Contents part 1: Introduction

Myalgia and myositis, unspecified

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Myalgia and myositis, unspecified (ICD9 729.1):

9-10 visits over 8 weeks

Neuralgia, neuritis, and radiculitis, unspecified (ICD9 729.2)

8-10 visits over 4 weeks

Reflex sympathetic dystrophy (CRPS) (ICD9 337.2):

26 visits over 16 weeks

Arthritis (ICD9 715):

9 visits over 8 weeks

Post-injection treatment: 1-2 visits over 1 week

Post-surgical treatment: Refer to the DWC MTUS Postsurgical Treatment Guidelines

Patients should be formally assessed after a "six-visit clinical trial" to evaluate whether PT has resulted in positive impact, no impact, or negative impact prior to continuing with or modifying the physical therapy.

Physical therapy (PT)

See Physical medicine treatment.

Physician-dispensed drugs

Physician dispensing is the process of distributing pre-packaged medications directly to patients at the point of care and is generally recommended only for the initial visit to provide patients with medications for acute injuries. According to some, the patient may prefer physician-dispensed drugs because of convenience. Physician-dispensing may create financial incentives that affect the use of compound drugs and other medications, due primarily to fee schedule ambiguities. In addition, physician-dispensed drugs typically do not go through the pharmacy benefit management companies (PBMs) but are submitted directly to the payer. Physician dispensing has been found to be associated with higher costs and more lost time than pharmacy-dispensed medications. (White, 2014).

Piriformis injections

Recommended for piriformis syndrome after a one-month physical therapy trial. Piriformis syndrome is a common cause of low back pain and accounts for 6-8% of patients presenting with buttock pain, which may variably be associated with sciatica, due to a compression of the sciatic nerve by the piriformis muscle (behind the hip joint).

Piroxicam (Feldene®)

Not recommended. See NSAIDs (non-steroidal anti-inflammatory drugs); NSAIDs, GI symptoms & cardiovascular risk; NSAIDs, hypertension and renal function; & NSAIDs, specific drug list & adverse effects for general guidelines, as well as specific Piroxicam (Feldene®) listing for more information and references, where it is indicated that pain is not listed as an FDA approved indication. In addition, according to the AHRQ Comparative Effectiveness Report on NSAIDS, piroxicam has the highest risk of upper GI bleeding (RR of 6.3 versus 1.9 for ibuprofen), the highest risk of myocardial infarction (RR of 1.25 versus 1.06 for ibuprofen), and it was also associated with Stevens-Johnson syndrome and toxic epidermal necrolysis. (Chou, 2006) And this high-quality systematic review also pointed out the high frequency of adverse events associated with piroxicam, including GI bleeding, renal failure, hypertension, and heart failure. In this study piroxicam was second only to ketorolac in its ability to induce gastrointestinal bleeding. Long-term use of full dosage piroxicam is potentially harmful in older adults due to its long half-life and long duration. (Massó, 2010) So piroxicam is not recommended as a first-line NSAID.


Recommended after at least six months of an insomnia complaint (at least four nights a week), unresponsive to behavior intervention and sedative/sleep-promoting medications, and after psychiatric etiology has been excluded. Not recommended for the routine evaluation of transient insomnia, chronic insomnia, or insomnia associated with psychiatric disorders. Home portable monitor testing may be an option. A polysomnogram measures bodily functions during sleep, including brain waves, heart rate, nasal and oral breathing, sleep position, and levels of oxygen saturation. It is administered by a sleep specialist, a physician who is Board eligible or certified by the American Board of Sleep Medicine, or a pulmonologist or neurologist whose practice comprises at least 25% of sleep medicine. (Schneider-Helmert, 2003) According to page 3-17 of the AMA Guides (5th ed), sleep disorder claims must be supported by formal studies in a sleep laboratory. (Andersson, 2000) However, home portable monitor testing is increasingly being used to diagnose patients with obstructive sleep apnea (OSA) and to initiate them on continuous positive airway pressure (CPAP) treatment, and the latest evidence indicates that functional outcome and treatment adherence in patients evaluated according to a home testing algorithm is not clinically inferior to that in patients receiving standard in-laboratory polysomnography. (Kuna, 2011) Insomnia is primarily diagnosed clinically with a detailed medical, psychiatric, and sleep history. Polysomnography is indicated when a sleep-related breathing disorder or periodic limb movement disorder is suspected, initial diagnosis is uncertain, treatment fails, or precipitous arousals occur with violent or injurious behavior. However, polysomnography is not indicated for the routine evaluation of transient insomnia, chronic insomnia, or insomnia associated with psychiatric disorders. (Littner, 2003)

