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.

Sprains and Strains, Cervical Spine (Neck)


Related Terms

  • Acceleration Injury
  • Acceleration-Deceleration Injury
  • CAD (cervical acceleration-deceleration injury)
  • Cervical Myofascial Pain
  • Deceleration Injury
  • Hyperextension
  • Neck Sprain
  • Neck Strain
  • Soft Tissue Cervical Hyperextension Injury
  • Whiplash

Specialists

  • Chiropractor
  • Clinical Psychologist
  • Ergonomist
  • Neurologist
  • Neurosurgeon
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Psychiatrist
  • Psychologist

Factors Influencing Duration

Extent of injury, presence of severe pain on initial injury, neurologic deficit, headache, cognitive impairment, presence of complications, and job requirements may influence length of disability.

Medical Codes

ICD-9-CM:
847 - Sprains and Strains of Other and Unspecified Parts of Back
847.0 - Sprains and Strains of Other and Unspecified Parts of Back, Neck; Anterior Longitudinal (Ligament), Cervical; Atlanto-Axial (Joints); Atlanto- Occipital (Joints); Whiplash Injury

Overview

A cervical strain occurs when muscles around the neck stretch or tear. A sprain occurs when the ligaments stretch or tear. The terms "cervical acceleration-deceleration injury," "CAD," or "whiplash" may also be used to describe the clinical findings of neck pain, particularly after a motor vehicle collision. CAD and whiplash are descriptive terms for neck pain, they do not represent specific diagnoses.

Neck pain is common, even without trauma. Cervical sprain and cervical strain by definition refer to injuries to neck ligaments and muscles. The term "neck pain" is used to refer to neck pain that begins without a specific traumatic incident.

Cervical strain/sprain injuries may occur as a result of trauma from a fall or, most commonly, from motor vehicle collisions. When associated with a motor vehicle collision, the direction or angle of the collision can occur from any direction, but most often occurs when the individual's car is hit from behind. The sudden acceleration thrusts the individual's body forward, with the head rapidly moving backward and then subsequently forward (acceleration-deceleration). That movement, if violent enough, can cause injury to many different tissues and structures of the neck, including bones, facet joints, muscles, blood vessels, ligaments, nerves, the esophagus, and intervertebral discs. However, almost all patients with neck pain without neurologic deficit or fracture after a motor vehicle collision have no definitive injury finding on x-ray, CT scan, and MRI. Thus the "whiplash" injury remains poorly understood (Kasch). In a systematic review of 47 studies, approximately 50 percent of adults with whiplash injury reported neck pain symptoms at one year (Carroll).

In severe trauma, concussion may also occur. Injuries to the brainstem, bruising of the brain (subdural hematomas), and bleeding (hemorrhage) on the surface of the brain may occur. These multiple injuries may give rise to a myriad of symptoms which are often seen soon after the initial injury.

Chronic pain develops in some patients who have experienced a cervical strain/sprain injury. In motor vehicle accidents there is no direct correlation between the magnitude of impact, the amount of vehicle damage, and the degree of injury, although immediate onset of neck pain may be a predictor for chronic pain. Absence of any significant vehicle damage generally means the impact was below the injury threshold, and personal injury would be very unlikely.

Other causes of cervical sprains and strains include a contact sports injury, a fall, or a blow to the head from a falling object.

Incidence and Prevalence: Over 1 million cervical strain and sprain injuries due to motor vehicle collisions are reported annually in the US; the incidence of whiplash injury is estimated at 3.8 individuals per 1,000 annually, and about 15.5 million individuals have long term pain from whiplash (Hunter). Cervical spine injury occurs in 10% to 15% of football players, and 17.2% are re-injuries (Malanga).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals at risk of cervical sprain and strain are those who drive a lot, engage in contact sports (e.g. football, wrestling), high-speed sports (e.g., skiing, diving), or work where falls and falling objects are more common. Severe sprains and strains with associated spinal cord injury can occur in sports-related injuries. Individual at increased risk include those with pre-existing rheumatoid arthritis or ankylosing spondylitis involving the cervical spine, and in elderly individuals with severe degenerative changes.

