Guideline Number 20
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF INDUSTRIAL ACCIDENTS
TREATMENT GUIDELINES
REVISED EFFECTIVE DECEMBER 1, 1999
GUIDELINE NUMBER 20 – DIAGNOSIS AND TREATMENT OF NECK AND BACK (SPINAL) INJURIES CONSERVATIVE OUTPATIENT TREATMENT
( UP TO 6 WEEKS FROM DATE OF INJURY)
I. Background:
A. The guideline for the diagnosis and treatment of spinal injuries is a
consensus document, not a scientific treatise on the subject. For this
reason the guideline must be broad enough to incorporate a wide
range of diagnostic and treatment modalities. This allows for
philosophical and practice differences between the various licensed
health care practitioners in the state of Massachusetts.
B. Some of the conservative treatment modalities dealt with in this
guideline are rest, medication, immobilization, mobilization,
manipulation, spinal adjustment, massage, physical agent modalities,
rehabilitation and education.
C. This guideline is meant to cover the majority of tests and treatments.
It is expected that approximately 10% of cases will fall outside this
guideline and require review on a case by case basis.
II. Exclusions:
A. Concurrent unexplained fever over 48 hours
B. Neoplasm
C. Severe trauma - such as fracture or ligamentous injury
D. Documented specific diagnoses (rheumatoid arthritis, herniated disc,
spinal stenosis, spondylolisthesis, congenital fusion,
diastematomyelia, hemivertebra, spinal osteomyelitis, prior spinal
surgery at the same level.)
E. A history of documented severe radicular pain and paresthesias
related to neck movement and physical findings displaying motor
weakness and reflex changes.
F. Impaired bowel and bladder function
G. Increasing pain and/or symptoms, despite treatment
III. Diagnostic and Treatment Measures (Up to 6 weeks from date of injury):
A. Diagnostic Tests: - Allowed
1. X-rays:
a. Back - Maximum 4 views (one study Allowed)
b. Neck - Maximum 5 views (one study Allowed)
B. Diagnostic Tests: - Not Allowed
1. CT, MRI, Bone Scan
2. Computer Back Testing (CBT)
3. All EMG and Nerve Conduction Studies
4. Functional Capacity Evaluation (FCE)
5. Work Capacity Evaluation (WCE)
6. Thermogram
7. Myelogram
8. Evoked Potentials
C. Outpatient Treatment - Allowed (Within scope of license):
1. Medical office treatment sessions - maximum 4 visits in first 6
weeks
2. Physical therapy treatment sessions - maximum 18 visits in first 6
weeks
3. Occupational therapy treatment sessions - maximum 6 visits in first
6 weeks
4. Chiropractic treatment sessions - maximum 18 visits in first 6 weeks
5. Bedrest - maximum 2 days
6. Prescribed non-narcotic analgesics: muscle relaxants, nonsteroidal
anti-inflammatory drugs
7. Narcotics - maximum 5 day course
8. Trigger point injection - maximum 2 injections within 4 weeks
9. Lumbar support
10. Cervical collar
11. Traction (Neck)
12. Manual therapy/spinal adjustment/manipulation
13. Therapeutic exercise (under the direct supervision of a licensed
healthcare provider)
14. Patient education including activities of daily living, joint protection
techniques, and back pain recovery and prevention - encouraged
15. Modified work activity through the recovery process - encouraged
16. Physical agents and modalities (e.g., heat/cold, electrical
stimulation, iontophoresis/phonophoresis, ultrasound, fluori-
methane) maximum of 2 allowed per treatment session
D. Outpatient Treatment - Not Allowed
1. Facet injection
2. Epidural block
3. Spinal Traction (Back)
4. Physical agents and modalities (e.g., heat/cold, electrical
stimulation, iontophoresis/phonophoresis, ultrasound, fluori-
methane) if only treatment procedure
E. Inpatient Treatment - Not Allowed
F. For patients treated by more than one discipline (physical
therapy, occupational therapy, allopathic medicine and
chiropractic), similar services should not be duplicated.