Criteria for Polysomnography:

Polysomnograms / sleep studies are recommended for the combination of indications listed below: (1) Excessive daytime somnolence; (2) Cataplexy (muscular weakness usually brought on by excitement or emotion, virtually unique to narcolepsy); (3) Morning headache (other causes have been ruled out); (4) Intellectual deterioration (sudden, without suspicion of organic dementia); (5) Personality change (not secondary to medication, cerebral mass or known psychiatric problems); (6) Sleep-related breathing disorder or periodic limb movement disorder is suspected; & (7) Insomnia complaint for at least six months (at least four nights of the week), unresponsive to behavior intervention and sedative/sleep-promoting medications and psychiatric etiology has been excluded. A sleep study for the sole complaint of snoring, without one of the above mentioned symptoms, is not recommended.

Power mobility devices (PMDs)

Not recommended if the functional mobility deficit can be sufficiently resolved by the prescription of a cane or walker, or the patient has sufficient upper extremity function to propel a manual wheelchair, or there is a caregiver who is available, willing, and able to provide assistance with a manual wheelchair. Early exercise, mobilization and independence should be encouraged at all steps of the injury recovery process, and if there is any mobility with canes or other assistive devices, a motorized scooter is not essential to care.

Pregabalin (Lyrica®)

An anticonvulsant recommended in neuropathic pain conditions and fibromyalgia, but not for acute pain. Pregabalin (Lyrica®) has been documented to be effective in treatment of diabetic neuropathy and postherpetic neuralgia, has FDA approval for both indications, and is considered first-line treatment for both. Pregabalin was also approved to treat fibromyalgia. See Anti-epilepsy drugs (AEDs) for general guidelines, as well as specific Pregabalin listing for more information and references. This Cochrane review concluded that pregabalin has proven efficacy in neuropathic pain conditions and fibromyalgia. A minority of patients will have substantial benefit with pregabalin, and more will have moderate benefit. Many will have no or trivial benefit, or will discontinue because of adverse events. Individualization of treatment is needed to maximise pain relief and minimise adverse events. There is no evidence to support the use of pregabalin in acute pain scenarios. (Moore-Cochrane, 2009)

Prevacid® (lansoprazole)

See Proton pump inhibitors (PPIs).


See Ziconotide (Prialt®).

Prilosec® (omeprazole)

See Proton pump inhibitors (PPIs).

Progressive goal attainment program (PGAP™)

Recommended as an option where there is access to trained providers. PGAP is a standardized community-based intervention delivered by OTs, PTs, kinesiologists, nurses, rehabilitation counselors and psychologists, who have been trained by the PGAP program. The primary goal of PGAP is to reduce psychosocial barriers to return-to-work. PGAP has produced positive results for individuals suffering from musculoskeletal conditions, depression, cancer, and other debilitating health conditions. This study showed that participation in PGAP increased the probability of return to work following whiplash injury by more than 50%. (Sullivan, 2006) Findings suggest that PGAP can be a cost-effective means of improving function and facilitating return to work in individuals at risk for prolonged disability. (Sullivan, 2010) (Adams, 2007)

Criteria for the Progressive goal attainment program (PGAP™):

- Lack of improvement with early active physical therapy

- Off work at least 5 weeks, but less than 5 months of continuous time lost

- Surgery not planned or likely

- No evidence of drug or alcohol problem

- Not currently in work hardening

- Maximum of 10 weeks treatment with one hour sessions on a weekly basis (L&I, 2013)