In a case controlled study of 1843 drivers involved in motor vehicle collisions, 26 percent had neck pain for more than one day. Predictors of injury were female, younger age, prior history of neck pain, rear collision, being in a stationary vehicle, the severity of the collision, not being at fault, and doing monotonous work (Wiles).

Source: Medical Disability Advisor



Diagnosis

History: The individual may report a history of trauma (usually a fall) or accident, most commonly a motor vehicle collision. The individual may have had a contact sports injury or blow to the head from a falling object. A history of previous neck or spinal injury should be sought.

The location and severity of the pain should be documented. Headache, pain radiating into the shoulders, pain in the upper chest and back, and changes in sensation in the upper extremity or face can occur.

Other common symptoms may include headache, dizziness (vertigo), nausea, blurred or double vision, ringing in the ears (tinnitus), fatigue, restlessness, loss of libido, insomnia, pain in the jaw or temporomandibular joint (TMJ), and difficulty swallowing (dysphagia).

Physical exam: In any individual with acute neck sprain or strain, care must be taken during the examination to evaluate for possible spinal instability. Lateral cervical spine x-rays are often taken to rule out a fracture or dislocation before any neck motion is tested. If there is suspicion of fracture, then CT scan, MRI, or both may need to be obtained before the person's cervical spine is said to be “cleared” permitting evaluation of neck motion. Once fracture and dislocation are ruled out, range of motion may be tested by having the individual actively move the neck, and flexion-extension x-rays may then be taken. Swelling and tenderness may be present. The presence, location, and duration of any neurological exam findings (e.g. weakness, sensory changes, reflex changes) are noted. A neurological assessment of the upper and lower extremities is performed to assess possible nerve or spinal cord damage.

Tests: Cervical spine x-rays are taken to rule out more serious injury, but sprains and strains do not have findings on x-ray. Imaging studies (CT and/or MRI) may be warranted to evaluate soft tissue damage and to check for a cervical disc herniation. Tests may be repeated in 6 months if symptoms do not resolve. Objective findings of injury on routine imaging studies are usually uncommon.

Source: Medical Disability Advisor



Treatment

Early introduction of movement has been shown to be superior to immobilization (Malanga). Passive therapies should be limited to the acute phase of recovery, and then the physician or physical therapist should progress individuals to activity as soon as possible. Conservative treatment may include a soft support collar, which should be worn for only a few days and only for those with severe pain. Rigid cervical collars are used infrequently, unless spinal stability has been compromised by fracture or dislocation. Medication to control pain is usually prescribed and may include narcotic analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants.

Physical therapy modalities for pain relief are appropriate for treatment of acute sprain/strain. Self application of ice or heat at home is usually as helpful as formal passive treatment with modalities often provided by a physical therapist. Traction may be used for symptoms of arm pain or radiculopathy resulting from the injury. However, a large prospective cohort study of motor vehicle collision neck pain patients found that those who had high utilization of health care (many physician and/or chiropractor visits) had significantly slower recoveries (Côté).

Trigger point injections of anesthetics or steroids may be performed on a selective basis. Symptoms of depression may be treated with antidepressants and psychotherapy, as many anti-depressants have an additional pharmacologic effect to decrease chronic pain. In a small percentage (fewer than 10%) of individuals, surgery may be appropriate, for fracture, dislocation, radiculopathy, or myelopathy. Surgery for neck pain alone is not recommended in evidence based guidelines. Radiofrequency medial branch rhizotomy to disrupt the nerves associated with the facet joints may be used, usually after facet joint injections have demonstrated effectiveness in relief of pain. The evidence supporting this procedure is controversial (Carragee), and thus insurance does not commonly approve this procedure. While theoretically the facets are permanently denervated, as the procedure is designed to “kill” the involved nerves, most patients have the pain recur.

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Neck and Upper Back Disorders
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

Healing of soft tissue is expected within a few weeks. Most individuals can return to work immediately or within a few weeks. Symptoms may still be present in 20% to 40% of individuals 6 months after injury, but the prognosis is good for those individuals who have progressive (even if slow) improvement with time, and their symptoms usually resolve (Petropoulos).

