Medical Unit - Neck problems
(Adopted May 15, 1997)
Neck injuries are common among workers. In the majority of injured workers with neck injuries recovery occurs within the first month of symptoms. Those who are not better at one month may need further diagnostic evaluation and consideration of other treatment options. The overall goal of the management of neck injuries in workers is to identify and correct both environmental and personal factors that may be causing or aggravating the injury, while providing appropriate management of disability so that it leads to a return to productive work.
Scope of the guideline
This guideline deals with the assessment and treatment of common industrial neck injuries in working age adults. This guideline addresses injuries affecting the neuromusculoskeletal structures of the neck and associated region. Initial assessment to rule out serious neck injuries is discussed, but definite diagnosis and treatment of serious disorders is beyond the scope of this guideline. This guideline does not deal with issues of legal causation or work-relatedness. Treatment guidelines are designed to assist providers by providing an analytical framework for the evaluation and treatment of the more common problems of injured workers. These guidelines are educational and descriptive of generally accepted parameters for the assessment and treatment of neck injuries. The guidelines are intended to assure appropriate and necessary care for injured workers diagnosed with these types of industrial conditions. Due to the many factors which must be considered when providing quality care, health providers shall not be expected to always provide care within the stated guidelines. Treatment authorization, or payment for treatment, shall not be denied based solely on a health care provider's failure to adhere to the IMC guideline. The guidelines are not intended to be the basis for the imposition of civil liability or professional sanctions. They are not intended to either replace a treating provider's clinical judgment or to establish a protocol for all injured workers with a particular condition. It is understood that some injured workers, for example those with red flag conditions, will not fit the clinical conditions contemplated by a guideline.
Symptom duration is classified as acute (one month), subacute (one to three months), and chronic (three months). If an injured worker experiences more than one recurrence of neck pain in a year, except in cases of a new injury, it should not be classified and treated as an acute neck problem. In this case, it is considered a recurrent or flare-up neck problem, and secondary assessment and treatment methods should be utilized along with an emphasis on active therapy and prevention strategies. This guideline does not address the evaluation and management of chronic neck problems including chronic pain syndrome.
For the purpose of this document, a provider is defined as any health care provider acting within the scope of his/her practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician.
All health care providers acting within the scope of their practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician, shall be allowed to bill and be reimbursed in accordance with usual practices.
A provider may vary from these guidelines if, in his or her judgment, variance is warranted to meet the health care needs of the injured worker and that variance remains within the standards of practice generally accepted by the health care community, and the provider documents the need for the variance in the evaluation report or the medical treatment record in the manner that is generally accepted by the health care community.
Not every medical situation can be addressed in this guideline and medical standards change constantly. The documentation required of the provider is necessary to monitor and explain the use of variances.
In all cases, the provider shall document, no later than six months from the date of injury whether further treatment is warranted and whether the injured worker has significant subjective and objective findings of the condition not having plateaued.
1.0 Initial assessment of neck injuries
The purpose of the initial assessment is to establish a working diagnosis and assign the injured worker into one of five initial clinical categories of neck problems:
1) Conditions involving the bony spinovertebral axis such as cancer, infection or fracture;
2) Intraspinal pathology involving neurological conditions such as radiculopathy or myelopathy;
3) Arthritic or inflammatory conditions;
4) Mechanical conditions; or
5) Referred neck pain due to viscerogenic and/or other causes.
In addition, the initial assessment looks for (and documents for the chart) other factors which might have an impact upon a injured worker's symptoms and/or response to treatment (e.g., work, personal, psychosocial, and economic factors).
1.2 Appropriate Initial Assessment Methods
1.2.1 History and physical
The history and physical examination are the basis upon which any assessment and treatment decisions are to be made. Decisions about diagnostic imaging, laboratory testing, and referral to a specialist should be guided by the clinical features of the history and examination. Only a minority of injured workers will require further diagnostic testing after the initial history and physical examination.
In the history, document the characteristics of pain (type, location, duration, severity, radiation), associated symptoms, precipitating factors, positions and activities that aggravate or relieve the symptoms as well as its impact on function at home and work. Information concerning previous neck injuries, diagnostic and treatment procedures, and response to previous therapies (including home treatments and use of appliances) should be obtained. Document any history of prior or repetitive trauma to the neck.
The use of a pain drawing and/or pain scale may assist in the evaluation of the location, characteristics, and severity of pain, and be utilized in the assessment of treatment response.
