Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Sprains and Strains, Lumbar Spine

sprains and strains, lumbar spine in 中文(中华人民共和国)

Related Terms

  • Low Back Injury
  • Low Back Pain
  • Lumbar Strain
  • Lumbosacral Soft Tissue Injury

Differential Diagnosis

Specialists

  • Cardiologist, Cardiovascular Physician
  • Chiropractor
  • Occupational Medicine Specialist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Sports Medicine Physician

Factors Influencing Duration

Duration is influenced by the severity of the initial pain and by the pain induced impairment in function, the individual's response to treatment, medical and psychiatric co-morbidity, current substance use disorders, use of opioid analgesics, and his or her job requirements and usual leisure activities.

Medical Codes

ICD-9-CM:
721.3 - Lumbosacral Spondylosis without Myelopathy; Arthritis; Osteoarthritis; Spondylarthritis
722.32 - Schmorls Nodes, Lumbar Region
722.93 - Disc Disorder, Other and Unspecified, Lumbar Region
724.2 - Lumbago; Low Back Pain; Low Back Syndrome; Lumbalgia
846.0 - Sprains and Strains of Sacroiliac Region, Lumbosacral Joint
846.1 - Sprains and Strains of Sacroiliac Region, Sacroiliac Ligament
846.2 - Sprains and Strains of Sacroiliac Region, Sacrospinatus (Ligament)
846.3 - Sprains and Strains of Sacroiliac Region, Sacrotuberous (Ligament)
846.8 - Sprains and Strains of Sacroiliac Region, Other Specified Sites
846.9 - Sprains and Strains of Sacroiliac Region, Unspecified Site
847.2 - Sprains and Strains of Other and Unspecified Parts of Back, Lumbar Spine
847.3 - Sprains and Strains of Other and Unspecified Parts of Back, Sacrum; Sacrococcygeal (Ligament)
847.4 - Sprains and Strains of Other and Unspecified Parts of Back, Coccyx
847.9 - Sprains and Strains of Other and Unspecified Parts of Back, Unspecified Site; Back NOS

Overview

The lumbar spine consists of five bony vertebrae separated by intervertebral discs. The lumbosacral region of the spine carries the upper body's weight and is responsible for much of the mobility of the trunk (back).

Sprains and strains imply stretching or tearing of the tissue involved, either muscles (strain) or ligaments (sprain). Recently it has been recognized that "sprain" and "strain" are inappropriate terms for acute low back pain. Typically, the events associated with the onset of their back pain are low force (low violence) activities the person has done multiple times in the past without injury. Physicians have historically diagnosed back "strain" as if muscles were torn, or back "sprain" as if ligaments were torn, although MRI studies in the first 48 hours after pain onset in patients who experience the acute onset of back pain have not shown either strained muscles or sprained ligaments to be present (Modic). Thus modern articles and texts discuss this problem under the heading or diagnosis of "Low Back Pain" and not as either back sprain or back strain. However, these terms have been used historically and are still used by many physicians along, with the associated ICD-9-CM code. It is quick and easy for physicians to explain to patients that back pain is present "because you pulled a muscle", while it is difficult and time consuming to try to explain that "the reason adults get episodes of low back pain is not scientifically established, and the exact structure in the back responsible for the pain cannot be determined."

Carragee et al. followed 200 persons without prior significant low back pain issues for 5 years. Each individual involved had a baseline MRI done despite no history of back problems. One-hundred-seventy of the 200 persons had episodes of minor trauma (including motor vehicle accidents, sports injuries, lifting "strains", and minor falls), as minor trauma events are very common. There were 118 minor trauma events associated with initially major low back pain, and 652 minor trauma events associated with back pain that was mild. There were even more episodes of back pain that began during activities of daily living or began spontaneously, with the person unable to recall what he/she was doing when the pain began. The only association of minor trauma with persisting disabling back pain was in those for whom the "event" was compensable (workers' compensation or personal injury). Out of the original 200 persons, 51 had a second MRI done shortly after an episode of severe acute back pain began. None of the second MRIs showed a muscle or ligament injury to be present. None of the second MRIs in those who associated the back pain with minor trauma showed a change from the baseline MRI done at the start of the study.

