The guidelines provided by the New York State Workers Compensation Board are intended to assist healthcare professionals in the domain of Rehabilitation Therapy. These directives aim to support physicians, therapists, and healthcare practitioners in determining the appropriate rehabilitation strategies for individuals undergoing therapy.
Healthcare professionals specializing in Rehabilitation Therapy can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the most suitable and effective rehabilitation approaches for their patients.
It is crucial to emphasize that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding rehabilitation therapy should involve collaboration between the patient and their healthcare provider.
Rehabilitation Therapy
Recovery from a work-related injury often involves supervised formal therapy, and the focus should be on restoring the necessary functional abilities for the patient’s daily and work activities, aiming to get them back to their pre-injury state as much as possible. Active therapy involves the patient’s internal effort to complete specific exercises or tasks, while passive therapy relies on interventions delivered by a therapist without the patient’s exertion.
Generally, passive interventions are seen as a way to support progress in an active therapy program, leading to tangible functional improvements. Prioritizing active interventions over passive ones is essential. Patients are advised to continue both active and passive therapies at home to sustain the progress achieved during treatment. Additionally, incorporating assistive devices into the rehabilitation plan can be beneficial in enhancing functional gains.
Physical / Occupational Therapy
Suggested – for enhancing function, which includes improving range of motion and strength.
Frequency/Dose/Duration: The frequency of visits is typically tailored to the severity of the limitation. Initiating an exercise program often involves two to three visits per week over two weeks. The total number of visits can range from as few as two to three for mild cases to 12 to 15 when there’s documented objective functional improvement.
As part of the rehab plan, patients should be encouraged to carry on with both active and passive therapy at home, extending the treatment process to maintain the progress made.
Indications: Applicable to all patients with neck injuries, whether postoperative or managed conservatively.
Indications for Discontinuation: Stop when pain is resolved, there’s intolerance to the treatment, it proves ineffective, or if the patient is noncompliant.
Activities of Daily Living (ADL)
Activities of Daily Living (ADLs) encompass guiding, assisted participation, and/or modifying activities or equipment. It’s advised for specific individuals to enhance their capabilities in routine activities like self-care, job reintegration training, household tasks, and driving.
Frequency: Usually, three to five sessions per week, with noticeable effects observed in four to five treatments, lasting a maximum of six weeks, as determined by clinical indications.
Aquatic Therapy
Is discouraged.
Functional Activities
Functional Activities involve therapeutic activities aiming to improve mobility, body mechanics, employability, coordination, balance, and sensory motor integration. It’s suggested for specific patients when clinically justified.
Frequency: Typically conducted three to five times weekly, with noticeable effects achieved in four to five sessions, and the optimal duration spanning four to six weeks.
Maximum Duration: Limited to six weeks.
Functional Electrical Stimulation
Functional Electrical Stimulation involves using electrical current to trigger involuntary or assisted contractions in muscles that may be atrophied or impaired. It’s advised for specific patients.
Indications: Suitable for addressing muscle atrophy, weakness, and sluggish muscle contraction resulting from pain, injury, neuromuscular dysfunction, or situations where the potential for atrophy exists. It might be appropriate when combined with an active exercise program.
As per the New York State Workers’ Compensation Board Medical Treatment Guidelines for Neck Injuries:
Frequency: Typically conducted three times a week, requiring two to six sessions to show an effect, with a maximum duration of eight weeks as clinically determined.
Neuromuscular Re-education
Suggested for specific individuals.
Indications: This is recommended when there’s a requirement to enhance neuromuscular responses through precisely timed proprioceptive stimuli. The goal is to elicit and improve motor activity in patterns similar to those seen in normally developed neurological sequences, ultimately enhancing neuromotor responses with independent control.
Frequency: Usually done three times a week, requiring two to six sessions to demonstrate an effect, and it should not extend beyond eight weeks as determined by clinical needs.
Therapeutic Exercise
Therapeutic Exercise, whether assisted or resisted by machines, can involve various types like isoinertial, isotonic, isometric, and isokinetic exercises.
It is recommended for specific individuals as per clinical need.
Indications: This is suggested for reasons such as improving cardiovascular fitness, reducing swelling, enhancing muscle and connective tissue strength, ensuring robust bone density, fostering circulation to support soft tissue healing, refining muscle recruitment, expanding range of motion, and promoting natural movement patterns. It can also encompass alternative exercise movement therapy.
Frequency: Typically performed three to five times weekly, requiring two to six sessions to show an effect, with a maximum duration of eight weeks based on clinical necessity.