The relationship of the symptoms to performance of specific activities should be sought (e.g. computer work, typing, overhead work, hobbies, recreational activities, etc.). In addition, ask key questions pertinent to serious spinal pathology or referred pain (see below). Specifically, ask about neurologic symptoms such as radiculopathy involving an upper extremity or myelopathy involving any extremity or bowel or bladder changes. The initial history should also document relevant past medical and surgical history, occupational history which should include a description of current job duties and the relationship of symptoms to performance of job tasks, and possibly social history which may include tobacco, alcohol and drug use, hobbies, recreational activities, and any pertinent psychosocial issues such as financial, family, or workplace difficulties.
A thorough physical examination that is based upon the complete history and presentation of the injured worker is expected. The evaluation includes, but is not limited to, general appearance, visual inspection and palpation, manual testing of range of motion (after fracture and instability have been excluded), vascular and neurologic examination. A focused neurologic examination that includes reflexes with reinforcement, strength and sensation testing in the upper extremities should be performed. Although most injured workers have localized, non-radiating pain with tenderness on palpation and/or limited range of motion, these findings are non-specific for most neck problems. Limited spinal motion may be useful for planning and monitoring response to treatment and developing appropriate work restrictions.
Examining physicians are frequently presented with the task of identifying the etiology of the pain generator in the upper extremity. Upper extremity pain may be caused by neurogenic problems, musculoskeletal problems, or referred pain related to visceral problems. For example, pain along the radial aspect of the forearm and hand poses a dilemma as to whether the etiology is focal, such as a de Quervain's tenosynovitis; local, such as a radial nerve entrapment syndrome; or a radiculopathy with referred pain down the C6 nerve root distribution.
126.96.36.199 Consider conditions involving the bony spinal vertebral axis
Certain key findings from the medical history and physical examination may raise suspicion of a possible serious underlying condition of the spine which requires immediate diagnosis and prompt treatment, including possible referral for surgical evaluation. The following serious underlying conditions of the spine are suggested by the "red flags" listed below:
For cancer especially in those people who are 50 years old or older: history of prior cancer, unexplained weight loss, neck pain not improved with rest, or unexplained fever.
For infection: fever, immunosuppression, intravenous drug use, history of septicemia, or incapacitating pain.
For spinal fracture: instability, history of significant trauma (e.g., motor vehicle accident or fall from height), prolonged use of corticosteroids, severe rheumatologic disease, or alcohol/substance abuse.
188.8.131.52 Consider intraspinal pathology
For compromise of the neuraxis related to spinal cord and/or nerve root compromise: history of significant trauma with sphincter control disturbance, or motor, sensory and/or reflex changes involving the extremities.
Injured workers with clinical findings that suggest underlying conditions of the spinal vertebral axis or intraspinal pathology may require further studies, such as laboratory tests, x-rays, or specialized tests to evaluate for these conditions. The provider should clearly document the need for any additional tests for other serious pathologies during the initial assessment. Management of serious spinal pathology is beyond the scope of this guideline. Injured workers with such problems should be promptly referred to an appropriate specialist for evaluation and management.
184.108.40.206 Consider arthritic or inflammatory conditions
Inflammatory arthridites of the spine which can cause neck symptoms includes ankylosing spondylitis and other spondyloarthropathies. Work-up of these conditions is beyond the scope of this guideline, but should be guided by the clinical findings and suspicion of a systemic illness.
220.127.116.11 Consider mechanical conditions and distinguish from pathology.
For the purposes of determining the appropriate management of neck problems and estimating prognosis, it is helpful to classify injured workers into diagnostic categories, as well as consider symptom duration. Most injured workers can be separated into diagnostic categories based on the location and characteristics of their symptoms and findings.
18.104.22.168.1 The symptoms of mechanical (or non-specific) neck problems are predominantly neck pain, with possible referral of pain to the shoulder or upper arm in a non-dermatomal pattern.
22.214.171.124 Consider radicular neck problems resulting from intraspinal pathology involving one or more nerve roots.
Presenting symptoms are related to specific nerve root(s) and type of pathology and include pain, alteration in sensation, loss of strength, or altered reflexes in various combinations.
126.96.36.199 Consider cord compression syndromes as a manifestation of spinal pathology such as trauma, degenerative changes, tumors or infections.
They are usually complex and beyond the scope of this guideline. However, the provider should be aware of their existence and consider prompt referral to a qualified specialist.
