Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Degeneration, Cervical Intervertebral Disc


Related Terms

  • Cervical Disc Disease
  • Degenerative Disc Disease (DDD)
  • Degenerative Disorder of the Cervical Spine
  • Disc Degeneration

Differential Diagnosis

Specialists

  • Anesthesiologist
  • Neurologist
  • Neurosurgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Pain Medicine Physician/Pain Specialist
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Primary Care Physician
  • Rheumatologist

Comorbid Conditions

Factors Influencing Duration

Length of disability depends on the location and number of the affected discs, severity of the disc disease, presence of neurological involvement, , duration of neurological deficits (acute or chronic), other sources of pain such as low back pain, major joint osteoarthritis, and type of treatment (conservative measures vs. surgical intervention). Psychosocial factors affect the length of disability.

Medical Codes

ICD-9-CM:
722.4 - Cervical Disc Degeneration
722.71 - Cervical Disc Disorder with Myelopathy

Overview

© Reed Group
Degeneration of cervical intervertebral discs is common, and often postulated as a cause of neck and arm pain. The neck (cervical spine) is made up of seven vertebrae. Starting with cervical vertebra number 2 (C2), an intervertebral disc separates each vertebra from the vertebrae below. A cervical intervertebral disc is a spongy structure that helps absorbs shock and allows movement of the cervical vertebrae. A degenerating disc loses some of its thickness and becomes less flexible, causing the space between two vertebrae to narrow. As part of the degenerative process, bone spurs (osteophytes) may form or the disc may protrude or herniate. This may lead to pressure on the spinal cord (myelopathy) or spinal nerve roots (radiculopathy). For more information on cervical disc herniation see the topic titled Displacement, Cervical Intervertebral Disc Without Myelopathy.

Degenerative changes to the cervical spine are a part of the normal aging process and are common in the general population beginning as early as the second decade of life. Previous neck injuries, muscle strains, arthritis of the cervical spine, and genetic predisposition increase the risk for early development of this condition. Although cervical disc disease is believed to be due primarily to age-related changes, some people with degenerative changes develop symptoms while others who also have degenerative changes remain symptom-free. The reason for this variation is unclear.

Incidence and Prevalence: On MRI, 25% percent of asymptomatic individuals under age 40 show signs of cervical disc degeneration; this increases to about 60% in asymptomatic adults over age 40 (Furman).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals over age 65 are at highest risk for developing cervical disc degeneration. The male to female ratio is estimated to be 1:1; however, women report a higher rate of disability than men (Furman). Cigarette smoking, poor nutrition, and job-related or sports-related neck stress are modifiable factors associated with increased risk of early development of cervical disc degeneration (Cherry; Furman).

Source: Medical Disability Advisor



Diagnosis

History: Important items to note in the history include information about pain (onset, location, quantity, quality, setting, aggravating and alleviating factors, associated symptoms), central (axial) vs. peripheral pain, and history of neck injury. Disc-related pain (discogenic pain) without nerve root involvement is typically neck pain that may be vague and diffuse. Nerve root (radicular) pain is arm pain, and can be dull and aching or sharp and electric. Neck pain may be absent. Individuals may complain of pain aggravated by neck movement, particularly when tilting the head backward (neck extension) and rotating or tilting the head to either side. Pain may improve when bending the head forward (flexion) or holding the affected arm over the head. Certain activities (e.g., lifting) may increase disc-related pain. Neck stiffness, and headache also may be present. Pain may extend into the shoulders, arms, chest, and/or face. Some individuals complain of worsening pain in the morning or with nighttime awakening. Some individuals report arm numbness (paresthesia) or weakness (paresis). If the individual reports abrupt onset of symptoms, an acute injury may be present. A history of prior or existing systemic illness should be obtained, including chronic disease (e.g., diabetes, heart disease or atherosclerosis, nervous system disorders, arthritis), infections, malignancies, and weight loss. Myelopathy (spinal cord involvement) is typically manifest as lower extremity weakness, incoordination, and perhaps bowel or bladder control (incontinence) issues. Myelopathy may produce lower limb numbness, but does not typically cause lower limb pain.