Not recommended. Prolotherapy describes a procedure for strengthening lax ligaments by injecting proliferating agents/sclerosing solutions directly into torn or stretched ligaments or tendons or into a joint or adjacent structures to create scar tissue in an effort to stabilize a joint. Agents used with prolotherapy have included zinc sulfate, psyllium seed oil, combinations of dextrose, glycerine and phenol, or dextrose alone. "Proliferatives" act to promote tissue repair or growth by prompting release of growth factors, such as cytokines, or increasing the effectiveness of existing circulating growth factors. Prolotherapy has been investigated as a treatment of various etiologies of pain, including arthritis, degenerative disc disease, fibromyalgia, tendinitis, and plantar fasciitis. In all studies the effects of prolotherapy did not significantly exceed placebo effects. (Dechow, 1999) (Reeves, 2000) (Yelland, 2004) (BlueCross BlueShield, 2006) This recent Cochrane review concluded that, when used alone, prolotherapy is not an effective treatment for chronic low-back pain, but when combined with spinal manipulation, exercise, and other co-interventions, prolotherapy may improve chronic low-back pain and disability, but this statement is confounded by co-interventions and heterogeneity of studies. (Dagenais-Cochrane, 2007) This systematic review concluded that despite its use for over 50 years, there is no evidence of efficacy for prolotherapy injections alone for chronic low back pain. (Dagenais, 2008) According to this review, additional larger, randomized controlled trials are needed to make specific recommendations regarding prolotherapy. (Distel, 2011)

Promethazine (Phenergan®)

Not recommended for nausea and vomiting secondary to chronic opioid use. See Antiemetics (for opioid nausea).

Propoxyphene (Darvon®)

Not recommended. [Off market in U.S.]

Proton pump inhibitors (PPIs)

Recommended for patients at risk for gastrointestinal events. See NSAIDs, GI symptoms & cardiovascular risk. Prilosec® (omeprazole), Prevacid® (lansoprazole) and Nexium® (esomeprazole magnesium) are PPIs. Omeprazole provides a statistically significantly greater acid control than lansoprazole. (Miner, 2010) Healing doses of PPIs are more effective than all other therapies, although there is an increase in overall adverse effects compared to placebo. Nexium and Prilosec are very similar molecules. For many people, Prilosec is more affordable than Nexium. Nexium is not available in a generic (as is Prilosec). Also, Prilosec is available as an over-the-counter product (Prilosec OTC®), while Nexium is not. (Donnellan, 2010) In general, the use of a PPI should be limited to the recognized indications and used at the lowest dose for the shortest possible amount of time. PPIs are highly effective for their approved indications, including preventing gastric ulcers induced by NSAIDs. Studies suggest, however, that nearly half of all PPI prescriptions are used for unapproved indications or no indications at all. Many prescribers believe that this class of drugs is innocuous, but much information is available to demonstrate otherwise. If a PPI is used, omeprazole OTC tablets or lansoprazole 24HR OTC are recommended for an equivalent clinical efficacy and significant cost savings. Products in this drug class have demonstrated equivalent clinical efficacy and safety at comparable doses, including esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), dexlansoprazole (Dexilant), and rabeprazole (Aciphex). (Shi, 2008) A trial of omeprazole or lansoprazole is recommended before Nexium therapy. The other PPIs, Protonix, Dexilant, and Aciphex, should also be second-line. According to the latest AHRQ Comparative Effectiveness Research, all of the commercially available PPIs appeared to be similarly effective. (AHRQ, 2011)

Provigil® (modafinil)

Provigil is the brand name for modafinil, manufactured by Cephalon, and is approved by the FDA for the treatment of narcolepsy. Prescribers using Provigil for sedation effects of opiate should consider reducing the dose of opiates before adding stimulants. See Modafinil (Provigil®).

P-Stim™ (pulse stimulation treatment)

See Auricular electroacupuncture.

