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Examine the association between New York State Workers’ Compensation Medical Treatment Guidelines (Guidelines) adherence and return-to-work after occupational low back injuries. Assess adherence to Guidelines by examining diagnostic and treatment utilization.Retrospective chart review of cases. Outcomes of interest were lost time duration and diagnostic/treatment utilization rates. Time to event analyses performed using Kaplan–Meier plots and Cox proportional hazard model.Care received after implementation of Guidelines resulted in decreased lost time. Treatment rates were consistent, while diagnostic imaging use was inconsistent with Guidelines recommendations.Guidelines use positively influenced return-to-work after acute occupational low back injuries. Inconsistencies in following Guidelines were observed for diagnostic tests, having a potential paradoxical effect on lost time. Further studies are necessary to test for additional hypotheses.