Background: Appropriately developed practice guidelines present statements of best practice based
on a thorough evaluation of the evidence from published studies on the outcomes of treatments,
which include the application of multiple methods for collecting and evaluating evidence for a wide
range of clinical interventions and disciplines. However, the guidelines are neither infallible, nor a substitute for clinical judgment. While the guideline development process is a complex phenomenon, conflict of interest in guideline development and inappropriate methodologies must be avoided.
It has been alleged that the guidelines by the American College of Occupational and Environmental Medicine (ACOEM) prevent injured workers from receiving the majority of medically necessary
and appropriate interventional pain management services. An independent critical appraisal of both
chapters of the ACOEM guidelines showed startling findings with a conclusion that these guidelines
may not be applied in patient care as they scored below 30% in the majority of evaluations utilizing
multiple standardized criteria.
Objective: To reassess the evidence synthesis for the ACOEM guidelines for the low back pain and
chronic pain chapters utilizing an expanded methodology, which includes the criteria included in the
ACOEM guidelines with the addition of omitted literature and application of appropriate criteria.
Methods: For reassessment, randomized trials were utilized as it was in the preparation of the
guidelines. In this process, quality of evidence was assessed and recommendations were made based
on grading recommendations of Guyatt et al. The level of evidence was determined utilizing the
quality of evidence criteria developed by the U.S. Preventive Services Task Force (USPSTF), as well
as the outdated quality of evidence criteria utilized by ACOEM in the guideline preparation. Methodologic quality of each individual article was assessed utilizing the Agency for Healthcare Research and Quality (AHRQ) methodologic assessment criteria for diagnostic interventions and Cochrane methodologic quality assessment criteria for therapeutic interventions.
Results: The results of reassessment are vastly different from the conclusions derived by the ACOEM guidelines. The differences in strength of rating for the diagnosis of discogenic pain by provocation discography and facet joint pain by diagnostic facet joint nerve blocks is established with strong
evidence. Therapeutic cervical and lumbar medial branch blocks and radiofrequency neurolysis, therapeutic thoracic medial branch blocks, cervical interlaminar epidural steroid injections, caudal epidural steroid injections, lumbar transforaminal epidural injections, percutaneous and endoscopic adhesiolysis, and spinal cord stimulation qualified for moderate to strong evidence. Additional insight is
also provided for evidence rating for intradiscal electrothermal therapy (IDET), automated percutaneous disc decompression, and intrathecal implantables.
Conclusion: The reassessment and reevaluation of the low back and chronic pain chapters of
the ACOEM guidelines present results that are vastly different from the published and proposed
guidelines. Contrary to ACOEM’s conclusions of insufficient evidence for most interventional techniques, the results illustrate moderate to strong evidence for most diagnostic and therapeutic interventional techniques.
Key words: Guidelines, evidence-based medicine, systematic reviews, ACOEM, interventional pain management, interventional techniques, guideline development, workers’ compensation,
chronic pain guidelines, low back pain guidelines
Reassessment of Evidence Synthesis of
Occupational Medicine Practice Guidelines for
Interventional Pain Management
