The guidelines provided by the New York State Workers Compensation Board present fundamental principles for addressing Non-Specific Hand, Wrist, and Forearm Pain. These directives are crafted to assist healthcare professionals in identifying appropriate therapeutic approaches within the context of a comprehensive assessment.
Healthcare professionals with expertise in managing Non-Specific Hand, Wrist, and Forearm Pain 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 essential to underscore that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding the management of Non-Specific Hand, Wrist, and Forearm Pain should involve collaboration between the patient and their healthcare provider.
Non-Specific Hand/Wrist/Forearm Pain: Diagnosis and Treatment
Non-specific hand/wrist/forearm pain often occurs without identifiable trauma but is associated with high physical job demands or unclear exposures. While most cases resolve, if no improvement is observed after several weeks of treatment, focused diagnostic testing should be considered. Non-specific pain persisting beyond 2 months is uncommon. In the search for a specific diagnosis, considerations should encompass proximal pathologies such as spine-related issues (e.g., radiculopathy, spinal tumor, infection), and psychological disorders, especially with widespread or recurrent unexplained symptoms.
Clinical Presentation
Patients typically report a gradual onset of pain or symptoms without specific trauma. Forearm symptoms are common and often lack precise localization.
Diagnostic Studies
Rheumatological Studies for Arthralgias
Recommended for evaluating patients with persistent unexplained arthralgias or tenosynovitis.
Indications: Persistent unexplained arthralgias or tenosynovitis. Frequency/Duration: Repeat studies may be necessary over time, particularly for patients with less severe diseases.
Arthrocentesis for Joint Effusions
Recommended in cases of unexplained joint effusions, especially for assessing infections and crystalline arthropathies.
Indications: Joint effusions without a clear diagnosis, including suspected infection or crystalline arthropathies.
Electrodiagnostic Studies
Recommended for evaluating non-specific hand, wrist, or forearm pain in patients with paresthesias or other neurological symptoms.
Indications: Persistent tingling and pain, particularly symptoms characteristic of radiculopathies and entrapment neuropathies. Frequency/Dose: Generally performed at least 3 weeks after symptom onset.
X-Rays
Recommended for evaluating cases where non-specific hand, wrist, or forearm pain persists.
Indications: Persistent non-specific hand, wrist, or forearm pain.
Medications
Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment
Recommended for acute, subacute, or chronic non-specific hand/wrist/forearm pain.
Indications: Acute, subacute, or chronic non-specific hand/wrist/forearm pain. OTC agents may be tried first. Frequency/Duration: As needed use may be reasonable.
Indications for Discontinuation: Resolution of symptoms, lack of efficacy, or development of adverse effects.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
Recommended for concomitant use of cytoprotective drugs in patients at high risk of gastrointestinal bleeding.
Indications: Patients with a high-risk factor profile who need NSAIDs.
Frequency/Dose/Duration: Follow manufacturer’s recommendations. No substantial differences in efficacy for prevention of gastrointestinal bleeding.
Indications for Discontinuation: Intolerance, adverse effects, or discontinuation of NSAID.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
Recommended discussion of risks and benefits for patients with known cardiovascular disease or multiple risk factors.
Recommended: Acetaminophen or aspirin as first-line therapy. If needed, non-selective NSAIDs are preferred over COX-2 specific drugs. For patients receiving low-dose aspirin, NSAIDs should be taken at least 30 minutes after or 8 hours before aspirin.
Acetaminophen for Treatment of Non-Specific Hand/Wrist/Forearm Pain
Recommended for treatment, particularly in patients with NSAID contraindications.
Indications: All patients with non-specific hand/wrist/forearm pain.
Dose/Frequency: Per manufacturer’s recommendations; may be utilized on an as-needed basis. Caution against exceeding four gm/day due to potential hepatic toxicity.
Indications for Discontinuation: Resolution of pain, adverse effects, or intolerance.
Evidence for the Use of NSAIDs and Acetaminophen for Non-specific Hand/Wrist/Forearm Pain
Opioids
Not Recommended for acute, subacute, or chronic non-specific hand, wrist, or forearm pain.
Treatment Approaches for Non-Specific Hand/Wrist/Forearm Pain
Relative Rest
Recommended in specific cases of acute non-specific hand, wrist, or forearm pain, particularly when there are high ergonomic exposures involving high force or a combination of high force with other risk factors.
Rationale for Recommendation: For patients with high ergonomic exposures, relative rest can be beneficial.
Splinting
Recommended for the treatment of select patients with acute or subacute non-specific hand, wrist, or forearm pain. Not recommended for chronic use.
Rationale for Recommendation: Splinting may be helpful at times but tends to enforce debility; hence, it is generally discouraged for prolonged use.
Rehabilitation
Rehabilitation following a work-related injury should focus on restoring functional ability to meet daily and work activities, aiming to return the injured worker to pre-injury status as much as feasible. Active therapy involves the patient’s internal effort to complete specific exercises, while passive therapy relies on modalities delivered by a therapist to facilitate progress in an active therapy program.
Emphasis should be on active interventions over passive ones. Patients are encouraged to continue both active and passive therapies at home to sustain improvement levels. Assistive devices may be included in the rehabilitation plan to enhance functional gains.
Active Therapy
Therapeutic Exercise
Recommended for the treatment of acute, subacute, or chronic non-specific hand, wrist, or forearm pain.
Frequency/Dose/Duration: The total number of visits may range from two to three for mild deficits to 12 to 15 for more severe deficits, with documentation of ongoing functional improvement. If ongoing deficits persist, more than 12 to 15 visits may be necessary, provided there is documentation of improvement toward specific functional goals.
Passive Therapy
Self-Application of Ice or Heat
Recommended for the treatment of acute or subacute non-specific hand, wrist, or forearm pain.