Psychological evaluations

Recommended based upon a clinical impression of psychological condition that impacts recovery, participation in rehabilitation, or prior to specified interventions (e.g., lumbar spine fusion, spinal cord stimulator, implantable drug-delivery systems). (Doleys, 2003) Psychological evaluations are generally accepted, well-established diagnostic procedures not only with selected use in pain problems, but also with more widespread use in subacute and chronic pain populations. Diagnostic evaluations should distinguish between conditions that are preexisting, aggravated by the current injury or work related. Psychosocial evaluations should determine if further psychosocial interventions are indicated. The interpretations of the evaluation should provide clinicians with a better understanding of the patient in their social environment, thus allowing for more effective rehabilitation. (Main-BMJ, 2002) (Colorado, 2002) (Gatchel, 1995) (Gatchel, 1999) (Gatchel, 2004) (Gatchel, 2005) For the evaluation and prediction of patients who have a high likelihood of developing chronic pain, a study of patients who were administered a standard battery psychological assessment test found that there is a psychosocial disability variable that is associated with those injured workers who are likely to develop chronic disability problems. (Gatchel, 1999) Childhood abuse and other past traumatic events were also found to be predictors of chronic pain patients. (Goldberg, 1999) Another trial found that it appears to be feasible to identify patients with high levels of risk of chronic pain and to subsequently lower the risk for work disability by administering a cognitive-behavioral intervention focusing on psychological aspects of the pain problem. (Linton, 2002) Other studies and reviews support these theories. (Perez, 2001) (Pulliam, 2001) (Severeijns, 2001) (Sommer, 1998) In a large RCT the benefits of improved depression care (antidepressant medications and/or psychotherapy) extended beyond reduced depressive symptoms and included decreased pain as well as improved functional status. (Lin-JAMA, 2003) See "Psychological Tests Commonly Used in the Assessment of Chronic Pain Patients" from the Colorado Division of Workers’ Compensation, which describes and evaluates the following 26 tests: (1) BHI 2nd ed - Battery for Health Improvement, (2) MBHI - Millon Behavioral Health Inventory [has been superceded by the MBMD following, which should be administered instead], (3) MBMD - Millon Behavioral Medical Diagnostic, (4) PAB - Pain Assessment Battery, (5) MCMI-111 - Millon Clinical Multiaxial Inventory, (6) MMPI-2 - Minnesota Inventory, (7) PAI - Personality Assessment Inventory, (8) BBHI 2 - Brief Battery for Health Improvement, (9) MPI - Multidimensional Pain Inventory, (10) P-3 - Pain Patient Profile, (11) Pain Presentation Inventory, (12) PRIME-MD - Primary Care Evaluation for Mental Disorders, (13) PHQ - Patient Health Questionnaire, (14) SF 36, (15) SIP - Sickness Impact Profile, (16) BSI - Brief Symptom Inventory, (17) BSI 18 - Brief Symptom Inventory, (18) SCL-90 - Symptom Checklist, (19) BDI–II - Beck Depression Inventory, (20) CES-D - Center for Epidemiological Studies Depression Scale, (21) PDS - Post Traumatic Stress Diagnostic Scale, (22) Zung Depression Inventory, (23) MPQ - McGill Pain Questionnaire, (24) MPQ-SF - McGill Pain Questionnaire Short Form, (25) Oswestry Disability Questionnaire, (26) Visual Analogue Pain Scale – VAS. (Bruns, 2001) Chronic pain may harm the brain, based on using functional magnetic resonance imaging (fMRI), whereby investigators found individuals with chronic back pain (CBP) had alterations in the functional connectivity of their cortical regions - areas of the brain that are unrelated to pain - compared with healthy controls. Conditions such as depression, anxiety, sleep disturbances, and decision-making difficulties, which affect the quality of life of chronic pain patients as much as the pain itself, may be directly related to altered brain function as a result of chronic pain. (Baliki, 2008) Maladjusted childhood behavior is associated with the likelihood of chronic widespread pain in adulthood. (Pang, 2010) Psychosocial factors may predict persistent pain after acute orthopedic trauma, according to a recent study. The early identification of those at risk of ongoing pain is of particular importance for injured workers and compensation systems. Significant independent predictors of pain outcomes were high levels of initial pain, external attributions of responsibility for the injury, and psychological distress. Pain-related work disability was also significantly predicted by poor recovery expectations, and pain severity was significantly predicted by being injured at work. (Clay, 2010) See also Comorbid psychiatric disorders.