188.8.131.52 Consider referred pain from visceral diseases or other musculoskeletal disorders unrelated to the cervical spine.
These conditions can usually be distinguished by a careful history and physical examination. There should be awareness of anginal equivalents. Examination of the shoulder and upper extremity may reveal findings consistent with a localized joint or muscle problem.
184.108.40.206 Consider other psychosocial factors
Psychological work factors that are known to increase the reporting of a neck injury and lead to prolonged symptoms and disability include job dissatisfaction. If psychological distress is suspected from the history, pain drawing, and/or the physical examination such as the presence of several "nonorganic" physical signs, the injured worker may be at risk for a delayed recovery or poor response to any surgical procedure.
The medical and social history may help the provider evaluate for other risks of delayed recovery and may help plan therapy accordingly. A history of previous neck injuries or surgery, failed previous treatments, prolonged or continuous litigation or disability claims, family or financial problems, or secondary gain may affect treatment response and prolong disability. Chronic pain, depression, and alcohol or substance abuse may prolong disability and influence the choices for therapy. Recreational and other non-work activities which might contribute to neck problems must also be considered in the evaluation and management of neck problems.
1.2.2 Laboratory studies
Laboratory tests should not be ordered routinely in the initial assessment unless an underlying illness is suspected. (Mail survey=4) (Consensus panel=4) [ 4 ]
If the injured worker's history, age, or examination suggests cancer, infection, inflammatory arthritis, metabolic or endocrine disorders, or visceral disease, then appropriate laboratory tests may be indicated. The physician must provide a clear rationale of the indications for the test ordered.
1.2.3 Diagnostic imaging
Plain x-rays of the cervical spine are recommended for ruling out fractures in injured workers with acute neck problems when any of the following 'red flags' are present: recent significant trauma (any age), recent mild trauma (injured worker over 50), suspected instability, history of prolonged steroid use, osteoporosis, or any other "red flag" consideration. (Sec 1.2.1) (M=4) (C=4) [ 4 ]
Plain x-rays may be required prior to manipulation, mobilization or traction of the cervical spine. (M=4) (C=4) [ 4 ]
Additional views are not routinely needed but may be indicated on the basis of findings on AP/lateral films. Significant soft tissue injuries may be suspected by the presence of asymmetric spinous process spreading on lateral flexion-extension views.
In the presence of "red flags", as defined in 220.127.116.11, the use of other imaging studies such as bone scan, CT, or MRI may be clinically indicated even if plain x-rays are negative.
1.2.4. Needle electromyography/nerve conduction studies (EMG/NCS) may be appropriate as baseline evaluation in injured workers with a past history of radiculopathy or spine surgery. (C=4) [ 4 ]
1.3 Inappropriate initial assessment methods
All of the following assessment methods have been determined inappropriate during the initial phase of assessment.
Routine use of:
1.3.1 Laboratory studies (M=1) (C=1) [ 1 ]
1.3.2 Plain x-rays for evaluation of injured workers with acute neck injuries except as indicated in 1.2.3 (M=1) (C=1)
1.3.3 CT, MRI, myelography, CT-myelography, and bone scan. (M=1) (C=1) [ 1 ]
1.3.4 Discography (M=1) (C=1) [ 1 ]
1.3.5 Surface electromyography (EMG) (M=1) (C=1) [ 1 ]
1.3.6 Computerized strength and range of motion testing (M=1) (C=1) [ 1 ]
2.0 Initial treatment of neck injuries
The purpose of the initial treatment of neck injuries is to relieve pain and suffering and to restore functional capacity. The goal is to allow the injured worker to resume necessary activities including return to modified or regular work. Injured workers with radicular neck problems and neurologic deficits may require more intensive management and closer monitoring for further neurologic deterioration that may require additional diagnostic testing with possible surgical treatment.
Treatment may include: 1) education about neck problems 2) activity and environmental modifications 3) exercise 4) medication; and/or 5) physical treatments as delineated later in this section. This guideline does not address treatment for certain types of conditions such as serious underlying spinal pathology or inflammatory arthritis of the cervical spine.
2.2 Appropriate initial treatment methods in the first month
18.104.22.168 General information
Accurate information concerning soft tissue injury and the usual, expected healing should be provided. (M=4) (C=4) [ 4 ]
Patients should be given realistic information regarding recovery, and should be taught principles related to posture (e.g., avoid slumping) and daily activities including work and sports. Safe and effective methods of symptom control need to be presented. Patients should be told that, unless there is pending surgical care or question of a fracture, tumor, or infection, special investigations are not warranted.
