The guidelines provided by the New York State Workers Compensation Board offer general principles for the management of Complex Regional Pain Syndrome (CRPS). These directives aim to assist healthcare professionals in determining appropriate strategies for addressing CRPS as part of a comprehensive treatment plan.
Healthcare practitioners specializing in CRPS management can rely on the guidance from the Workers Compensation Board to make well-informed decisions about the most suitable approaches for managing this complex pain condition in their patients.
It is important to emphasize that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding the management of Complex Regional Pain Syndrome should involve collaboration between the patient and their healthcare provider.
Management of CRPS
The New York State Workers’ Compensation Board has created guidelines to assist healthcare professionals, including physicians and podiatrists, in determining the appropriate level of care for patients with ankle and foot disorders.
These guidelines are not a replacement for clinical judgment or professional experience, and the final decision regarding care should be made by the patient in consultation with their healthcare provider. The guidelines aim to ensure that workers receive the necessary and reasonable medical treatment for their work-related injuries.
They are based on evidence-based medicine and are designed to help restore the patient’s functional ability. The Board’s Medical Treatment Guidelines are an essential part of the workers’ compensation system, providing a framework for the delivery of healthcare to injured workers.
Work Activities of Management of CRPS
It is often recommended to modify work activities as part of a treatment plan. One way to do this is by reviewing job responsibilities to see if modifications can be made without notifying the employer. This can help avoid activities that may significantly aggravate pain, at least for a time.
It is important to keep patients engaged in their highest levels of activity, including work activities, as this is in their best clinical and psychological interests.
To determine workability, it is necessary to evaluate “risk,” “capacity,” and “tolerance.” The term “risk” refers to what a patient can accomplish but must not do because of the high likelihood of suffering serious consequences. Providers set job limits based on their assessments of risk.
It is important to determine what a patient is physically capable of accomplishing, which is referred to as their capacity. This can be determined by evaluating factors such as the range of motion and exercise capacity in metabolic equivalents (METs). A patient, not a clinician, should determine whether the benefits of labor outweigh the expense of the symptoms based on their tolerance for persistent symptoms.
The first step in deciding whether work activity changes are necessary is to have a discussion with both the patient and their healthcare provider about whether or not they have control over their job duties.
In certain situations, even if the discomfort may be incapacitating, there may not be a need to write some restrictions if the worker can receive assistance from another person.
According to NYS WCB MTG-Complex Regional Pain Syndrome 34, a workplace inspection and analysis by a healthcare professional with the requisite expertise can facilitate the assessment of work duties and the possibility for adjustments.
When designing work adjustments, the physical demands of the job and the job’s safety, in the scope of case-specific circumstances, should be taken into account. If the patient knows that total rest or other forms of inactivity are advised, this should also be considered.
In some cases, it may be necessary to impose restrictions or prescribed activity levels that are higher than what the patient feels they can handle. In such circumstances, information on CRPS and the necessity of continuing to be active should be given.
Common restrictions include adjusting the weight of the objects being lifted, the amount of physical activity permitted (low, medium, or high), the number of lifts, and posture. When considering the patient’s skills, prescriptions for physical activities must be tailored to each individual because there are so many aspects that must be considered.
Here are some suggestions for initial restrictions on occupational and extracurricular activities in the early stages of severe CRPS affecting the upper extremity:
- Limit work to two hours per day.
- Avoid lifting more than five pounds.
- Refrain from using the affected hand in activities that require a lot of repetition or force, such as pushing or pulling.
For severe CRPS affecting the lower extremities or the spine, initial restrictions for work and extracurricular activities could potentially include:
- Limit work to two hours per day.
- Do not lift more than 10 pounds.
- Change between standing and sitting as necessary.
In the early stages of therapy, it is typical to reevaluate these home and work activity requirements every week. Gradual increases in activity are advised so that CRPS patients can retain or regain their optimum level of function.
It is preferable to explain early during treatment that restrictions will be gradually eased as the patient improves. To lessen the element of surprise and actively support the patient’s most crucial aspects of an active, functional restoration program, experienced healthcare providers communicate the intended changes in restrictions for the upcoming week at the current visit (like forecasting increases in exercise program components).
Due to the variability in symptoms and functionality, practically all CRPS patients require customized limitations. The employer should be consulted as well when formulating plans to hasten and aid the patient’s integration into the workplace.
Here are some suggestions for patients with CRPS:
- Patients may experience greater pain even when performing “light” duty during the early stages of rehabilitation. Increases in sensations should be addressed, and the causes of major rises in pain should be heard with a helping hand. For people with CRPS, rises in pain do not always indicate injury.
- Any limitations are meant to give time for exercise to increase activity tolerance. It could be beneficial to remind the patient, if necessary, that this rehabilitation program will also assist them in regaining their normal non-occupational life functions.
- In the patient’s best short- and long-term interests, every effort should be made to keep them engaged in their highest levels of activity, including work activities. Regardless of whether the operator is thought to have restricted duty available, work activity restrictions should still be documented.
- Written activity limitation guidance conveys the patient’s condition and instructs the patient on what to do and what not to do at home. Recommendations for activity adjustment and time away from the workplace due to CRPS are shown in Table 3.
Please note that these recommendations are made for patients who lack comorbid conditions or other complicating issues, such as severe past injuries. From the standpoint of physiologic recovery, they are targets to serve as a reference. Each case will be unique.