Psychological evaluations, IDDS & SCS (intrathecal drug delivery systems & spinal cord stimulators)

Recommended pre intrathecal drug delivery systems (IDDS) and spinal cord stimulator (SCS) trial.

Psychological treatment

Recommended for appropriately identified patients during treatment for chronic pain. Psychological intervention for chronic pain includes setting goals, determining appropriateness of treatment, conceptualizing a patient’s pain beliefs and coping styles, assessing psychological and cognitive function, and addressing co-morbid mood disorders (such as depression, anxiety, panic disorder, and posttraumatic stress disorder). Cognitive behavioral therapy and self-regulatory treatments have been found to be particularly effective. Psychological treatment incorporated into pain treatment has been found to have a positive short-term effect on pain interference and long-term effect on return to work. The following “stepped-care” approach to pain management that involves psychological intervention has been suggested:

Step 1: Identify and address specific concerns about pain and enhance interventions that emphasize self-management. The role of the psychologist at this point includes education and training of pain care providers in how to screen for patients that may need early psychological intervention.

Step 2: Identify patients who continue to experience pain and disability after the usual time of recovery. At this point a consultation with a psychologist allows for screening, assessment of goals, and further treatment options, including brief individual or group therapy.

Step 3: Pain is sustained in spite of continued therapy (including the above psychological care). Intensive care may be required from mental health professions allowing for a multidisciplinary treatment approach. See also Multi-disciplinary pain programs. See also ODG Cognitive Behavioral Therapy (CBT) Guidelines. (Otis, 2006) (Townsend, 2006) (Kerns, 2005) (Flor, 1992) (Morley, 1999) (Ostelo, 2005) Several recent reviews support the assertion of efficacy of cognitive-behavioural therapy (CBT) in the treatment of pain, especially chronic back pain (CBP). (Kröner-Herwig, 2009)

Pulsed radiofrequency treatment (PRF)

Not recommended. Pulsed radiofrequency treatment (PRF) has been investigated as a potentially less harmful alternative to radiofrequency (RF) thermal neurolytic destruction (thermocoagulation) in the management of certain chronic pain syndromes such as facet joint pain and trigeminal neuralgia. Pulsed radiofrequency treatment is considered investigational/not medically necessary for the treatment of chronic pain syndromes. (BlueCross, 2005) A decrease in pain was observed in patients with herniated disc and spinal stenosis, but not in those with failed back surgery syndrome. However, this option does not appear to be an ideal modality of treatment for lumbar radicular pain because neurodestructive methods for the treatment of neuropathic pain are in principle generally considered inappropriate. (Abejón, 2007)

Pumps, implantable

See Implantable drug-delivery systems (IDDSs).

Pycnogenol (maritime pine bark)

Not recommended as a treatment for chronic pain. There is insufficient literature to support the use of pycnogenol for chronic pain.


See Internal qigong.


Not generally recommended as a diagnostic test for CRPS. See CRPS, diagnostic tests.

Quantitative sensory threshold (QST) testing

Not recommended. See also Current perception threshold (CPT) testing. Quantitative sensory testing (QST) has been used to assist in the diagnosis and management of a variety of conditions such as diabetic neuropathy and other neuropathies, as well as carpal tunnel syndrome and other nerve entrapment/compression disorders or damage. Because QST combines the objective physical sensory stimuli with the subjective patient response, it is psychophysical in nature and requires that its use be in patients who are alert, able to follow directions, and cooperative. Due to the subjective component of testing, psychological factors must be taken into consideration during testing and in evaluating test results, thus reducing the degree of objectivity QST can provide. QST is considered experimental or investigational, as there are no quality published studies to support any conclusions regarding the effects of this testing on health outcomes.


Not recommended. See Benzodiazepines.

Qutenza (capsaicin) 8% patch

See Capsaicin, where it is recommended only in patients who have not responded or are intolerant to other treatments. On November 17, 2009, the FDA approved an 8% capsaicin dermal patch (Qutenza, made by Lohmann Therapie-Systems AD, marketed by NeurogesX, Inc) for the management of pain associated with postherpatic neuralgia. Blood pressure should be carefully monitored for 1 hour after each application, and caution is advised when treating patients with unstable or poorly controlled hypertension or a recent history of cardiovascular or cerebrovascular events. (FDA, 2009)

Regional sympathetic blocks

See CRPS, sympathetic blocks (therapeutic).

