The guidelines provided by the New York State Workers Compensation Board offer fundamental principles for functional maintenance care for non-acute pain. These directives aim to assist healthcare professionals in implementing appropriate strategies to maintain functional abilities within the scope of comprehensive care.
Healthcare professionals with expertise in functional maintenance care can rely on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most suitable approaches for their patients.
It is crucial to emphasize that these principles are not intended to replace clinical judgment or professional expertise. The implementation of functional maintenance care should involve collaboration between the healthcare provider and the patient, considering individual factors such as rehabilitation goals, functional limitations, and potential risks associated with the intervention.
Functional Maintenance Care
Maximum Medical Improvement (MMI) and Ongoing Care:
- Attainment of Maximum Medical Improvement (MMI) does not negate the necessity of medically required care. Although patients at MMI typically do not necessitate ongoing maintenance medical care, there might be instances of clinical flare-ups or fluctuations requiring episodic care. Such care must be medically essential to sustain function at the level of maximum medical improvement. In rare cases, regular and minimal clinical intervention may be vital to prevent or minimize deterioration in function that has been clearly and objectively documented in the absence of such care.
General Recommendations for Functional Maintenance Care:
Ongoing, Independent, Self-Management Plan:
- As patients reach a plateau in their response to treatment, the physician (MD/DO) and the patient should collaborate to establish clinically appropriate, independent self-management programs that promote physical activity and/or work activities despite residual pain, aiming to preserve functional status. These independent programs may include active techniques like strength training, stretching, and range of motion exercises, typically conducted at home and self-directed. Occasional or short-term counseling or support may be beneficial to prevent reliance on physicians and other healthcare providers, covering education on the proper use of pain medications, including over-the-counter ones. Encouraging referral to community support or self-help groups, programs, and networks is advisable.
Self-Directed Pain Management Plan:
- Alongside an ongoing active self-management program, a self-directed pain management plan should be devised, which the patient can implement if symptoms worsen and function declines. This plan should incorporate short-term interventions and/or medication usage. The MD/DO must be vigilant about the potential adverse clinical and functional outcomes associated with long-term pain medication use, taking early steps to prevent or minimize such risks.
Review of Self-Management and Self-Directed Treatment Programs:
- The MD/DO should periodically reassess the self-management/self-directed treatment plan and any new clinical information, particularly concerning alternative causes of functional deterioration. Continuation or modification of the treatment plan depends on the medical provider’s evaluation of the patient’s symptoms and documentation of objective findings.
- As the condition stabilizes, progressively longer trials of therapeutic withdrawal should be attempted to determine whether therapeutic gains can be sustained without active clinical interventions. If the patient’s condition no longer shows functional improvement from therapy, a decision must be made regarding the necessity of continued treatment or whether the patient can maintain functional status with a self-management program without additional medical interventions. Therapy modalities should be discontinued, and the patient should transition to an independent, home-based, self-directed program. For patients exhibiting documented functional decline, a clinical reassessment should be conducted to rule out comorbid conditions, assess the adequacy of the current self-management program, and determine the value, if any, of reintroducing clinical interventions tailored to the patient’s specific needs.
Ongoing Maintenance Care:
- A maintenance program involving physical therapy, occupational therapy, or spinal manipulation (conducted by a physician (MD/DO), chiropractor, or physical therapist) might be warranted in specific cases post Maximum Medical Improvement (MMI) if it contributes to maintaining functional status.
- Despite the lack of consistent scientific evidence supporting routine use, maintenance therapy modalities may be necessary in certain instances to sustain functional status, especially if prior medical records indicate objective functional decline without such interventions.
- Clear, measurable objectives should be established to justify the need for ongoing maintenance care.
- Progressive trials of therapeutic withdrawal should be attempted periodically to assess whether therapeutic objectives can be maintained without active clinical interventions.
- A trial without maintenance treatment should be initiated within a year post MMI and annually thereafter.
- Management of non-acute pain symptoms should involve an ongoing patient self-management plan performed regularly by the patient and a self-directed pain management plan activated as needed:
- An ongoing clinically appropriate self-management plan, typically independent, home-based, and self-directed, should be jointly developed by the provider and patient to encourage physical activity and/or work despite residual pain, aiming to preserve function.
- Alongside the self-management plan, a self-directed pain management plan should be devised, which the patient can initiate if symptoms worsen and function declines.
- If documented deterioration in the ability to maintain function occurs, reinstatement of ongoing maintenance care may be warranted.
- Frequency:
- Up to a maximum of ten visits per year post MMI, contingent upon objectively documented maintenance of functional status.
- No deviations from the maximum frequency are allowed.