2.2.2 Activity and environmental modifications
22.214.171.124 Work restrictions
Modifications of activities including work specific restrictions which are based on the injured worker's work requirements and clinical findings are desirable if functional limitations do not allow continuation of regular work duties. (M=4) (C=4) [ 4 ]
Complete work cessation should be avoided, if possible, through the use of modified duty. Written work restrictions should be as specific as possible, and it may be necessary to contact the employer to discuss alternative work within the prescribed restrictions. Injured workers with work restrictions should be re-evaluated within two weeks for determination of work status, response to treatment, and for making appropriate decisions concerning progression to full activities.
126.96.36.199 Environmental/job modification
Environmental modifications including engineering (e.g., work station adjustment) and administrative controls (e.g., job rotation) to limit or eliminate work activities that might lead to or aggravate neck problems should be considered early on for symptomatic workers who have work-related risk factors for neck problems. (M=4) (C=4) [ 4 ]
188.8.131.52 General exercise recommendations
Exercise programs under the supervision of a qualified physician or physical therapist may be used for up to six visits. Rehabilitative exercise may be indicated to strengthen the neck muscles, for stabilization, to improve range of motion, to normalize posture and to promote safe body biomechanics. (C=3) [ 3 ]
There is evidence that one-on-one training in home exercises for cervical motion and extension postures will reduce the duration of pain, compared to rest and the use of a collar. Home programs need to be monitored and reinforced weekly for compliance and progress.
Acetaminophen has commonly been regarded as having an analgesic effect, but little or no known antiinflammatory effect. (M=4) (C=4) [ 4 ]
The therapeutic objective for its use in acute neck problems is pain relief. Acetaminophen is reasonably safe and is acceptable for treating injured workers with acute neck problems.
184.108.40.206 Non-steroidal antiinflammatory drugs (NSAID's)
NSAID's and aspirin are acceptable for treating injured workers with acute neck problems but have a number of potential side effects. (M=4) (C=4) [ 4 ]
220.127.116.11 Muscle relaxants
Muscle relaxants are an option in the treatment of injured workers with acute neck problems. (M=4) (C=4) [ 3]
18.104.22.168 Opioid analgesics
Opioids may be necessary if the pain is refractory to treatment with non-opioid analgesics. (M=3)(C=4)
Oral opioid analgesics commonly given to injured workers with cervical problems include morphine derivatives (opioids) and synthetic opioids. Their therapeutic objective in treating neck problems is temporary pain relief. The decision to use opioids should be guided by consideration of their potential complications relative to other treatment options.
22.214.171.124 Other medications
Other medications not mentioned above may also be beneficial with appropriate justification, including, but not limited to:
(a) Antidepressants (C=4) [ 3 ]
(b) Other non narcotic analgesics (C=4) [ 3 ]
(c) A short course of oral corticosteroids. (C=4) [ 2 ]
2.2.5 Physical treatments
126.96.36.199 Manual medicine/manipulative techniques, as performed by a physician defined by the California Labor Code and the scope of practice for each group, may be helpful in injured workers with acute problems. (M=4) (C=4) [ 4 ]
Neurologic deficits should be clinically investigated and instability resulting from fracture subluxation should be ruled out before manipulation is undertaken. Functional improvement should be demonstrable as well as symptomatic benefit. If this has not occurred after one month, the injured workers should be re-evaluated.
188.8.131.52 Manual medicine/mobilization, as performed by a physician or another appropriately licensed health care provider as defined by their scope of practice, may be helpful in injured workers who have acute problems without radiculopathy when used within the first month of the symptoms. (M=4) (C=3) [ 3 ]
Progressive neurologic deficits should be investigated and instability should be ruled out before aggressive mobilization is undertaken. Functional improvement should be demonstrable as well as symptomatic benefit. If this has not occurred after one month, the injured workers should be re-evaluated.
184.108.40.206 Other physical modalities/treatments
Manual medicine/therapy can be supplemented by passive modalities including but not limited to iontophoresis, phonophoresis, electrical stimulation, ultrasound, diathermy, and other physical agents during the first four weeks of treatment. (M=4) (C=3) [ 3 ]
Passive modalities should not be used as the sole form of treatment. They may be combined with an active program which emphasizes progressive exercises. Use of thermal modalities in conjunction with physical treatment may be useful.
