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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.
1.2.1.1 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.
1.2.1.2 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.
1.2.1.3 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.
1.2.1.4 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.
1.2.1.4.1 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.
1.2.1.5 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.
1.2.1.6 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.
1.2.1.7 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.
1.2.1.8 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 age 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 1.2.1.1, 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]
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
2.1 Purpose
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.
2.2.1 Education
2.2.1.1 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
2.2.2.1 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.
2.2.2.2 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]
2.2.3 Exercise
2.2.3.1 General exercise recommendations
Exercise programs under the supervision of a qualified physician or physical therapist may be used for up to 6 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.
2.2.4 Medications
2.2.4.1 Acetaminophen
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.
2.2.4.2 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]
2.2.4.3 Muscle relaxants
Muscle relaxants are an option in the treatment of injured workers with acute neck problems. (M=4) (C=4) [3]
2.2.4.4 Opioid Analgesics
Opioids may be necessary if the pain is refractory to treatment with non-opioid analgesics. (M=3) (C=4) [3]
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.
2.2.4.5 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
2.2.5.1 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 reevaluated.
2.2.5.2 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 reevaluated.
2.2.5.3 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.
2.2.5.4 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]
2.2.5.5 Transcutaneous Electrical Nerve Stimulation (TENS)
Use is limited to 4 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]
2.2.5.6 Traction
Traction (either manual or mechanical) may be of benefit in the treatment of acute neck problems. (M=4) (C=4) [3]
2.2.5.7 Acupuncture
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]
2.2.5.8 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 4 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 1-2 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 is significant disability due to pain, referral to a provider trained and experienced in the evaluation and treatment of occupational disorders is warranted in the 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 4 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)[1]
2.4.4 Biofeedback (M=1) (C=1) [1]
3.0 Secondary Assessment of Neck Injuries (from 1 - 3 months)
3.1 Purpose
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]
Clinical indications:
Persistent cervical symptoms.
3.2.2 CT, MRI
Clinical indications:
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
Clinical indications:
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
Clinical indications:
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)[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)
Clinical indications:
EMG/NCS may be helpful for evaluating suspected nerve root dysfunction, or neuropathy. (M=4) (C=4) [4]
3.2.7 Ergonomic evaluation
Clinical indications:
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
Clinical indications:
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
4.1 Purpose
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
Clinical indications:
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
Clinical indications:
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
4.2.5.1 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]
4.2.6 Acupuncture
Acupuncture treatment is a physical treatment which may be useful following initial treatment to manage pain. Treatment may be up to 12 visits in 8 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]
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 8 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.
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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.
Appendix 7.0. Description of IMC Appropriateness Levels

Level 4 Level 3 Level 2 Level 1
Good Research Yes No No No
Based Evidence
Clinical Evidence Yes Yes Some No
Consensus Of The Yes Yes Partial No

Health Care Community
Clinical Utility Approp- Accepta- Appropriate
riate ble
Of Appropriateness and or appr- in uncommon Inappropriate
opria-
te
Level For Common recomm- in most individual cases.
ended
Neck cases Document the
case-specific
Injuries clinical factors circumstances
or which make this
procedure
reasonable and
necessary for this
injured worker.






Note: Authority cited: Section 139(e)(8), Labor Code. Reference: Section 139(e)(8), Labor Code.






s 72. Treatment Guideline for Occupational Asthma.




Note: Authority cited: Section 139(e)(8), Labor Code. Reference: Section 139(e)(8), Labor Code.






s 73. Treatment Guideline for Contact Dermatitis.
The method of treating contact dermatitis shall be as set forth below in the "Treatment Guideline for Contact Dermatitis" as adopted by the Industrial Medical Council on July 20, 1995.
TREATMENT GUIDELINE FOR CONTACT DERMATITIS

