, Local Committee Affiliations—Member, Reed Group Medical Disability Advisory Board; Member, Disability Research Institute Advisory Board; Member, International Association of Rehabilitation Professionals (IARP) Case Management Board of Directors; Member, American Psychological Association's Health Psych Board

Guidelines Related Professional Activities—Sole author of Work Loss Data Institute's Mental Health Guidelines; developed evidence-based guidelines for all major adult psychological diagnoses; Advisor, ACOEM's APG Insights; Reviewer, Mental Health and Behavioral Disorders Chapter, AMA Guides to the Evaluation of Permanent Impairment, 6th Edition; consulted with the Social Security Administration Medical Policy administration in development of utilization of best practice standards for federal psychological guidelines for disability claims

Research Grants/Other Support—Co-investigator for study on evaluation of psychological concerns in women with breast cancer; Co-investigator for EUMASS (European Union of Medicine in Assurance and Social Security) study on psychological aspects of disability and healthcare

Financial/Non-Financial Conflict of Interest—Consultations: health plans and insurers, state and federal governmental agencies, corporations, and legal firms

Janet S. Weiss, MD (Panel Member)

Medical Director, TheToxDoc

National, Regional, Local Committee Affiliations—Member, Reed Group Medical Disability Advisory Board; Member, American Industrial Hygiene Association's Environmental Health Committee; Occupational and Environmental Medicine Committee and Education Committee, American Academy of Clinical Toxicology

Guidelines Related Professional Activities—Contributed 32 chapters to Workplace Guidelines for Disability Duration, 5th Edition

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—Consultation: state and federal governmental agencies, insurance agencies, corporations, and legal firms

Thomas Winters, MD, FACOEM (Panel Member)

Chief Medical Officer & Principal, OEHN; Visiting Scientist, Occupational and Environmental Health, Harvard School of Public Health; Visiting Lecturer, Harvard Medical School

National, Regional, Local Committee Affiliations—Member, Residency Advisory Committee, Occupational/Environmental Health, Harvard School of Public Health

Guidelines Related Professional Activities—None

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—Consultations: health care and business organizations

This is the current release of the guideline.

The American College of Occupational and Environmental Medicine (ACOEM) reviews the literature periodically to identify any major changes in the evidence-base by content area. Subsequent updates of the guidelines will be a full review of previous recommendations. The Panels will review new evidence and revise recommendations at least every 3 years.

Print copies are available from ACOEM, 25 Northwest Point Boulevard, Suite 700, Elk Grove Village, IL 60007; Phone: 847-818-1800. To order a subscription to the online version, call 800-441-9674 or visit http://www.acoempracguides.org/ 

The following is available:

• Methodology for the update of the occupational medicine practice guidelines, 2nd edition. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2006. Available from the ACOEM Web site .

Also, the appendices of the original guideline document  provide assessment forms and a sample treatment agreement form.

None available

This NGC summary was completed by ECRI Institute on June 9, 2010. The information was verified by the guideline developer on July 13, 2010. This summary was updated by ECRI Institute on December 10, 2010 following the U.S. Food and Drug Administration (FDA) advisory on Bisphosphonates. This summary was updated by ECRI Institute on March 16, 2011 following the U.S. Food and Drug Administration advisory on acetaminophen-containing prescription products. This summary was updated by ECRI Institute on April 13, 2011 following the U.S. Food and Drug Administration advisory on Topamax (topiramate).

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