Sprains are ligamentous injuries typically caused by sudden movement of a joint beyond the limits of joint motion imposed by the supporting ligaments. The ligaments cannot stretch enough to accommodate the abnormal motion, and thus the ligament stretches, and if enough force is applied, the ligament tears. An example is hyperextension of a knee causing the anterior cruciate ligament in the knee to rupture. Strains are either partial or complete tears of muscle-tendon units, usually as a result of strong muscular contraction sustained in forceful stretching. The events patients associate with the onset of back pain do not typically involve enough motion to cause ligament sprains or enough muscle force to cause muscle strains.

Spinal discs have a hard outer casing (annulus fibrosis) and a softer center (nucleus pulposis). The term "annular tear", also know as "high intensity zone" is used for the MRI imaging finding of increased signal intensity in the annulus. While the name suggests that trauma has occurred and has "torn" the disc annulus, these have been shown to be common age related degenerative findings. These findings do not correlate with pain, and do not necessarily correlate with attempts to provoke pain (e.g. discography). Thus these "annular tears" have no significance and do not confirm that trauma has occurred.

Incidence and Prevalence: Low back pain is very common. Up to 84% of adults will experience low back pain their life time. In the 2002 US National Health Interview Survey, 26% of 31,044 adults reported having had at least 1 day of low back pain in the last 3 months (Deyo). In a separate epidemiology survey in Saskatchewan, Canada 50% of adults reported having had low back pain in the last 6 months, and 11% had had disabling low back pain (Cassidy).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Causation of low back pain has been studied extensively, but without consensus. While back pain patients frequently want to ascribe their back pain episodes to work activity, attempts to scientifically establish work activities as risk factors have yielded conflicting results. The current edition of the AMA’s book “Guides to the Evaluation of Disease and Injury Causation” should be consulted for an expanded discussion. Neither the Dutch systematic review (Bakker), nor the Canadian systematic review (a series of articles published in "The Spine Journal" in 2010 by Roffey and Wai) found clear scientific evidence to indicate that work activity or leisure time activity places the spine at risk for back pain or back strain.

Two of the Bradford-Hill criteria used to prove causation (risk) are the presence of a “dose-response relationship” (e.g. more cigarettes equals more emphysema) and reversibility in experiments (elimination of exposure results in a decrease incidence of the condition). A systematic review of back pain prevention found no evidence that decreasing or eliminating the proposed risk factor of lifting from the workplace altered the incidence of low back pain (Bigos).

Back pain that resolves quickly is not a major return to work or disability duration issue. The problem cases are back pain that persists at a level that causes people to choose not to do specific tasks (including work). Chou reviewed 20 prospective studies of acute low back pain in 10,842 patients to determine predictors that result in long-term “disabling” low back pain. The presence of Waddell’s nonorganic signs on physical examination, high levels of maladaptive pain coping behaviors, high baseline functional impairment , the presence of psychiatric comorbidities, and low general health status were the most useful predictors of worse outcomes at 1 year. Low levels of fear avoidance (understanding that pain during activity does not mean the activity is harmful, and thus being willing to function despite pain) and low baseline functional impairment were the most useful items for predicting recovery at 1 year. Results were similar for outcomes at 3 to 6 months. Variables related to the work environment (baseline pain, and presence of radiculopathy) were less useful for predicting worse outcomes, and a history of prior low back pain episodes and demographic variables were not useful. Similar findings were noted in Carragee’s 2006 prospective cohort in which poor long term outcomes were predicted by abnormal psychometric testing, smoking, and compensation issues.

In the past, back pain was viewed by some as the result of cumulative trauma, and the term “chronic back strain” was used by some not to denote pain that persisted, but rather to describe pain attributed to chronic activity. This cumulative trauma model assumed the age-related (degenerative) changes visible on imaging (like x-ray or MRI) were due to repetitive work activity. Modern twin studies have clarified that the rate at which age-related (degenerative) change occurs is largely genetically determined, with little or no effect on adult activity noted (Battié).

Source: Medical Disability Advisor



Diagnosis

History: Other than recording the event the person associates with the onset of pain, there is no difference in the history taken from those diagnosed as having low back “strain/sprain” and those diagnosed with acute low back pain (with unknown cause).

If the pain lasts less than 6 weeks it is classified as an episode of acute low back pain. If the pain lasts between 6 and 12 weeks, it is classified as an episode of subacute low back pain. If the pain lasts longer than 12 weeks, it is classed as chronic low back pain with the assumption that the pain may well be permanent.