220.127.116.11 Frequency of treatment
The total number of visits for physical treatments may be up to 12 within the first month. (M=4) (C=4) [ 4 ]
18.104.22.168 Transcutaneous electrical nerve stimulation (TENS)
Use is limited to four weeks in conjunction with other conservative measures. If no functional and symptomatic benefit has been demonstrated after two weeks, this treatment should be discontinued. (C=3) [ 3 ]
Traction (either manual or mechanical) may be of benefit in the treatment of acute neck problems. (M=4) (C=4) [ 3 ]
Acupuncture has been reported as useful for acute pain and may be of benefit to facilitate exercises. The frequency of treatment may be up to three times per week for four weeks as long as the injured worker has documented improvement. (M=4) (C=4) [ 3]
22.214.171.124 Cervical collars
Collars that adequately stabilize the neck may be of benefit for up to a week for acute neck problems. Continual dependence on a cervical collar is not advisable. (M=4) (C=4) [ 3
2.3 Case management
Management during the first four weeks of treatment will be determined by the clinician's evaluation of the injured worker's response to therapy. Generally, re-evaluation of the problem, determination of treatment effectiveness and work status should be performed every one-two weeks until return to modified or full work is achieved. At each visit, the initial diagnosis should be confirmed or modified and the treatment plan adjusted if necessary. If symptoms continue to increase despite adequate conservative therapy, or if there initial treatment phase. Once the acute pain is controlled, the treatment should focus on progressive rehabilitative exercises to increase strength and endurance and activity modification. This approach minimizes the chance of recurrence once normal occupational duties are resumed.
2.4. Inappropriate Initial Treatments
The following treatment methods are inappropriate as routine treatment in the initial four week symptom phase.
2.4.1 Bed rest (M=1) (C=1) [ 1 ]
2.4.2 Surgical treatments (M=1) (C=1) [ 1 ]
Except for acute neurologic deterioration or structural disruption, surgery is unwarranted.
2.4.3 Exclusive use of passive physical modalities (M=1)(C=1)
2.4.4 Biofeedback (M=1) (C=1) [ 1 ]
3.0 Secondary assessment of neck Injuries (from one - three months)
The purpose of reassessment is to determine the reason for delayed recovery in injured workers who remain symptomatic and have not functionally improved and returned to regular work after one month of conservative treatment. The first step of reassessment is a complete interval history and physical examination with assignment of the injured worker into one of the five clinical categories:
1) Conditions involving the bony spinovertebral axis such as cancer, infection or fracture
2) Intraspinal pathology involving neurological conditions such as radiculopathy or myelopathy
3) Arthritic or inflammatory conditions
4) Mechanical conditions or
5) Referred neck pain due to viscerogenic and/or other causes.
Depending on the findings, diagnostic evaluation at this point may include spinal imaging tests, bone scan, electrophysiologic tests, lab tests, functional capacity tests, and/or ergonomic evaluation. The clinical indications for each of these diagnostic methods is given below. Physician assessment should be at least twice monthly. Results of all studies should be reviewed and reported within a week.
3.2 Appropriate secondary assessment methods
3.2.1 Plain film x-rays (M=4) (C=4) [ 4 ]
Persistent cervical symptoms.
3.2.2 CT, MRI
Findings that suggest compromise of the neuraxis (radiculopathy from a herniated disc and/or spinal stenosis), or a neurologic deficit. These studies are most suitable when surgery is being considered and/or the injured worker has failed an appropriate course of treatment. (M=4) (C=4) [ 4 ]
Findings are suggestive for tumor or infection, fracture or dislocation. (M=4) (C=4) [ 4 ]
3.2.3 Myelography, and CT myelography
Same indications as for CT/MRI, but should only be ordered in conjunction with a specialist referral. (M=4) (C=4) [ 4 ]
3.2.4 Bone scan
Findings on history, examination, laboratory or other imaging studies are suggestive for, but not limited to, tumor, infection, fracture, arthritis, and reflex sympathetic dystrophy. (M=4)(C=4)
3.2.5 Laboratory testing
Clinical indications: As deemed appropriate by the reassessment findings. (M=4) (C=4) [ 4 ]
3.2.6 Needle electromyography / nerve conduction study (EMG/NCS)
EMG/NCS may be helpful for evaluating suspected nerve root dysfunction, or neuropathy. (M=4) (C=4) [ 4 }
3.2.7 Ergonomic evaluation
A worksite evaluation with the affected injured worker may be performed if clinically indicated. (M=4) (C=3) [ 3 ]
The evaluation should be done by a professional trained in these types of evaluation. History, job description, and workplace inspection can be useful to identify physical work factors that may be contributing to the development or exacerbation of neck problems,which can prevent return to usual work.