Physical exam: The exam may reveal localized or diffuse tenderness in the neck, shoulder, arm, or upper back. The affected arm may show abnormal or absent reflexes, muscle weakness, and sensory changes, all of which are signs of nerve root involvement (radiculopathy). Pain may be reduced with flexing the neck or with longitudinal traction on the head, and pain may be increased when the physician presses the patient's head down while the neck is extended and rotated laterally (Spurling maneuver). An individual experiencing disc-related pain without nerve root involvement may have decreased cervical range of motion and a normal neurological exam.

Tests: Laboratory blood analysis may include erythrocyte sedimentation rate (ESR) to evaluate inflammation; a complete blood count (CBC) to look for infection or multiple myeloma; rheumatoid factor; and serum protein electrophoresis to rule out multiple myeloma. Human leukocyte antigens (HLA-B27) associated with ankylosing spondylitis may be typed. Results of these tests help rule out other conditions, but do not confirm cervical disc degeneration.

Imaging studies show the extent of degenerative changes, but do not give any information about function or whether the imaging changes are symptomatic. Plain x-rays may show narrowing of the disc space and osteophyte formation, if present, as well as possible metastatic disease, spinal deformity, and spine instability. Other imaging studies may include CT, MRI (study of choice in the cervical spine), and cervical myelography with CT.

If radiculopathy is suspected, nerve conduction studies (NCVs) and electromyography (EMG) may be done to assess nerve function.

Diagnosis is based on history and physical examination findings and their correlation with imaging studies and/or electrodiagnostic testing. Because imaging findings of disc degeneration are so common and may have no relationship to pain symptoms or changes in function, they are insufficient to make the diagnosis. Care must be taken to rule out other conditions that could be causing neck pain.

Source: Medical Disability Advisor



Treatment

The goals of treatment are to relieve pain and improve mobility. Medications frequently used include nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and antidepressants, which can reduce pain and improve sleep quality. Oral, sublingual, or transdermal opioids are sometimes prescribed for pain in individuals with severe pain, although this is becoming increasingly controversial. Usually, corticosteroids are not used unless inflammatory radiculopathy develops as a complication of acute disc herniation. Heat (heating pad, hot pack) can help relax muscles and reduce soft tissue pain. When symptoms are acute, activity should be modified accordingly. Regular activities should be resumed as soon as possible. Bed rest is rarely necessary.

Manipulation of the cervical spine is a common procedure for neck pain. It is not used specifically for disc degeneration, but may help reduce pain and improve mobility in the acute phase (first 1 to 2 months) of symptoms. There is no evidence that manipulation has long-term benefits or alters the course of degenerative disc disease. As symptoms subside, activity is gradually increased. This may include physical therapy and/or a home exercise program to mobilize and strengthen the muscles of the neck and shoulders.

Strain caused by poor sitting posture is common among sedentary workers and may increase existing symptoms. Attention to spinal alignment, use of the backrest of a chair, and tucking the chin in position while performing seated work will reduce strain on the neck. Good posture and frequent change of position can help relieve or prevent symptoms and reduce fatigue. A neck pillow may help nocturnal pain, and is probably underutilized. Postural training supervised by a therapist may be recommended, as well as work station analysis by an ergonomist.

Techniques for reducing muscle tension such as relaxation training and biofeedback also may be helpful. Preventive and maintenance measures (exercise, stress management techniques, proper body mechanics) should be continued indefinitely by the individual to prevent recurrence. Medically directed functional restoration programs may help individuals overcome obstacles to recovery such as poor motivation and psychopathology.

Individuals whose pain is not relieved by conservative measures may benefit from a pain clinic or rehabilitation program. If pain does not subside within several weeks, further evaluation is necessary. Cervical epidural injections of a combination of corticosteroid drugs and an anesthetic may provide temporary relief of radiculopathy (not just neck pain) and allow for more aggressive physical therapy. Surgical intervention is indicated only for intractable radicular pain, myelopathy, or deformity/instability. Surgical outcomes are much more successful in patients with radicular complaints than in individuals with only axial (neck pain) complaints.