If the individual with low back pain reports an “injury” (e.g., lifting event, accident, or a fall) but does not have visible bruising or skin abrasions, a physical examination does not permit a conclusion about the cause of the back pain.

The history includes:

- assessing “red flags” that suggest the episode of back pain is caused by serious systemic disease like cancer, infection, or fracture. These include age < 20 or > 50, fever, unexplained weight loss, immunosuppression from medications (transplant patients, chemotherapy patients) or from disease (e.g. leukemia, AIDS patients), intravenous drug abuse, osteoporosis (documented, or suggested by prolonged use of corticosteroids), or pain that worsens supine or in bed at night. Gastrointestinal or genitourinary symptoms to suggest disease (rectal cancer, prostatitis). Another finding is pain worsens rather than lessens over time. Injuries heal, or attempt to heal, and thus pain from injury peaks 24-72 hours after injury and then progressively decreases either to zero or to a stable, much lower level. Pain that is worsening over time suggests infection, tumor, or something else, but not injury.

- assessing radiculopathy. Is the pain just in the back or buttocks, or does the pain radiate to a leg suggesting the possibility of radiculopathy?

- assessing numbness. Is there pain in both legs, numbness in the perineum (groin area), and / or bowel or bladder control difficulty suggesting cauda equina syndrome (huge disc rupture causing compression and dysfunction in multiple nerve roots on both the left and right sides)?

Usually these things are not present, and for 95% of patients with episodes of low back pain/strain there is no serious cause, and the exact structure in the back responsible for the pain cannot be identified.

Physical exam: There is no difference in the physical exam recorded on those diagnosed as having low back “strain/sprain” and those diagnosed with acute low back pain. These are equivalent conditions.

Physical examination is helpful for ruling out serious disease, but is rarely helpful in determining the cause of low back pain. Patients with low back pain typically have reduced back motion. They may, or may not, have back tenderness. Involvement of the nerves that exit the low back is evaluated by testing sensation, strength, and reflexes in the legs. Straight leg raising is a test looking for mechanical irritation of lumbar nerve roots in the back. If the lower lumbar nerve roots (L4 root, L5 root, or S1 root) have decreased ability to move or stretch as the result of a herniated disc, a spur, or scar from prior surgery, stretching the roots by this maneuver will produce pain in the leg being raised.

Waddell’s signs are physical exam tests that are performed for which there is no anatomical or neurologic explanation if positive findings are present. If multiple Waddell’s signs are present, the implication is psychosocial stressors are probably causing an exaggerated pain response during testing rather than a specific physiological cause (Main).

Tests: The only difference in diagnostic testing strategies used for those diagnosed with low back “strain/sprain” and those diagnosed with acute low back pain is the physician decides whether lumbar x-rays are indicated to rule out fracture in those with more significant trauma associated with the onset of back pain.

Most cases of lower lumbar strains and sprains (i.e. most cases of acute low back pain) do not require diagnostic tests, but if an individual has persistent symptoms that fail to respond to the usual interventions, additional laboratory studies may be appropriate to assess for underlying rheumatic or systemic disease. The white blood cell count and erythrocyte sedimentation rate or C-reactive protein screen for infection or inflammatory arthritis, and human leukocyte antigen assay for HLA-B27 suggest ankylosing spondylitis. MRI may be needed to rule out specific uncommon potential causes of back pain, such as infection, tumor, and herniated disc or spinal stenosis with involvement of spinal nerve roots. In a lumbar “sprain or strain” injury, MRI findings will be unremarkable.

Current evidence base guidelines recommend against routine imaging (MRI) (Chou; Hegmann)."Diagnostic imaging is indicated for patients with low back pain only if they have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition" (Chou).

Source: Medical Disability Advisor



Treatment

There is no difference in the treatment recommended for those diagnosed as having low back “strain/sprain” and those diagnosed with acute low back pain. These are basically the same condition but are provided different labels for the pain.

For initial treatment non-steroidal anti-inflammatory medication or acetaminophen, manipulation (especially for those who are positive on the Clinical Prediction Rule), aerobic exercise, stretching in the direction that decreases the pain, continuing to do the activities that are normal for that person, and reassurance that most episodes of back pain resolve over time are the recommended treatments in evidence based guidelines from multiple countries.