One-third of individuals report persistent symptoms of neck pain 10 years after the injury (Hunter). Persistent neck pain is more common in women, older individuals, those Individuals who experience severe initial neck pain, upper back pain, multiple symptoms, reduced range of motion, neurological deficit, cognitive impairment, and/or headaches at the back of the head (occipital region).

Source: Medical Disability Advisor



Rehabilitation

A careful assessment for serious pathologies (fractures, spinal cord compromise, nerve compression, and head injury) must be performed prior to rehabilitation for a neck sprain and strain. It is important for the therapist to identify if there is an underlying etiology of the neck symptoms, or if exams and tests fail to show the injury. The primary focus of rehabilitation is to decrease pain, increase function, and teach individuals how to manage their symptoms.

The first goal in treating sprains and strains of the cervical spine is to decrease pain. In combination with pharmacological management, modalities such as heat and cold may be used. Immobilization with a soft collar is rarely indicated; however, with significant soft tissue damage, it might be necessary for a short period of time (up to 3 days) (Verhagen).

While managing pain, therapists may instruct individuals in gentle exercises. Because of variability in individual response, the treating practitioner must pay careful attention to the individual's tolerance to treatment. Initial exercises may include isometrics, accompanied by stretching or gentle range of motion of the cervical spine. Once the acute phase has subsided, spinal manual therapy may help reduce symptoms when combined with active treatment. Postural training should be initiated as soon as tolerated by the individual.

Therapy should progress to strengthening and stabilization exercises of the neck, shoulders, and upper trunk (Weinhardt). In addition to undergoing supervised rehabilitation, the individual should be instructed in a home exercise program to be practiced daily and continued independently after the completion of rehabilitation. Individuals should also be instructed how to care for and protect the neck from recurrence of symptoms.

If symptoms persist, further treatment is best addressed by a multidisciplinary team. An ergonomic evaluation can provide information regarding the avoidance or modification of activities and positions at work that may increase the symptoms. Psychological intervention such as cognitive and behavioral pain management may be indicated to support the individual and identify associated factors that may be contributing to symptoms (Sterner).

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistSprains and Strains, Cervical Spine (Neck)
Physical or Occupational TherapistUp to 12 visits within 6 weeks
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

Fractures, instability, nerve stretch or traction injuries, or disc disruption (herniation) can complicate treatment. Disc herniation occurs in up to 33% of individuals within two years after they’ve had whiplash injury (Hunter). Headaches and referred pain are part of the expected ongoing problems of a cervical sprain and may complicate or prolong treatment. Complications of cervical strains and sprains include instability, nerve damage, headache, stiffness, and referred pain. Individuals with underlying spondylosis may develop cervical myelopathy and/or radiculopathy as a complication of cervical flexion/extension injury.

Twenty to forty percent of individuals who sustain a whiplash injury will develop chronic whiplash syndrome, with persistent symptoms for up to 6 months (Petropoulos).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Any activity that requires flexion or extension of the neck such as overhead work, lifting, or carrying a heavy object may be temporarily restricted in newly symptomatic individuals. Evaluation may be needed if the individual works at a desk or drafting table. Workstation ergonomics need to be addressed. An adjustable chair and proper height of the computer monitor allow for optimal posture and neck positioning. Individuals who spend a great deal of time on the telephone would benefit from a headset.

A worksite evaluation helps to assess risk factors that might increase symptoms during recovery, which can be slow. The use of a soft support collar may restrict function, and is not generally necessary. Safety and policy drug issues must be evaluated if medication is needed during work time.

Source: Medical Disability Advisor



Maximum Medical Improvement

In the absence of a fracture, a dislocation, a nerve injury, or a spinal cord injury, the cervical sprain/strain is considered a “soft tissue injury.” Like other soft tissue injuries, the majority of the healing occurs in the first 3 months. Other than surgery, additional treatment after 3 months from the date of injury is not likely to result in dramatic improvement, so MMI is frequently achieved by 3 months after injury.