Repackaged drugs

Repackaged drugs are prescription or over-the-counter drugs taken from initial drug producers and repackaged and repriced, usually for physician dispensing. Repackaged medications are difficult to price consistently, since a pharmaceutical product is removed from the original container with an original NDC and put into a new container with new quantities, therefore requiring a new NDC, with a new repackaging company label and price for the medication. There are no high-quality medical studies to evaluate physician dispensing of repackaged drugs versus pharmacy dispensing on patient outcomes. See also Compound drugs; Co-pack drugs; Medical foods; Physician-dispensed drugs.

Restless legs syndrome (RLS)

See specific body-part chapters in the DWC MTUS.

Return to work

Recommended. Expedited return-to-work has been shown to be more useful in improving function and decreasing pain than extended disability. (Bernacki, 2000) (Boseman, 2001) (Colorado, 2002) (Melhorn, 2000) Lost productive time from common pain conditions among active workers costs an estimated 61.2 billion dollars per year. The majority (76.6%) of the lost productive time was explained by reduced performance while at work and not work absence. (Stewart, 2003) Chronic pain is independently related to low self-rated health in the general population. (Mantyselka-JAMA, 2003) Significant pain improvement is seen in groups that are prescribed light activity over groups that receive only medical treatment, especially in cases involving back pain. Extended bed rest is not recommended. (van Lankveld, 2000)

Rotta glucosamine sulfate

See Glucosamine (and Chondroitin Sulfate).

Roxicodone® (oxycodone)

See DWC “Guideline for the Use of Opioids to Treat Work-Related Injuries” for additional

information on oxycodone.

RS-4i sequential stimulator

See Interferential current stimulation (ICS).

RSD (reflex sympathetic dystrophy)

Definition of this pain syndrome (not a procedure): New name for Reflex sympathetic dystrophy (RSD) is CRPS I. See CRPS, diagnostic criteria.

Ryzolt (tramadol ER)

See DWC “Guideline for the Use of Opioids to Treat Work-Related Injuries” for prescribing information on opioids. The FDA has determined that Ryzolt is equivalent to generic extended release tramadol. (FDA, 2012) With no clear advantages over generic tramadol ER, it is not recommended over generic tramadol ER. See Tramadol (Ultram®) for overall recommendations for tramadol ER. On 12/30/08 the FDA approved an extended-release once-daily formulation of tramadol (Ryzolt) for the management of moderate to moderately severe chronic pain. Labopharm and marketing partner in the United States, Purdue Pharma, launched the product in 100-mg, 200-mg, and 300-mg dosage strengths in the second quarter of 2009. (FDA, 2008) If a patient is already stabilized on a long-acting tramadol, then the immediate-release component of the biphasic product has the potential to cause a higher than desired blood level of tramadol, which might impact a patient in a negative way, but this has not been proven in studies. The clinical rationale for using a long-acting opioid is to maintain a stable blood level around-the-clock, so it is not entirely clear how a biphasic formulation adds to chronic, around-the-clock opioid therapy. (FDA2, 2012) In addition, efficacy was demonstrated in only one of four studies that were conducted for approval of biphasic tramadol ER. (FDA3, 2012) See also ConZip (tramadol ER), another biphasic tramadol ER that is not available as a generic.