In the largest prospective studies, there is no difference in speed of recovery or chances of failure to recover (transition to chronic low back pain) based on the type of non-operative treatment or the specialty of the treatment provider(Carey 1995; Carey 1999). Thus the goal of treatment is to make the individual more comfortable while the episode of low back pain resolves.

There is emerging evidence that opioid (narcotic) use early after “strain/sprain” or early after acute back pain onset predicts longer disability durations and worse outcomes (Webster; Franklin; Volinn).

For those in whom the low back pain (or “strain/sprain”) has become chronic, the best treatment is active exercise by itself, or with cognitive and behavioral therapy in what is called multidisciplinary rehabilitation.

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Low Back Disorders
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

Regardless of the type of treatment or specialty of the health care provider, the lumbar sprains and strains pain, or of acute low back pain, typically lasts about 5 to 10 days. Most lumbosacral injuries (90%) resolve within 6 weeks regardless of type of treatment (see above). A more serious underlying condition may be considered if the individual does not respond to conservative treatment. Screening lab tests and MRI usually rule out such serious disease.

Source: Medical Disability Advisor



Rehabilitation

Refer to the recommended visits below.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistSprains and Strains, Lumbar Spine
Occupational or Physical TherapistUp to 6 visits within 8 weeks

Source: Medical Disability Advisor



Complications

The “complications” are essentially persistence of acute back pain, meaning transition to chronic back pain with disability.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals with severe back pain, whether this is called “back pain” or “sprains or strains”, whose normal work duties require extensive lifting or bending, may appreciate temporary reassignment to lighter or sedentary duties, with a scheduled decrease in these activity guidelines over time. Usually a return to full activity is possible at 6 weeks for those with moderate duty jobs, and to very heavy work by 3 months. If a minor trauma event has created a “strain/sprain,” studies on wound healing indicate that by 6 weeks muscle and ligament injuries have done most of their healing, and that by 12 weeks muscle and ligament have regained 90% of their pre-injury strength.

For further information refer to “Ability to Work," page 165, and to "Disease and Injury Causation," pages 113-140.

Risk: For individuals with low back pain/strain/sprain, there is no scientific evidence of significant risk of substantial harm with activity that is imminent. Risk is not an issue.

Capacity: Most patients regain the capacity for moderate work within 6 weeks and for any work within 12 weeks (3 months).

Tolerance: Tolerance for symptoms (pain and stiffness) is the key issue in low back pain/strain/sprain. The disability durations reflect what greater than 90% of compensable episodes do after onset of low back pain/strain/sprain.

Accommodations: If employers can introduce engineering controls or administrative controls to decrease the physical demands of work, individuals with low back “strain/sprain” or low back pain may have less discomfort on the job, and thus choose to return to work.

Since there is no objective evidence of significant risk of substantial harm that is imminent (Americans with Disabilities Act), accommodations are optional, and workers can work despite back pain if they choose to. The introductory section on “Incidence” at the beginning of this topic indicates that back pain/strain is very common, and obviously many workers choose to work despite back pain each and every day.

Source: Medical Disability Advisor



Maximum Medical Improvement

In the absence of fracture, dislocation, nerve injury, or spinal cord injury, the lumbar sprain/strain is considered a “soft tissue injury.” Like other soft tissue injuries, the majority of the healing occurs in the first 84 days. Other than surgery, additional treatment after 84 days from the date of injury is not likely to result in dramatic improvement, so MMI is frequently achieved by 84 days after injury.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Have diagnostic tools, such as x-rays and / or MRI, been used to rule out herniated discs, fractured vertebrae, and rare serious conditions like cancer or spinal infection?
  • Were any signs of nerve involvement noted? If “yes,” refer to the section on intervertebral disc herniation.
  • Has psychological stressors as a reason for delayed recovery, been evaluated?
  • Does individual have symptoms of depression, or of a mental disorder?
  • Is there another underlying condition that may affect recovery (e.g., morbid obesity and substance abuse)?
  • Does individual have continued back pain and disability following an adequate time for recovery (> 3 months)? If so, the diagnosis should be changed to chronic low back pain.