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:

  • What symptoms persist?
  • Is there a neurologic deficit? Has it been confirmed by an EMG/nerve conduction study, or by a second physician?
  • What injury related findings are present on x-ray, CT scan, and/or MRI? Is there a specific diagnosis based on these tests, or is “cervical sprain/strain” still the working diagnosis?
  • Does individual exhibit symptoms such as headache, pain in upper chest and back, changes in sensation, dizziness (vertigo), nausea, blurred or double vision, ringing in ears (tinnitus), fatigue, restlessness, loss of libido, insomnia, pain in the jaw or temporomandibular joint (TMJ), and difficulty swallowing (dysphagia)? These symptoms suggest consultation first with a neurologist, then with a psychologist or psychiatrist may be helpful.
  • Is there evidence of symptom magnification behavior?

Regarding treatment:

  • Have all aspects of conservative treatment been utilized?
  • Is the individual still wearing (inappropriately) a soft support (cervical collar)?
  • Were pain medications (analgesics, NSAIDs, antidepressants, anticonvulsants, and cortisone) prescribed?
  • Has individual participated in a comprehensive, appropriate rehabilitation program?
  • Did individual require surgical interventions?

Regarding prognosis:

  • How severe was initial injury?
  • Did the individual have prior episodes of neck pain with disability?
  • Does the individual have chronic widespread pain (pain in multiple sites)?
  • To what degree do symptoms affect the individual’s ability to work?
  • Does individual have an underlying condition that may affect recovery?
  • To what degree do symptoms impact individual's ability to perform daily activities? Is this improving with time, or worsening with time?

Source: Medical Disability Advisor



References

Cited

Carragee, E. J. , et al. "Treatment of Neck Pain Injections and Surgical Interventions: Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders." Spine 33 s4 (2010): s153-s169.

Carroll, L. J. , et al. "Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders." Spine 33 (2008): s83.

Côté, P. , et al. "Initial Patterns of Clinical Care and Recovery From Whiplash Injuries: A Population-Based Cohort Study ." Archives of Internal Medicine 165 (2005): 2257-2263.

Hunter, Oregon K. "Cervical Sprain and Strain." eMedicine. Eds. Consuelo T. Lorenzo, et al. 4 Sep. 2012. Medscape. 7 Feb. 2013 <http://emedicine.medscape.com/article/306176-overview>.

Kasch, H. , et al. "Development in pain and neurologic complaints after whiplash: a 1- year prospective study." Neurology 60 (2003): 743.

Malanga, Gerard A. "Cervical Spine Sprain/Strain Injury." eMedicine. Eds. Janos P. Ertl, et al. 18 Nov. 2011. Medscape. 7 Feb. 2013 <http://emedicine.medscape.com/article/94387-overview>.

Petropoulos, P. "Whiplash Injury (PTG)." Ferri's Clinical Advisor: Instant Diagnosis and Treatment. Ed. Fred Ferri. 2004 ed. St. Louis: Mosby, Inc., 2004. 927-928. MD Consult. Elsevier, Inc. 28 Oct. 2004 <http://home.mdconsult.com/das/book/41010365-2/view/1161?sid=300920724>.

Sterner, Y., et al. "Early Interdisciplinary Rehabilitation Programme for Whiplash Associated Disorders." Disability Rehabilitation 23 10 (2001): 422-429. National Center for Biotechnology Information. National Library of Medicine. 18 Mar. 2009 <PMID: 11400904>.

Verhagen, A. P., et al. "Conservative Treatments for Whiplash." Cochrane Database of Systematic Reviews 1 (2004): CD003338. National Center for Biotechnology Information. National Library of Medicine. 18 Mar. 2009 <PMID: 14974013>.

Weinhardt, C., and K. D. Heller. "A Systematic of the Value of Physical Therapy in Whiplash Neck Injury." Z Orthop Ihre Grenzgeb. 140 5 (2002): 499-502. National Center for Biotechnology Information. National Library of Medicine. 18 Feb. 2009 <PMID: 12226772>.

Wiles, N. J. , et al. "Onset of neck pain after a motor vehicle accident: a case-control study." Journal of Rheumatology 32 (2005): 1576.

Source: Medical Disability Advisor






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