3.2.8 Psychological assessment
Focused psychological assessment may be indicated if factors (e.g., stress, job dissatisfaction, depression, substance abuse, symptom magnification) may be contributing to delayed recovery, noncompliance or lack of response to appropriate treatment in subacute and chronic neck problems. (M=4) (C=4) [ 4 ]
In an injured worker manifesting signs of risk for delayed recovery, psychological assessment may be helpful for determining if significant psychological or personality factors are contributing to the injured worker's disability.
The presence of several "nonorganic" physical signs may also identify injured workers who need further psychological testing and evaluation. These injured workers may need specific behavioral or psychological treatments early on.
Psychological and personality evaluations may be utilized preoperatively in an injured worker who is being considered for surgical treatment to assist in selection and planning if a behavioral intervention is necessary.
3.2.9 Somatosensory evoked potentials (SEP) should only be performed after EMG and other diagnostic modalities have proven to be of no help and specific justification must be given. (M=4) (C=3) [ 3 ]
3.3 Inappropriate secondary assessment methods
The following methods have been determined inappropriate for secondary assessment.
3.3.1 Discography (M=1) (C=1) [ 1 ]
3.3.2 Surface EMG (M=1) (C=1) [ 1 ]
3.3.3 Diagnostic blocks and injections including facet joint injections are inappropriate at this phase of the treatment. (M=1) (C=1) [ 1 ]
3.3.4 Computerized strength and range of motion testing
Computerized testing is only useful if it leads to a specific exercise program which allows measurable progress. Its routine use is not recommended. (M=1) (C=1) [ 1 }
4.0 Secondary treatment of neck injuries
The purpose of secondary treatment is to provide symptomatic relief for the injured worker with a cervical problem while continuing to intensify efforts in active treatments, such as exercise. The goal of secondary treatment is to prevent progressive deconditioning and permanent disability, while promoting return to full work for those who are either off work or on modified duty. Treatment is based on the findings of the diagnostic re-evaluation at four to six weeks.
4.2 Appropriate secondary treatment methods
4.2.1 Physical treatments
Treatment following the initial trial of four weeks generally should not exceed two times a week. (M=4) (C=3) [ 3 ]
The continuation of treatments is based on reported improvement in subjective complaints, decreased objective factors/clinical findings, return to work, or decreased work restrictions.
Active care, education and rehabilitative exercise may be indicated for strengthening of the neuromusculoskeletal structures of the neck and associated regions and for pain control. (M=4) (C=4) [ 4 ]
4.2.2 Work conditioning
Work conditioning programs which include general conditioning exercises and graduated performance of simulated job tasks may be useful in preparing the injured worker to return to a specific job or in determining work restrictions. (M=4) (C=4) [ 4 ]
4.2.3 Epidural steroid injections
For a patient with a radicular neck problem, a trial of epidural steroid injections may be helpful for short-term pain relief and avoiding surgery. (M=4) (C=4) [ 3]
4.2.4 Surgical treatment methods
Surgical treatment may be appropriate for injured workers with radicular neck problems in the following circumstances: 1) the clinical evaluation demonstrates persistent symptoms and findings that prevent resumption of normal activities, and they are unresponsive to an appropriate six weeks of active non-surgical treatment and 2) the diagnostic test findings objectively verify a surgically remediable condition that corresponds with the clinical exam and 3) surgery is not contraindicated by significant physical or psychological comorbidity that might suggest a poor surgical outcome for the injured worker. (M=4) (C=4) [ 4 ]
4.2.5 Injection therapies
126.96.36.199 Trigger point injections
Standard trigger point injections with saline or local anesthetic are only for occasional use, not standing alone as a sole treatment but as part of a multi-disciplinary approach. (M=4) (C=4) [ 3]
Acupuncture treatment is a physical treatment which may be useful following initial treatment to manage pain. Treatment may be up to 12 visits in eight weeks as long as the injured worker is showing documented, incremental improvement. (M=4) (C=4) [ 3]
4.2.7 TENS unit
Use is limited to four weeks in conjunction with other conservative measures. (C=4) [ 3]
4.2.8 Appropriate medication as listed under 2.2.4 (M=4)(C=4) 
4.2.9 Biofeedback [ 3]
4.3 Inappropriate secondary treatments
The following treatments have been determined as inappropriate for secondary treatment:
4.3.1 Ligamentous injections (sclerotherapy/prolotherapy) (M=1) (C=1) [ 1 ]
4.3.2 Bed rest (M=1) (C=1) [ 1 ]
4.4 Case management
If the injured worker has not resumed near normal work duties after eight weeks in the secondary treatment phase, including adherence to a graded exercise program, a referral to a physician or surgeon trained and experienced in the evaluation and treatment of occupational disorders is recommended. Consultation should include a complete evaluation and recommendations for treatment and return to appropriate work. If psychosocial issues are judged to contribute to delayed recovery or heightened disability, it may be appropriate to have a psychiatric evaluation. If the condition becomes chronic or disabling despite full conservative treatment including appropriate medical, rehabilitative, and ergonomic interventions (and surgery if indicated), the injured worker should be evaluated for permanent disability.