Regarding treatment:

  • Is continued use of opioids (narcotics) with or without sedatives (benzodiazepines and / or carisoprodol) occurring?
  • Did individual undergo physical rehabilitation supervised by a physical therapist?

Regarding prognosis:

  • Was accommodation in the workplace made to allow for a gradual return to full activity?
  • What additional treatment options are available and planned?
  • If individual is obese, would weight reduction counseling be appropriate?
  • Has a forensic psychological evaluation been done to rule out co-existing mental disorders (especially personality disorders), somatization, malingering, and seeking of secondary gain?
  • Would individual benefit from counseling?

Source: Medical Disability Advisor



References

Cited

Bakker, E. WP, et al. "Spinal Mechanical Load as a Risk Factor for Low Back Pain: A Systematic Review of Prospective Cohort Studies." Spine 34 (8) (2009): e281-e293.

Battié, M. C. , et al. "Genetic and Environmental Effects on Disc Degeneration by Phenotype and Spinal Level: A Multivariate Twin Study." Spine 33 (25) (2008): 2801-2808.

Bigos, S. J. , et al. "High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults." Spine Journal 9 (2009): 147-168.

Carey, T. S. , et al. "Recurrence and Care Seeking After Acute Back Pain: Results of a Long-Term Follow Up Study." Medical Care 37 (2) (1999): 149-156.

Carey, T. S., et al. "The Outcomes and Costs of Care for Acute Low Back Pain Among Patients Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons." New England Journal of Medicine 333 (14) (1995): 913-917.

Carragee, E. J. , et al. "Activity Restriction After Posterior Lumbar Discectomy." Spine 24 (22) (1999): 2346-2351.

Carragee, E. , et al. "Are first-time episodes of serious LBP associated with new MRI findings? " Spine Journal 6 (2006): 624-635.

Carragee, E., et al. "Does Minor Trauma Cause Serious Low Back Pain Illness?" Spine 31 25 (2006): 2942-2949.

Cassidy, J. D. , et al. "The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults." Spine 23 (1998): 1860-1866.

Chou, R. , et al. "Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care from the American College of Physicians." Annals of Internal Medicine 154 (2011): 181-189.

Deyo, R. A. , et al. "Back pain prevalence and visit rates." Spine 31 (2006): 2724-2727.

Franklin, G. M. , et al. "Early Opioid Prescription and Subsequent Disability Among Workers with Back Injuries." Spine 33 (2) (2008): 199-204.

Hegmann, K. T. , et al., eds. "Low Back Pain." Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. Third ed. ACOEM, 2011. Chapter 8.

Main, C. J. , G. Waddell, and . "Behavioral Responses to Examination: A Reappraisal of the Interpretation of “Nonorganic Signs”." Spine 23 (21) (1998): 2367-2371.

Melhorn, J. Mark, and William Ackerman, eds. Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008.

Modic, M. T. , N. A. Obushowski, and J. S. Ross. "Acute Low Back Pain and Radicuolopathy: MR Imaging Findings and Their Prognostic Role and Effect on Outcome." Radiology 237 (2005): 597-604.

Radebold, Andrea, et al. "Lumbosacral Spine Sprain/Strain Injuries." eMedicine. 8 Oct. 2012. Medscape. 25 Feb. 2013 <http://emedicine.medscape.com/article/95444-overview>.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

Volinn, E. , J. D. Fargo, and P. G. Fine. "Opioid therapy for nonspecific low back pain and the outcome of chronic work loss." Pain 142 (2009): 194-201.

Webster, B. S. , et al. "Relationship Between Early Opioid Prescribing for Acute Occupational Low Back Pain and Disability Duration, Medical Costs, Subsequent Surgery, and Late Opioid Use." Spine 32 (19) (2007): 2127-2132.

Webster, B. S. , S. K. Verma, and R. J. Gatchel. "Relationship Between Early Opioid Prescribing for Acute Occupational Low Back Pain and Disability Duration, Medical Costs, Subsequent Surgery, and Late Opioid Use." Merck Manual of Medical Information. Eds. Mark H. Beers, et al. 2nd Home Online ed. New York: Pocket Books, 1997. 2127-2132. Merck. 32 Merck & Co., Inc. 6 Jan. 2005 <http//www.merck.com/mmhe/sec06/ch094/ch094a.html>.

Source: Medical Disability Advisor






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