Electrical Stimulation (Physician or Therapist Applied)
It’s advisable for specific individuals as part of a holistic treatment approach.
Frequency: Ideally, this should be done two to three times a week, not exceeding a total duration of two months.
Discouraged: Using Electrical Stimulation, like other passive modalities, is not recommended as a sole treatment method.
Manipulation
Manipulative treatment, not to be confused with therapy, refers to the application of manual forces by an operator to enhance physiological function and/or restore homeostasis affected by injury or occupational disease, with significant clinical implications. It’s important to note that manipulation, in this context, excludes the reduction of dislocations in the cervical spine.
Contraindications to manipulation may involve conditions like joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthritides, and indications of progressing neurologic deficits, myelopathy, vertebrobasilar insufficiency, or carotid artery disease. Relative contraindications encompass stenosis, spondylosis, and disc herniation.
It’s advisable for the treatment of acute and sub-acute neck pain when connected to measurable improvements, and there’s no evidence of fracture or significant instability. Special consideration is necessary for patients with known spinal stenosis.
Frequency: Initially, it can be done up to three times per week for the first four weeks, based on the severity of involvement and desired effects. Afterward, up to two treatments per week for the next four weeks, with reevaluation for signs of functional improvement or the need for further assessment. The time to see results for all types of manipulative treatment is typically one to six sessions. The continuation of treatment will depend on observed functional improvement.
Optimum Duration: Ideally, the treatment plan should last between eight to 12 weeks.
Maximum Duration: Limited to three months. However, extended care beyond this maximum may be necessary in cases of re-injury, interrupted care continuity, symptom exacerbation, or for patients with comorbidities.
Additionally, a maintenance program of spinal manipulation, performed by a physician (MD/DO), chiropractor, or physical therapist, may be recommended in certain situations after determining Maximum Medical Improvement (MMI), especially when linked to maintaining functional status. Refer to Section D.10, Therapy: Ongoing Maintenance Care, for further details.
Discouraged: It’s not advisable to undergo prophylactic treatment.
Reasoning: There is no evidence supporting the effectiveness of prophylactic treatment, whether for primary prevention (before the first episode of pain) or for secondary prevention (after recovering from an episode of neck pain).
Manipulation of the Spine under General Anesthesia (MUA) –
Not Advised
Manipulation under Joint Anesthesia (MUJA) –
Not Recommended
Massage (Manual or Mechanical)
Massage, whether done manually or with mechanical assistance, involves manipulating soft tissues to induce broad relaxation and improved circulation. This can include stimulating acupuncture points, using suction cups, and employing techniques like pressing, lifting, rubbing, and pinching by or with the practitioner’s hands. It’s recommended for conditions such as edema, muscle spasms, adhesions, the need to enhance peripheral circulation and range of motion, or to increase muscle relaxation and flexibility before exercise. Like all passive therapies, massage should be combined with exercise and patient education. Demonstrating objective benefits, such as functional improvement and symptom reduction, is crucial for ongoing treatment.
Recommended – Suggested for selective use in non-acute neck pain as a supplement to more effective treatments, primarily involving a graded aerobic and strengthening exercise program.
Recommended – Advised for acute neck pain and chronic radicular syndromes where neck pain is a significant symptom.
Recommended – Suggested for patients with non-acute neck pain without underlying serious issues like fractures, tumors, or infections.
Frequency: Typically, one to two times per week, with immediate effects and a maximum duration of two months as clinically indicated.
Discontinuation: Cease when the issue is resolved, if there’s intolerance, or if no benefit is observed.
Not Recommended – Discouraged the use of mechanical devices for administering massage.
Joint Mobilization:
Joint mobilization involves gently moving vertebral segments with oscillatory motions. This passive mobility is done in a graded manner (I, II, III, IV, or V), indicating the speed and depth of joint motion. It may also include skilled manual stretching of joint tissues.
Recommended: It is suggested for specific patients based on clinical indications.
Indications: It’s recommended when there’s a need to enhance joint play, segmental alignment, improve intracapsular arthrokinematics, or alleviate pain associated with tissue impingement. Mobilization should always be accompanied by active therapy. For Level V mobilization, contraindications include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthritides, and signs of progressive neurologic deficits, myelopathy, vertebrobasilar insufficiency, or carotid artery disease. Relative contraindications include stenosis, spondylosis, and disc herniation.