Salicylate topicals

Recommended as an option. Topical salicylate (e.g., Ben-Gay, methyl salicylate) is significantly better than placebo in acute and chronic pain, but especially acute pain. Three double blind placebo controlled trials had information on 182 patients with acute conditions. Topical salicylate was significantly better than placebo (relative benefit 3.6; number needed to treat 2.1). Six double blind placebo controlled trials had information on 429 patients with chronic conditions. Topical salicylate was significantly better than placebo overall (relative benefit 1.5; number needed to treat 5.3), but larger, more valid studies were without significant effect. (Mason-BMJ, 2004) This review found evidence that was limited by the quality, validity and size of the available studies, particularly for studies in acute pain conditions like strains and sprains, where there was inadequate information to support the use of topical rubefacients containing salicylates. In chronic pain conditions such as osteoarthritis the evidence was more robust, but rubefacients appear to provide useful levels of pain relief in one in six individuals over and above those who also responded to placebo. This compares poorly with topical NSAIDs where substantial amounts of good quality evidence indicate that one in every three individuals treated will experience useful levels of pain relief over and above those who also responded to placebo. (Matthews-Cochrane, 2009) Neither salicylates nor capsaicin have shown significant efficacy in the treatment of OA. (Altman, 2009) Topical OTC pain relievers that contain menthol, methyl salicylate, or capsaicin, may in rare instances cause serious burns, a new alert from the FDA warns. (FDA, 2012) See also Topical analgesics; & also Topical analgesics, compounded.


See Milnacipran (Savella®).

Sclerotherapy (prolotherapy)

Not recommended for treatment of chronic pain. Sclerotherapy/prolotherapy has no proven value via well-controlled, double blind studies and may have harmful effects. (ChronicPain, 1998) See Prolotherapy.

Scrambler therapy (Calmare®)

Not recommended for the treatment of chronic pain. Under study, with several promising pilot studies, but higher quality studies are needed and are currently being conducted. The evidence is not yet sufficient to permit conclusions about the benefits of Scrambler therapy, also known as transcutaneous electrical modulation pain reprocessing, for the treatment of chronic pain. The device is intended to scramble pain information with no-pain information, to reduce the perception of pain intensity. Scrambler therapy interrupts transmission of pain signals by delivering electrical stimulation that is interpreted by the nervous system as no pain, and it is performed using a type of transcutaneous electrical stimulation (TENS) device that is specifically designed for this therapy. Cutaneous nerves are stimulated using 5 surface electrode pairs that are placed in the dermatomes above and below the pain area. Unlike conventional TENS, scrambler therapy is administered in the office setting under physician supervision. Treatment applications are interactive between the patient and the provider, with the provider attending and making adjustments approximately every 10 minutes throughout the treatment session, which typically lasts an hour. There have been pilot studies, but the preliminary findings from these pilot studies need to be validated by well-designed studies. While preliminary results suggested that cutaneous electro-stimulation with the Calmare can be hypothesized as part of a multi-modality approach to the treatment of chronic pain, further studies on larger numbers of patients are needed to assess its efficacy, to quantify the effects of inter-operator variability, and to compare results obtained from the active device versus those from a sham machine. The pilot studies are useful in informing hypothesis formation, but they do not permit conclusions on efficacy and safety due to small size, lack of a sham control group, and short-term followup period. (Marineo, 2012) (Ricci, 2012)


See Work conditioning, work hardening. The SDET (single-discipline exercise therapy) terminology is frequently used to refer to work hardening.

Sedative hypnotics

See Insomnia treatment.

Sensory nerve conduction threshold (sNCT) device

See Current perception threshold (CPT) testing.

Sentra PM™

Sentra PM™ is a medical food that is a proprietary blend of choline bitartrate, glutamate, and 5-hydroxytryptophan. See Medical foods.

Serotonin norepinephrine reuptake inhibitors (SNRIs)

See Duloxetine (Cymbalta®); & Milnacipran (Ixel®). See Antidepressants for chronic pain for general guidelines, as well as specific SNRI listing for more information and references.


See SSRIs (selective serotonin reuptake inhibitors).

Skelaxin® (metaxalone)

Skelaxin® is a brand name for metaxalone marketed by King Pharmaceuticals. See Metaxalone (Skelaxin®).

Sleep studies

See Polysomnography.

Sleeping pills

See Insomnia medications.

SNRIs (serotonin noradrenaline reuptake inhibitors)

Recommended as an option in first-line treatment of neuropathic pain, especially if tricyclics are ineffective, poorly tolerated, or contraindicated. See Antidepressants for chronic pain for general guidelines, as well as specific SNRI listing for more information and references. See also Venlafaxine (Effexor®) and Duloxetine (Cymbalta®).

Soma® (carisoprodol)

See Carisoprodol (Soma®).

