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Brief Summary

GUIDELINE TITLE

Neck and upper back complaints.

BIBLIOGRAPHIC SOURCE(S)

  • Neck and upper back complaints. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 30 p. [75 references]

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Harris, J, ed. Occupational Medicine Practice Guidelines: American College of Occupational and Environmental Medicine. Beverly Farms, MA: OEM Press; 1997.

** REGULATORY ALERT **

FDA WARNING/REGULATORY ALERT

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory information has been released.

BRIEF SUMMARY CONTENT

 ** REGULATORY ALERT **
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Recommendations are followed by evidence classification (A-D) identifying the type of supporting evidence. Definitions for the types of evidence are presented at the end of the "Major Recommendations" field.

Summary of Recommendations for Evaluating and Managing Neck and Upper Back Complaints (refer to the original guideline document for more detailed information)

Clinical Measure Recommended Optional Not Recommended
History and physical exam Basic history and exam (C)

History of cancer infection (B)

History of significant trauma (D)

Neurologic exam (C) 		   
Medication (See chapter 3 in the original guideline document) Acetaminophen (C)

Non-steroidal anti-inflammatory drugs (NSAIDs) (B) 		Muscle relaxants (C)

Opioids, short course (C) 		Use of opioids for more than 2 weeks (C)
Physical treatment methods   Physical manipulation for neck pain early in care only (B)

At-home applications of heat or cold (D)

Radio-frequency neurotomy (C) 		Traction (B)

Transcutaneous electrical stimulation (TENS) (C)

Other modalities (D)
Injections   Epidural injection of corticosteroids to avoid surgery (D)

Botulinum toxin (dystonia only) (B) 		Facet injection of corticosteroids (D)

Diagnostic blocks (D)
Rest and immobilization   1 or 2 days' partial bed rest for severe pain (D) Bed rest longer than 1 or 2 days (B)

Cervical collar more than 1 or 2 days
Activity and exercise Maintenance of activity levels while recovering (B)

Office instruction on exercises after initial pain decreases (D)

Low-stress conditioning and aerobic exercises to avoid debilitation (D) 		   
Detection of neurologic abnormalities Electromyography (EMG) to clarify nerve root dysfunction in cases of suspected disk herniation preoperatively or before epidural injection (D) Sensory evoked potentials (SEPs) if spinal stenosis or myelopathy suspected (D) EMG for diagnosis of nerve root involvement if findings of history, physical exam, and imaging study are consistent (D)
Radiography Initial studies when red flags for fracture, or neurologic deficit associated with acute trauma, tumor, or infection are present (D)   Routine use in first 4 to 6 weeks if red flags are absent (D)
Other imaging procedures Magnetic resonance imagery (MRI) or computer tomography (CT) to evaluate red-flag diagnoses as above (D)   Imaging before 4 to 6 weeks in absence of red flags (C, D)
MRI or CT to validate diagnosis of nerve root compromise, based on clear history and physical examination findings, in preparation for invasive procedure (D). If no improvement after 1 month, bone scan if tumor or infection possible (D)   Preoperative diskography (D)
Surgical considerations Careful preoperative education of the patient regarding expectations, complications, and short- and long-term sequelae of surgery (D)

Indications clear for failed conservative treatment and history, exam, and imaging consistent for specific lesion (D) 		  Diskectomy or fusion without conservative treatment 4 to 6 weeks minimum (D)

Diskectomy or fusion for nonradiating pain or in absence of evidence of nerve root compromise (D)

Definitions:

Levels of Evidence

A = Strong research-based evidence (multiple relevant, high-quality scientific studies).

B = Moderate research-based evidence (one relevant, high-quality scientific study or multiple adequate scientific studies).

C = Limited research-based evidence (at least one adequate scientific study of patients with neck and upper back disorders).

D = Panel interpretation of information not meeting inclusion criteria for research-based evidence.

CLINICAL ALGORITHM(S)

The following clinical algorithms are provided in the original guideline document:

  • American College of Occupational and Environmental Medicine Guidelines for care of acute and subacute occupational neck and upper back complaints
  • Initial evaluation of occupational neck and upper back complaints
  • Initial and follow-up management of occupational neck and upper back complaints
  • Evaluation of slow-to-recover patients with occupational neck or upper back complaints (symptoms >4 weeks)
  • Surgical considerations for patients with persistent radiating arm pain
  • Further management of occupational neck and upper back complaints
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EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

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IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • Neck and upper back complaints. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 30 p. [75 references]

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

1997 (revised 2004)

GUIDELINE DEVELOPER(S)

American College of Occupational and Environmental Medicine - Medical Specialty Society

SOURCE(S) OF FUNDING

American College of Occupational and Environmental Medicine

GUIDELINE COMMITTEE

American College of Occupational and Environmental Medicine Practice Guidelines Committee

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Chapter Lead: Michael N. Goertz, MD, MPH, FACOEM

Committee Members: Jennifer H. Christian, MD, MPH, FACPM; Philip I. Harber, MD, MPH, FACOEM, FCCP; John P. Holland, MD, MPH, FACOEM; Kathryn L. Mueller, MD, MPH, FACEP, FACOEM; Douglas J. Patron, MD, MSPH; Bernyce M. Peplowski, DO, MS; and Jack Richman, MD, CCFP, DOHS, FACOEM

Timothy J. Key, MD, MPH, FACOEM, as Responsible Officer and ACOEM President Elect, and Edward A. Emmett, MD, MS, FACOEM, Chair of the ACOEM Council on Occupational and Environmental Medical Practice, contributed to the development of the guidelines as well.

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Harris, J, ed. Occupational Medicine Practice Guidelines: American College of Occupational and Environmental Medicine. Beverly Farms, MA: OEM Press; 1997.

GUIDELINE AVAILABILITY

Print copies are available from ACOEM, 25 Northwest Point Boulevard, Suite 700, Elk Grove Village, IL 60007; Phone: 847-818-1800 x399. To order a subscription to the online version, call 800-441-9674 or visit http://www.acoempracguides.org/.

AVAILABILITY OF COMPANION DOCUMENTS

None available

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI on March 13, 2006. The information was verified by the guideline developer on November 3, 2006.

COPYRIGHT STATEMENT

The American College of Occupational and Environmental Medicine, the signator of this license, represent and warrant that they are the publisher of the guidelines and/or possess all rights necessary to grant the license rights to AHRQ and its agents.

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DISCLAIMER

NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.
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