Frequency: Typically done up to three times per week, requiring six to nine sessions to show an effect, with the optimum duration being four to six weeks. The maximum recommended duration is six weeks.
Soft Tissue Mobilization:
Soft tissue mobilization is the skilled application of techniques like muscle energy, strain/counter strain, manual trigger point release, and other manual therapy methods. Its aim is to enhance or normalize movement patterns by reducing soft tissue pain and restrictions. These techniques can involve patient participation or relaxation, allowing the practitioner to move the body tissues.
Indications: It’s recommended for conditions like muscle spasm around a joint, trigger points, adhesions, and neural compression. Like joint mobilization, soft tissue mobilization should be accompanied by active therapy.
Frequency: Typically up to three times per week, requiring four to nine sessions to produce an effect, with the optimum duration being four to six weeks.
Short-Wave Diathermy
Not Encouraged
Superficial Heat and Cold Therapy (Excluding Infrared Therapy):
Superficial heat and cold are methods involving temperature changes in body tissues to alleviate pain, inflammation, and/or swelling from injury or exercise-induced effects. This includes applying heat just above the skin’s surface at acupuncture points.
Recommended: It is suggested for specific individuals based on clinical indications.
Indications: It’s recommended for acute pain, edema, and hemorrhage, the need to raise pain threshold, reduce muscle spasm, and promote stretching/flexibility. It can be used alongside other active therapies and can even be self-administered by the patient.
Frequency: Typically, done two to five times per week, showing immediate effects, with a maximum duration of two months as clinically indicated.
Optimum Duration: Primarily for three weeks or intermittently as an addition to other therapeutic procedures for up to two months.
Traction:
Manual traction is a vital component of manual manipulation or joint mobilization. It’s indicated for conditions involving reduced joint space, muscle spasms around joints, and the necessity for enhanced synovial nutrition and response.
Recommended: It’s suggested for specific patients with radicular complaints as clinically indicated.
Frequency: Typically performed two to three times per week, requiring one to three sessions for immediate effects, with a maximum duration of one month as clinically indicated.
Optimum Duration: Advised for 30 days.
Mechanical Traction:
Recommended: Suggested for specific patients with radicular complaints as clinically indicated.
Indications: Mechanical traction is commonly applied for patients with radicular findings, and it is sometimes used to address symptoms related to reduced joint space and muscle spasms around the joints. If successful, the treatment may transition to home traction. However, traction methods are not suitable for patients with tumors, infections, fractures, or fracture/dislocations. Patients can consider purchasing a home cervical traction unit if the therapy proves effective.
Frequency: Usually performed two to three times per week, requiring one to three sessions for an effect, with a maximum duration of four weeks as clinically indicated.
Discontinuation: If there’s a negative response after three treatments, it’s recommended to stop this modality.
Transcutaneous Neurostimulator (TCNS/ Electroanalgesic Nerve Block)
Not Recommended
Transcutaneous Electrical Nerve Stimulation (TENS):
TENS treatment should include at least one instructional session for proper application and use.
Recommended: It is suggested for selective use in treating chronic neck pain or chronic radicular pain syndrome, serving as a second-line adjunct to other first-line treatments.
Indications: Useful for addressing muscle spasms, atrophy, and managing concurrent pain in the office setting. It’s crucial to document consistent, measurable, functional improvement, and assess the likelihood of chronicity before providing a home unit. TENS treatment should be combined with active physical therapy.
Maximum Duration: Limited to three sessions. If effective, patients can either purchase or be provided with a home unit.
Ultrasound (Including Phonophoresis):
Ultrasound, including Phonophoresis, employs sonic generators to deliver acoustic energy for therapeutic thermal and/or non-thermal effects on soft tissues.
Recommended: It is advised for specific patients based on clinical indications.
Indications: Useful for addressing scar tissue, adhesions, collagen fibers, muscle spasms, and the need to lengthen muscle tissue or accelerate soft tissue healing. When ultrasound is combined with electrical stimulation, it involves the concurrent delivery of electrical energy with dispersive electrode placement. This combination is recommended for conditions such as muscle spasm, scar tissue, pain modulation, and muscle facilitation. Phonophoresis, a part of this treatment, involves transferring medication to the target tissue using sonic generators to control inflammation and pain. Topical medications for this purpose include, but are not limited to, steroidal anti-inflammatories and anesthetics.
Frequency: Typically performed three times per week, requiring six to 15 sessions to show an effect, with a maximum duration of eight weeks as clinically indicated.
Optimum Duration: Advised for four to eight weeks.