SpeedGel RX

Not recommended. There are no quality published studies. SpeedGel RX is a homeopathic topical analgesic gel for pain. The exact pharmacology by which SpeedGel RX works to control aches and pains associated with arthritis or trauma is unknown. According to the FDA, there is no scientific evidence to support this treatment. (NIH, 2014)

Spinal cord stimulators (SCS)

Recommended only for selected patients with Complex Regional Pain Syndrome (CRPS) Type I. More trials are needed to confirm whether SCS is an effective treatment for certain types of chronic pain. (Mailis-Gagnon-Cochrane, 2004) (BlueCross BlueShield, 2004) This supporting evidence is significantly supplemented and enhanced when combined with the individually based observational evidence gained through an individual trial prior to implant. This individually based observational evidence should be used to demonstrate effectiveness and to determine appropriate subsequent treatment. (Sundaraj, 2005) Further, the introduction of the percutaneous electrode implantation has enabled trial stimulation, which is now commonly recognized as an indispensable step in assessing whether the treatment is appropriate for individual patients. (Furlan-Cochrane, 2004) CRPS patients implanted with SCS reported pain relief of at least 50% over a median follow-up period of 33 months. (Taylor, 2006) SCS appears to be an effective therapy in the management of patients with CRPS. (Kemler, 2004) (Kemler, 2000) Recently published 5-year data from this study showed that change in pain intensity was not significantly different between the SCS plus PT group and the PT alone group, but in the subgroup analysis of implanted SCS patients, the change in pain intensity between the two groups approached statistical significance in favor of SCS, and 95% of patients with an implant would repeat the treatment for the same result. A thorough understanding of these results including the merits of intention-to-treat and as-treated forms of analysis as they relate to this therapy (where trial stimulation may result in a large drop-out rate) should be undertaken prior to definitive conclusions being made. (Kemler, 2008) Permanent pain relief in CRPS-I can be attained under long-term SCS therapy combined with physical therapy. (Harke, 2005) As batteries for both rechargeable and nonrechargeable systems are nearing end of life, there are both early replacement indicators and end of service notifications. Typical life may be 8-9 years for rechargable batteries, but this depends on the unit. In addition, the physician programmer can be used to interrogate the implanted device and determine the estimated remaining battery life. (Restore, 2011)

Indications for stimulator implantation:

  • Complex Regional Pain Syndrome (CRPS) when all of the following are present: (1) there has been limited response to non-interventional care; (2) psychological clearance indicates realistic expectations and clearance for the procedure; (3) there is no current evidence of substance abuse issues; (4) there are no contraindications to a trial; (5) Permanent placement requires evidence of 50% pain relief and medication reduction or functional improvement after temporary trial.

Refer to the DWC MTUS chapter on Low Back Complaints for additional information on issues related to the low back.

Spinal cord stimulators, psychological evaluations

See Psychological evaluations, SCS (spinal cord stimulators).

Sprix (ketorolac tromethamine nasal Spray)

See Ketorolac. In May 2010, FDA approved an intranasal formulation of ketorolac tromethamine (Sprix Nasal Spray) for the short-term management of moderate to moderately severe pain requiring analgesia at the opioid level. The total duration of use of this intranasal formulation, as with other ketorolac formulations, should be for the shortest duration possible and not exceed 5 days. Both studies used for approval were for short-term pain after abdominal surgery, so it is not recommended as a first-line medication for chronic pain. (FDA, 2010)

SSRIs (selective serotonin reuptake inhibitors)

Not recommended as a treatment for chronic pain, but SSRIs may have a role in treating secondary depression. Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants that inhibit serotonin reuptake without action on noradrenaline, are controversial based on controlled trials. It has been suggested that the main role of SSRIs may be in addressing psychological symptoms associated with chronic pain. More information is needed regarding the role of SSRIs and pain. SSRIs have not been shown to be effective for low back pain. See Antidepressants for chronic pain for general guidelines, as well as specific SSRI listing for more information and references. SSRIs that are commonly prescribed include the following: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, & sertraline. (Clinical Pharmacology, 2010)

Stellate ganglion block

See CRPS, sympathetic blocks (therapeutic).

Stress infrared telethermography

See Thermography.

Suboxone® (buprenorphine)

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