Source: Medical Disability Advisor



Prognosis

Cervical disc degeneration is a chronic, irreversible condition as we age. The presence of degenerative changes on imaging studies (x-rays, CT, MRI) is not predictive of symptoms or indicative of function. Most degenerative disc disease can be managed successfully with conservative measures.

Source: Medical Disability Advisor



Rehabilitation

The primary focus of rehabilitation of a degenerated cervical intervertebral disc is to decrease pain, to increase function and to teach individuals how to manage their symptoms. Although exercise may initially be uncomfortable, individuals must be instructed in the benefits of ongoing exercise in managing the symptoms assumed to be associated with degenerative changes.

The first goal in treating acute neck pain is to decrease symptoms. In combination with pharmacological management, modalities, such as heat and cold, can be used for symptomatic relief (Braddom). Immobilization with a soft collar is rarely indicated; however with significant soft tissue pain, it might be necessary for intervals over a short period of time (up to 3 days).

While managing symptoms, individuals can be instructed in gentle exercises. Initial exercises may include isometrics, stretching or gentle range of motion of the neck. Spinal manual therapy might be beneficial in reducing symptoms when combined with active exercises (Gross).

Once range of motion is restored, therapy should progress to strengthening and stabilization exercises of the neck, shoulders and upper trunk (Philadelphia Panel). A home exercise program should be taught to complement the supervised rehabilitation. The individual should also be instructed how to care for and protect the neck from recurrence of symptoms. Inconclusive evidence exists regarding the benefits of cervical traction (Gross).

An ergonomic evaluation can provide information regarding the avoidance or modification of activities and positions at work that may aggravate the symptoms. A visit to the work setting may be helpful for the individual returning to the same line of work that may have contributed to the disorder.

Chronic neck pain may be best addressed by a multidisciplinary team (Karjalainen; Storro). For more information on multidisciplinary rehabilitation, see Low Back Pain.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistDegeneration, Cervical Intervertebral Disc
Physical or Occupational TherapistUp to 12 visits within 6 weeks
Surgical
SpecialistDegeneration, Cervical Intervertebral Disc
Physical or Occupational TherapistUp to 6 visits within 4 weeks
Note on Surgical Guidelines: Rehab usually begins after tissue healing, about 6 to 8 weeks after surgery.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Compression of the spinal cord by an intervertebral disc can lead to neurological symptoms (myelopathy) with associated limb weakness, especially in the lower limbs. Surgical intervention (spinal fusion) may accelerate disc degeneration in some individuals, but the concept of "adjacent segment disease" is still controversial. Inflammatory radiculopathy with associated limb weakness and numbness is a possible complication. Complications of cervical epidural injections may include spinal cord injury and stroke.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Activities involving lifting and carrying may need to be limited. An ergonomic analysis of the work station and the worker’s body mechanics may be helpful. Overhead work (neck extension) may produce symptoms. Use of pain medications, especially narcotics and muscle relaxants, can affect dexterity and alertness and should be used in accordance with company policies. If the individual is undergoing extensive physical or occupational therapy, time off may be needed for regularly scheduled appointments.

Source: Medical Disability Advisor



Maximum Medical Improvement

By definition “degenerative disc disease” (aging change) occurs over long time periods and this is not an acute injury. However, in workers’ compensation, workers will allege their pain begins during a work activity, and physicians who use this diagnosis will state the work activity “aggravated the degenerative changes.” There is no scientific way to prove or disprove this claim, so the diagnosis of work-aggravated-degenerative-disc disease is at times in the workers’ compensation system. By 4 months after pain onset, the condition is unlikely to change, absent surgical treatment. Thus MMI can be established usually by 4 months after the “aggravating incident.”

