The guidelines provided by the New York State Workers Compensation Board offer fundamental principles for managing injuries to the hand, arm, and forearm. These directives aim to assist healthcare professionals in identifying appropriate therapeutic approaches within the context of a comprehensive assessment.
Healthcare professionals with expertise in treating injuries to the hand, arm, and forearm can rely on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most suitable therapeutic methods for their patients.
It is important to emphasize that these guidelines are not intended to replace clinical judgment or professional expertise. The final decision regarding the management of injuries to the hand, arm, and forearm should involve collaboration between the patient and their healthcare provider.
General Guideline Principles
- Medical Care: Medical care for work-related injuries should aim to restore the patient’s functional ability for daily and work activities, with a focus on returning to work and restoring health to pre-injury levels as much as possible.
- Rendering of Medical Services: All medical providers treating workers’ compensation patients must adhere to the Treatment Guidelines for work-related injuries and illnesses.
- Positive Patient Response: Positive outcomes are primarily defined by measurable functional improvements, including positional tolerances, range of motion, strength, endurance, activities of daily living, cognition, psychological behavior, and efficiency measures. Subjective reports of pain and function are also considered, especially when they correlate anatomically and physiologically with the injury.
- Re-Evaluate Treatment: If a treatment fails to produce positive results within a defined timeframe, the provider should adjust or discontinue the treatment. Re-evaluation of treatment efficacy should occur 2 to 3 weeks after initiation and then 3 to 4 weeks thereafter.
- Education: Educating patients, families, employers, insurers, policymakers, and the community is essential in treating work-related injuries. Effective educational strategies should be implemented to facilitate self-management of symptoms and injury prevention.
Time Frames
- Acuity: Acute, subacute, and chronic stages are generally categorized based on timeframes: Acute (less than one month), Subacute (one to three months), and Chronic (greater than three months).
- Initial Evaluation: Refers to the acute period following an injury, not the first physician evaluation in an office or clinical setting.
- Diagnostic Time Frames: Diagnostic testing time frames start from the date of injury but may be adjusted based on clinical judgment.
- Treatment Time Frames: Treatment time frames start once interventions are initiated and may vary depending on the disease process, patient compliance, and service availability.
- Delayed Recovery: Patients not progressing as expected 6-12 weeks after injury should undergo reexamination to confirm diagnosis accuracy and treatment program evaluation. Assessments for potential barriers to recovery should be ongoing, and alternate treatment programs, including psychological evaluation, should be considered if needed. Referrals to mental health providers for delayed recovery management do not imply establishing a psychiatric claim.
Active Interventions
- Emphasis on Active Interventions: Active interventions, which require patient involvement and responsibility, such as therapeutic exercise and functional treatment, are typically prioritized over passive modalities as treatment progresses. Passive interventions are often seen as a way to support progress in an active rehabilitation program while achieving measurable functional improvements.
Active Therapeutic Exercise Program
- Goals of Active Therapeutic Exercise: The objectives of an active therapeutic exercise program should encompass enhancing patient strength, endurance, flexibility, range of motion, sensory integration, coordination, cognition, and behavior when relevant, along with education as deemed clinically necessary. This includes practical application in work or community settings.
Diagnostic Imaging And Testing Procedures
- Role of Clinical Information: Clinical history and physical examination should guide the selection of imaging procedures and the interpretation of results. Each diagnostic procedure has its own specificities and sensitivities for different diagnoses.
- Need for Repeat Diagnostic Procedures: When a diagnostic procedure, in conjunction with clinical information, sufficiently establishes an accurate diagnosis, a second procedure is generally unnecessary. However, a repeat or complementary diagnostic procedure may be warranted if the initial study was of insufficient quality to make a diagnosis.
- Consideration for Repeat Imaging Studies: Repeat imaging studies may be warranted based on the clinical course or to monitor treatment progress. It may be necessary to repeat diagnostic procedures to reassess or stage pathology, before surgical interventions or therapeutic injections as clinically indicated, and postoperatively to monitor healing.
- Prudent Choice of Procedures: Careful selection of diagnostic procedures, whether as a single procedure, complementary procedure, or in a proper sequential order, ensures maximum diagnostic accuracy, minimizes adverse effects on patients, and promotes efficiency by avoiding duplication. Additionally, consideration should be given to the cumulative radiation dose and associated risks of repeat imaging studies.
Surgical Interventions
- Consideration of Surgery: The decision to pursue surgery should be based on the expected functional outcome rather than the notion of achieving a complete cure through surgical means alone. Surgical interventions should be guided by a positive correlation of clinical findings, the patient’s clinical course, and diagnostic test results, leading to a specific diagnosis and identification of underlying pathological conditions. Clear correlation between pain symptoms and objective evidence of its cause is essential for surgery to address pain-related issues. Shared decision-making with the patient is recommended, providing information on the advantages and disadvantages of surgery, alternative rehabilitation options where applicable, evidence-based outcomes, and the surgeon’s specific experience.
Pre-Authorization
- Authorization of Procedures: All diagnostic imaging, testing procedures, non-surgical and surgical therapeutic procedures, and other treatments within the scope of the Medical Treatment Guidelines, and based on the correct application of these guidelines, are considered authorized. However, procedures listed in section 324.3(1)(a) of Title 12 NYCRR are exceptions and require pre-authorization from the carrier before they can be performed.
Psychological/Psychiatric Evaluations
- Purpose and Frequency of Evaluations: Mental health evaluations may be necessary in select patients to establish, confirm, or secure a diagnosis. The extent and duration of evaluations and interventions by mental health professionals may vary based on several factors, including whether the clinical issue is primarily a mental health concern, or if there are secondary or pre-existing mental health issues exacerbated by the work-related injury or illness. Psychological function tests may be conducted, but they should be interpreted alongside other clinical data, and the diagnosis should be made following a comprehensive analysis. It’s preferred to have a provider fluent in the patient’s primary language, but if unavailable, the services of a professional interpreter must be provided.
Personality/Psychological/Psychosocial Intervention
- Implementation and Duration of Intervention: Psychological intervention, when recommended, should be initiated promptly and may be used alone or alongside other treatment modalities. It should be accompanied by an assessment and treatment plan with measurable behavioral goals, time frames, and specific interventions planned. Counseling aims to enhance functional recovery and should not be intended to delay it. The duration of intervention varies depending on the condition, with regular documentation of progress and functional prognosis.
Functional Capacity Evaluation (FCE)
- Purpose and Considerations: FCE assesses various aspects of function related to the patient’s ability to return to work, including physical, cognitive, and psychosocial factors. While an FCE is not always necessary to determine work status, it may be considered at maximum medical improvement (MMI) or when the treating physician cannot make a clear determination on work status at case closure. It should not be used early in treatment or as the sole criteria for diagnosing malingering. The treating physician should interpret the FCE in light of the patient’s individual circumstances and medical history.