5.0 Tertiary management of neck injuries
Late rehabilitation after three months of disabling symptoms may require a multi-disciplinary approach focused on returning the injured worker to work. At this time, this guideline does not address the evaluation and management of chronic neck problems including chronic pain syndrome.
6.0 Primary references
1. Amlie E, Wever H, Holme I: Treatment of acute low-back pain with piroxicam: Results of a double-blind placebo-controlled trial. Spine 1987; 12(5):473-6.
2. Anderson R, Meeker WC, Wiriek BE, et at.: A meta-analysis of clinical trials of spinal manipulation. J Man Physiol Ther 1992;15(30):181-94.
3. Baratta RR: A double-blind study of cyclobenzaprine and placebo in the treatment of acute musculoskeletal conditions of the low back. Curr Ther Res 1982;32(5):646-52.
4. Basmajian JV: Acute back pain and spasm: A controlled multicenter trial of combined analgesic and antispasm agents. Spine 1989;14(4):438-9.
5. Bass MJ, Buck C, Turner L, et al.: The physician's actions and the outcome of illness in family practice. J Fam Pract 1986; 23(1):43-7.
6. Boden SD, Davis DO, Dina TS, et al.: Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. J Bone JT Surg [Am] 1990;72(3):403-8.
7. Boline PD, Meyer JJ: Chiropractic management of mechanical cervical spine syndrome and concomitant myofacial pain syndrome: a case study using time series descriptive design. Chiropractic Technique 1990; 2(4):176-81.
8. Boyles WF, Glassman JM, Soyka JP: Management of acute musculoskeletal conditions; thoracolumbar strain or sprain. A double-blind evaluation comparing the efficacy and safety of carisoprodol with diazepam. Today's Ther Tends 1983; 1(1):1-16.
9. Brewerton DA, Nichols PJ, Logue V, et al.: Pain in the neck and arm: a multicentre trial of the effects of physiotherapy. Brit Med J 1966;1:253-8.
10. Brooks PM, Day RD: Nonsteroidal anti-inflammatory drugs-differences and similarities. New Engl J Med 1991; 324:1716.
11. Bush C, Ditto B, Feuerstein M: A controlled evaluation of paraspinal EMG biofeedback in the treatment of chronic low back pain. Health Psychol 1985; 4(4):307-21.
12. Cassidy JD, Lopes AA, Yong-Hing K: The immediate effect of manipulation versus mobilization of pain and range of motion in the cervical spine: a randomized controlled trial. J Man Phys Ther 1992; 15(9):570-5.
13. Deyo RA, Diehl AK: Patient satisfaction with medical care for low-back pain. Spine 1986;11(1):28-30.
14. Fitz-Ritson D: The chiropractic management and rehabilitation of cervical trauma. J Man Phys Ther 1990;13(1):17-25.
15. Fowler PD: Aspirin, Paracetamol and non-steroidal anti-inflammatory drugs: A comparative review of side effects. Med Toxicol 1987; 2:338-66.
16. Garvey TA, Marks MR, Wiesel SW: A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain. Spine 1989;1499):962-4.
17. Greenfield J, Ilfeld FW: Acute cervical strain. Clin Orth Rel Res 1977;122:196-200.
18. Haimovic IC, Beresford HR: Dexamethasone is not superior to placebo for treating lumbosacral radicular pain. Neurol 1986;36(12):1593-4.