Contact dermatitis
Contact dermatitis is a common problem among workers and constitutes approximately 5.7 million physician visits per year. All age groups are affected, and there is a slight female predominance as reflected in patients seen for diagnostic patch testing.
The complex nature of the chemical environment (natural and synthetic) in which we live brings the skin into contact with many potential exposures which may or may not pose a hazard, depending on individual susceptibility.
There are more than 100,000 chemicals in the environment today. Almost any substance can be an irritant, depending on the exposure circumstances. Further, over 2,800 substances have been alleged to be contact allergens. The potential for these substances to cause contact dermatitis varies greatly, and thus the severity of the dermatitis ranges from a mild, short-lived condition to a severe, persistent, job-threatening and sometimes life-threatening disease.
Contact dermatitis is an altered state of skin reactivity induced by exposure to an external agent. Substances which produce this condition after single or multiple exposures may be irritant or allergic in nature and will often present as an inflammatory process. Direct tissue damage results from contact with irritants. Following contact with strong irritants the reaction is immediate with blistering and pain, resembling a burn. From contact with weak irritants, the reaction develops more slowly, over several days or weeks, with redness, pain and/or itching, and scaling. Tissue damage by allergic substances, however, is mediated through immunologic mechanisms; the reaction consists of redness, marked itching, slight thickening of the skin and/or small vesicles at the site(s) of contact. The generic term for both of these conditions is contact dermatitis. Tissue damage by allergic substances is mediated through immunologic mechanisms. The most common clinical expression of this induced inflammation is dermatitis (eczema).
CAUTION: Exogenous dermatoses may morphologically and histologically mimic endogenous dermatoses, and vice versa, and may co-exist. Before considering a job change, or if chronicity is involved (more than 12 weeks), appropriate consultation is indicated.
Scope of the guideline : This guideline deals with the assessment and treatment of contact dermatitis in working-age adults. Another contact elicited phenomenon, the contact urticaria syndrome, which in its immunologic form, has produced fatalities, is not discussed here.
A physician may vary from these rules if in the judgment of the physician, variance is warranted to meet the health care needs of the patient and that variance remains within the standards of practice generally accepted by the health care community, and the physician 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 these regulations and medical standards change constantly. The documentation required of the physician is necessary to monitor and explain the use of variances.
I. Initial Assessment
A. Purpose
Accurate diagnosis is the key to proper management of contact dermatitis. If the agent(s) causing the dermatitis can be found and successfully avoided, recovery can be anticipated; but if contact continues, the dermatitis may become chronic, disabling, and a serious threat to continued work and the activities of daily living. After prolonged and repeated episodes of dermatitis, a small number of individuals may not fully recover, even with adequate medical care and following avoidance of its causes.
B. Appropriate assessment methods
1. History may include:
a. General medical status

b. Onset
1) Location
2) Symptoms -- itching, burning, sting
3) Description -- redness, blisters, scales, urtication (welts), dryness, rash
4) Home remedies used, including over-the-counter preparations.
c. Progression
1) Relation between exposure and time interval of dermatitis
2) Relation to home and recreation
3) Relation to specific work activity
4) Relation to activity -- sweating, friction, pressure, heat, cold, etc.
5) Relation to sun/air exposure, season, and time of day

d. Remissions
1) Relation to non-work related weekends and/or vacations
2) Response to treatment and rapidity of recurrence after discontinuing medication
3) Relation to stress and/or anxiety
4) Relation to water exposure
e. Occupational history
1) Exact nature of work
2) Duration of present activity
3) Others similarly affected
4) Changes in procedure or chemical exposure

5) Protective measures -- type and effectiveness
6) Related symptomatology -- burning eyes, sneezing, wheezing, asthma, and anaphylaxis
7) Cleansing agents -- type and frequency of use
8) Hand washing frequency and agents used; protective creams -- type and use
9) Second job
10) Review of Material Safety Data Sheets in relation to patient's job
11) Moisturizers and over the counter topicals
12) Other factors
f. Other exposure
1) Hobbies and non-work activities

a) Gardening, house plants, lawn care, and other outdoor activities (e.g., poison ivy, oak, and sumac, chrysanthemums, primula, Peruvian lily)
b) Knitting, sewing, macrame
c) Painting, ceramics, jewelry
d) Cooking, baking
e) Wood working, carpentry, gluing
f) Auto, motorcycle, truck repair
g) Photography and photographic developing
h) Sports
i) Other
2) Animals and substances on their skin or fur

a) Dogs and cats
b) Birds and caged animals
c) Farm animals, horses
d) Other
3) Cosmetics, fragrances, and personal care products
a) Soaps and detergents
b) Shampoos and other scalp/hair products
c) Creams and lotions
d) Perfumes, colognes, deodorants
e) Nail polishes, artificial nails, and nail/cuticle products

f) Consort or other interpersonal contact/products
g) Other
4) Household activities and products
a) Dishwashing products
b) Laundry detergents
c) Furniture waxes, polishes, and dusting agents
d) Bathroom cleaning agents
e) Floor care products
f) Use of gloves (type and frequency)
g) Other
g. Family history

1) Atopic background -- nature, prevalence and severity including relation to eczema
2) Ichthyosis, psoriasis, and hand eczema or other significant skin disorder
3) Family members with contact dermatitis
a) Relationship
b) Age of onset
c) Type and severity of problems
d) Results of therapy and/or testing procedures
e) Other
h. Past medical history
1) History of contact dermatitis -- nature, severity, and causative agent(s), if known
2) Previous treatment
a) At onset
b) Self treatment -- over the counter treatments -- relation to dermatitis
c) By other physicians
3) Medications -- topical and systemic -- past and present -- relation to dermatitis as well as medication allergy
4) Other
2. Physical examination may include:
a. Location
1) Symmetry