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual complain of just neck pain, or neck and arm pain/numbness suggesting radiculopathy, or leg weakness, incoordination (gait impairment), and incontinence suggesting myelopathy?
  • Does individual have associated headache? Is headache limiting function, and has headache been addressed with tests and treatment?
  • Does pain extend into the shoulders, as neck problems and shoulder problems have symptoms that overlap, and differentiating whether a person has a neck problem, a shoulder problem, or both, can be difficult.
  • Is there neurologic deficit in the arms (radiculopathy) or legs (myelopathy)?
  • Were plain x-rays done? CT, contrast-enhanced CT, or MRI?
  • Were blood tests performed including ESR, CBC, and rheumatoid factor?
  • Were nerve conduction tests and/or electromyography performed?
  • Were other causes of neck and/or arm pain (such as infection, cancer or chronic disease) considered in the medical records and ruled out?

Regarding treatment:

  • Was manipulation tried during the acute phase?
  • Is individual taking pain medications? Are they helpful? Is medication overuse/dependence an issue?
  • Is individual actively participating in physical therapy and/or home exercise program?
  • If individual has a sedentary job, have measures been taken to correct posture and change position frequently? Have the work station and the worker’s body mechanics been evaluated?
  • Have relaxation training or biofeedback techniques been tried?
  • Has the individual accessed the employer’s EAP or seen a mental health professional to address psychosocial confounders/co-morbidity?
  • Has individual participated in a pain clinic or rehab program? Is a functional restoration program needed?
  • Has individual been evaluated for surgical intervention? Is surgery needed?
  • Is a functional restoration program needed?

Regarding prognosis:

  • Can individual's employer accommodate necessary restrictions?
  • How severe are the symptoms? Are symptoms improving or becoming progressively worse?
  • Could individual be exaggerating symptoms because of impending litigation or avoidance of work?

Source: Medical Disability Advisor



References

Cited

Braddom, Randolph L. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia: W.B. Saunders, 2006.

Cherry, Cecile. "Anterior Cervical Discectomy and Fusion for Cervical Disc Disease." Operating Room Nurses Journal 76 (2002): 998.

Furman, Michael B., et al. "Cervical Disc Disorder." eMedicine. Eds. Everett C. Hills, et al. 21 Feb. 2007. Medscape. 15 Dec. 2008 <emedicine.com/pmr/topic25.htm>.

Gross, A. R., et al. "Physical Medicine Modalities for Mechanical Neck Disorders." Cochrane Database of Systematic Reviews 2 (2000): CD000961. National Center for Biotechnology Information. National Library of Medicine. 15 Nov. 2004 <PMID: 10796402>.

Hsu, W. K. , and . "Outcomes Following Nonoperative and Operative Treatment for Cervical Disc Herniations in National Football League Athletes." Spine 36 (10) (2011): 800-805.

Karjalainen, K., et al. "Multidisciplinary Biopsychosocial Rehabilitation for Neck and Shoulder Pain Among Working Age Adults." Cochrane Database of Systematic Reviews 2 (2003): CD002194. National Center for Biotechnology Information. National Library of Medicine. 15 Nov. 2004 <PMID: 12804428>.

Philadelphia Panel. "Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Neck Pain." Physical Therapy 81 10 (2001): 1701-1717. National Center for Biotechnology Information. National Library of Medicine. 15 Nov. 2004 <PMID: 11589644>.

Storro, S., J. Moen, and S. Svebak. "Effects on Sick-Leave of a Multidisciplinary Rehabilitation Programme for Chronic Low Back, Neck or Shoulder Pain: Comparison with Usual Treatment." Journal of Rehabilitation Medicine 36 1 (2004): 12-16. National Center for Biotechnology Information. National Library of Medicine. 15 Nov. 2004 <PMID: 15074433>.

General

Al-Shatoury, Hassan A., et al. "Cervical Spndylosis." eMedicine. Eds. Curtis W. Slipman, et al. 21 Dec. 2007. Medscape. 15 Dec. 2008 <http://emedicine.com/pmr/TOPIC27.HTM#top>.

Source: Medical Disability Advisor






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