19. Highland TR, Dreisinger TE, Vie LL, et al.: Changes in isometric strength and range of motion of the isolated cervical spine after eight weeks of clinical rehabilitation. Spine 1992;17. (6 Suppl.): 577-82.
20. Hoffman RM, Kent DL, Deyo RA: Diagnostic accuracy and clinical utility of thermography for lumbar radiculopathy. A meta analysis. Spine 1991;16(60): 623-8.
21. Hopkinson JH, Bartlett FH, Steffens AO, et al.: Acetaminophen versus propoxyphene hydrochloride for relief of pain in episiotomy patients. J Clin Pharm 1973;13:251-63.
22. Klein R, Eek BC, DeLong WB, et al.: A randomized double-blind trial of dextrose-glycerin-phenol injections for chronic low back pain. J Spinal Dis 1992;6(1):23-33.
23. Koes BW, Bouter LM, Mameren HV, et al.: A randomised clinical trial of manual therapy and physiotherapy for persistent back and neck complaints: Subgroups analysis and relationship between outcome measures. J Man Physiol Ther 1993;(694):211-9.
24. Koes BW, Bouter LM, Mameren HV, et al.: A ramdomized clinical trial of manual therapy and physiotherapy for persistent back and neck complaints: results of one year follow up. Brit Med J 1992;304:601-5.
25. Koes BW, Bouter LM, Mameren HV, et al.: The effectiveness of manual therapy, physiotherapy and treatment by the general practitioner for nonspecific back and neck complaints. A randomized clinical trial. Spine 1992;17(1):28-35.
26. Leggett SH, Graves JE, Pollock ML, et al.: Quantitative assessment and training of isometric cervical extension strength. Am J Sports Med 1991;19(6):653-9.
27. Levoska S, Keinanen-Kiukaanniermi S: Active or passive physiotherapy for occupational cervicobrachial disorders? A comparison of two treatment methods with a 1 year follow-up. Arch Phys Med Rehabil 1993;74:425-30.
28. Mandell P, Lipton MH, Bernstein J, et al.: Low back pain. A historical and contemporary overview of the occupational, medical, and psychosocial issues of chronic back pain. New Jersey: SLACK, Inc., 1989. 219p.
29. Mckinney LA: Early mobilization and outcome in acute sprains of the neck. Brit Med J 1989;299:1006-8.
30. Mealy K, Brennan H, Fenelon GC: Early mobilisation of acute whiplash injuries. Brit Med J 1986;292:656-7.
31. Mills GH, Davies GK, Getty CJ, et al.: The evaluation of liquid crystal thermography in the investigation of nerve root compression due to lumbosacral lateral spinal stenosis. Spine 1986;11(5):427-32.
32. Pennie BH, Agambar LJ: Whiplash injuries. J Bone JT Surg 1990;72B(2):277-9.
33. Pollock ML, Graves JE, Bamman MM, et al.: Frequency and volume of resistance training: effect on cervical extension strength. Arch Phys Med Rehabil 1993;74:1080-6.
34. Sihvonen T, Pantanen J, Hanninen O, et al.: Electric behavior of low back muscles during lumbar pelvic rhythm in low back pain patients and healthy controls. Arch Phys Med Rehabil 1991;729130:1080-7.
35. Sloop PR, Smith DS, Goldenberg E, et al.: Manipulation for chronic neck pain: A double-blind controlled study. Spine 1982;7(6):532-5.
36. Stankovic R, Johnell O: Conservative treatment of acute low-back pain. A prospective randomized trial: McKenzie method of treatment versus patient education in "mini back school". Spine 1990;15(20120-3.
37. Taylor RS, Bonfiglio RP: Industrial rehabilitation medicine. 4. Assessment of the outcome of treatment in industrial medicine, program development, documentation, and testimony. Arch Phys Med Rehabil 1992;73:S369-73.
38. Thomas KB: General practice consultations--Is there any point in being positive? Br Med [Clin Res] 1987;294:1200-2.
39. Young A, Getty J, Jackson A, et al.: Variations in the pattern of muscle innervation by the L5 and S1 nerve roots. Spine 1983;8(6):616-24.
Description of IMC appropriateness levels
|Level 4||Level 3||Level 2||Level 1|
Good research Based evidence
Consensus of the health care community
Clinical utility of appropriateness level for common neck injuries
Appropriate and recommended
Acceptable or appropriate in most cases
Appropriate in uncommon individual cases. Document the case-specific clinical factors or circumstances which make this procedure reasonable and necessary for this injured worker.