2) Involved vs. uninvolved skin
a) Demarcation--sharp or unclear
b) Evidence of protection by clothing
c) Distribution suggestive of photo or air-borne pattern exposure (e.g., exposed or uncovered skin areas)
b. Lesion type
1) Acute
a) Dermatitis (eczema)
b) Vesicular/bullous
c) Urticarial
d) Excoriations

e) Crusts
2) Chronic
a) Lichenification
b) Pigmentary changes
c) Atrophy
d) Scarring
e) Loss of hair
c. Other
3. The patch test
The patch test is the standardized diagnostic procedure of choice for allergic contact dermatitis. In general, practitioners who do such patch testing should adhere to the following guidelines when performing patch tests. It should be used only by primary care physicians with previous knowledge, training and skill in the application and interpretation of such testing. In the vast majority of cases, patients who require patch testing should be referred to a dermatologist or allergist who includes patch testing in his/her practice.
a. Standardized test kits containing a number of allergens are available. In testing with substances brought from work, appropriate dilutions must be used to avoid irritant reactions which can be very severe. In general, testing with raw substances from the workplace should be done by a dermatologist or allergist experienced in patch testing.
b. The most widely used patch test material consists of strips of paper tape onto which are fixed 8 mm diameter aluminum discs. A small amount of allergen is placed within these discs, discs, covering slightly more than one-half the diameter of the disc providing a dose approximately 17 ul.
c. Apply the patch to the upper or mid back, which must be free of dermatitis and devoid of hair. If shaving is necessary, it should be done only with an electric razor.
d. Leave the patch in place and keep dry for two days (48 hours) before removing unless symptoms of severe reaction occur.
e. Read tests:
1) The same day that patches are removed from the skin, allowing 20-30 minutes for erythema to resolve before preliminary interpretation.
2) One additional reading at 72 or 96 hours, and occasionally at one week. Reading solely at 48 hours will miss up to 35% of positive reactions.
3) If two readings are impossible, a single reading three or four days (72-96 hours) after patches are initially applied.
f. Grade test reactions according to intensity (International Contact Dermatitis Research Group Scale): [Color plates available]
1) 0 = no reaction.
2) ?(+ or - reaction) = weak erythema only.
3) 1+ = erythema with edema.

4) 2+ = erythema and papules. Tiny vesicles are present over the surface.
5) 3+ = vesicles or bullae.
g. Interpret reactions cautiously:
1) 0 = no evidence of contact allergy.
2) ? = doubtful existence of contact allergy.
3) 1+ = possible contact allergy. (1+ is a common intensity of false positive reactions).
4) 2+ and 3+ = probably contact allergy.
5) If several questionable and 1+ reactions are present along with strong 2+ or 3+ reactions, the weaker reactions may mean that the "excited skin syndrome" is present, the weak reaction representing only irritation.
4. Additional tests of occasional value

a. Skin biopsy to differentiate from other diseases.
b. Open application of a suspected allergenic product to the antecubital fossa twice daily for up to one week (the PUT, Provocative Use Test or ROAT, repeat open application test). This is applicable to leave-on products intended for use on the skin, not wash-off products.
c. Prick or scratch test in the evaluation of contact urticaria. Emergency resuscitation equipment should be available. Contact urticaria should first be evaluated with an open test on sites adjacent to active dermatitis.
d. Chemical analysis of environmental materials to determine if they contain a substance to which the patient is patch-test positive. The most commonly employed of these is the dimethylglyoxime test for nickel.
e. Potassium hydroxide (KOH) preparation, fungal and bacterial cultures and appropriate laboratory examinations as needed.
C. Inappropriate initial assessment methods

1. Occlusive patch test with irritant concentrations of material or material where the irritant concentration is unknown.
2. A specific IgE (RAST) test is not helpful in the diagnosis of contact dermatitis (with the exception of contact urticaria when prick or scratch tests may be hazardous).
3. Sublingual allergen application with vital sign monitoring as an indicator of adverse reactions.
D. Evolving diagnostic tests
In vitro lymphocyte stimulation tests, migration inhibition factor, and other laboratory tests of lymphokine production remain investigational tools which at present are insufficiently standardized to allow clinical application.
II. Initial Treatment
A. Purpose
The purpose of initial treatment is to prevent further exposure to the causative agent(s) and control itching and/or edema.
B. Appropriate initial treatment methods
1. Topical treatment
Topical treatment alone may be indicated for mild cases of contact dermatitis, limited site of involvement, acute contact dermatitis when the offending agent has been removed, or chronic contact dermatitis with limited symptoms.
Topical therapy most commonly used includes but is not limited to:
a. Cool compresses with saline, water, milk, aluminum subacetate, or other agents for acute, blistering dermatitis
b. Shake lotions, such as calamine
c. Topical corticosteroid cream, ointment, lotion, gel, or spray
d. Colloidal oatmeal baths

e. Antibiotic treatment, if required, should be systemic only (Many antibiotic creams and ointments are sensitizing.)
f. Coal tar in low concentration (in chronic eruptions)
g. Emollients, lubricants, moisturizers (in chronic eruptions) and for prevention of irritation
h. Non-alkaline cleansers instead of soap
2. Systemic treatment
Systemic treatment may be indicated for control of itching and/or edema even in cases of limited extent. Systemic treatment may also be indicated for moderate to severe acute and/or chronic contact dermatitis.
Systemic therapy most commonly used includes but is not limited to:
a. Antihistamine -- sedative types for nighttime sedation; non-sedating types for daytime use.

b. Corticosteroids, oral or intramuscular (Intravenous corticosteroids may be useful in severe acute cases) (continued)