General Guideline Principles for Post traumatic stress disorder in workers compensation patients

The overarching principles outlined by the New York State Workers Compensation Board provide general guidelines for addressing Post-Traumatic Stress Disorder (PTSD). These directives aim to assist healthcare professionals in determining appropriate strategies for managing PTSD as part of a comprehensive care plan.

Healthcare practitioners specializing in PTSD can rely on the guidance from the Workers Compensation Board to make well-informed decisions about the most suitable approaches for supporting individuals affected by this condition.

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 Post-Traumatic Stress Disorder should involve collaboration between the patient and their healthcare provider.

General Guiding Principles

The principles outlined in this section are crucial for the intended application of the New York State Medical Treatment Guidelines (MTG) and are relevant to all Workers’ Compensation Medical Treatment Guidelines.

A.1 Focus on Medical Care
Medical care and treatment resulting from a work-related injury should concentrate on restoring functional ability necessary for the patient’s daily and work activities, emphasizing a return to work. Simultaneously, efforts should be directed towards restoring the patient’s health to its pre-injury state to the extent feasible.

A.2 Utilization of Medical Services
Any medical provider offering services to a workers’ compensation patient must adhere to the Treatment Guidelines prescribed for all work-related injuries and/or illnesses.

A.3 Recognition of Positive Patient Response
Positive outcomes are primarily defined as demonstrable functional improvements that can be objectively measured. Objective functional gains encompass factors such as positional tolerances, range of motion, strength, endurance, activities of daily living (ADL), cognition, psychological behavior, and quantifiable efficiency/velocity measures. Subjective reports of pain and function may be considered, with due weight given when pain aligns anatomically and physiologically with the injury.

A.4 Reassessing Treatment
If a specific treatment or approach fails to yield positive outcomes within a clearly defined timeframe, the provider should consider adjusting or discontinuing the treatment regimen. The effectiveness of the treatment or approach should be evaluated 2 to 3 weeks after the initial visit and subsequently every 3 to 4 weeks. Adjustments may be made for conditions that involve mental health, allowing for slightly longer timeframes, while non-musculoskeletal medical conditions (e.g., pulmonary, dermatologic) may warrant shorter intervals. Recognizing that treatment failure can stem from an inaccurate diagnosis, clinicians should reevaluate the diagnosis if an unexpected poor response occurs despite an otherwise reasonable intervention.

A.5 Emphasis on Education
The education of the patient, family, employer, insurer, policymakers, and the community should be a primary focus in treating work-related injuries or illnesses. Practitioners should develop and implement effective educational strategies, beginning with communication that provides reassuring information to the patient. A comprehensive treatment plan should include addressing individual and/or group patient education to facilitate symptom self-management and prevent future injuries.

A.6 Severity Classification and Timeframes
Acuity, categorized into Acute, Subacute, and Chronic, serves as a framework for delineating stages in the progression of diseases:

– Acute: Less than one month
– Subacute: One to three months
– Chronic: Greater than three months

A.7 Clarity on Initial Evaluation

The term “Initial Evaluation” specifically pertains to the acute period following an injury. It does not define the moment when a physician first assesses an injured worker (initial encounter) in an office or clinical setting.

A.8 Diagnostic Time Frames

The timeframes for diagnostic testing initiation begin on the date of injury. Clinical judgment may justify the need to expedite or extend the time frames outlined in this document.

A.9 Treatment Time Frames

Time frames for specific interventions commence once treatments are initiated, not from the date of injury. It is acknowledged that treatment duration may be influenced by the disease process and severity, patient adherence, and service availability. Clinical judgment may warrant adjustments to the time frames discussed in this document.

A1.0Extended Recovery Period

In cases where patients do not show the expected progress within 6-12 weeks post-injury, and their subjective symptoms do not align with objective signs and tests, a reexamination is necessary to verify the accuracy of the diagnosis. The treatment program should also undergo reevaluation. When dealing with a clinical issue not inherently related to mental health, ongoing assessment for potential barriers to recovery (yellow flags/psychological issues) is crucial throughout the patient’s care. At the 6-12 week mark, alternative treatment plans, including formal psychological or psychosocial evaluations, should be considered.

Clinicians need to stay alert to pre-existing mental health issues or subsequent mental health problems that might be impacting recovery. In cases where the issue is clearly and inherently a mental health concern from the beginning (e.g., when there is evident work-related mental health disorder as part of the claim), referral to a mental health provider can and should happen much earlier. Referrals to mental health providers for evaluating and managing delayed recovery do not imply or necessitate the establishment of a psychiatric or psychological condition. The evaluation and management of delayed recovery do not mandate the establishment of a psychiatric or psychological claim.

A.11 Promotion of Active Interventions

Active interventions, which highlight patient involvement, such as therapeutic exercise and functional treatment, are generally prioritized over passive modalities, particularly as treatment advances. Passive and palliative interventions are typically seen as tools to support progress within an active rehabilitation program, facilitating the achievement of objective functional improvements.

A.12 Goals of Active Therapeutic Exercise Program

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 applicable), along with education as clinically indicated. This includes integrating functional applications in vocational or community settings.

A.13 Utilization of Diagnostic Imaging and Testing Procedures

Clinical information gathered through history-taking and physical examination should serve as the foundation for choosing imaging procedures and interpreting results. Each diagnostic procedure has specific sensitivities and specificities for various diagnoses. The selection of one procedure over others typically depends on factors such as relative diagnostic value, the risk/benefit profile of the procedure, the availability of technology, a patient’s tolerance, and the treating practitioner’s familiarity with the procedure.

Diagnostic Procedures and Repetition

When a diagnostic procedure, coupled with clinical information, furnishes adequate data to establish an accurate diagnosis, there is generally no need for a second diagnostic procedure. However, a subsequent diagnostic procedure, including a repetition of the original (same) procedure, may be conducted if the specialty physician (e.g., physiatrist, sports medicine physician, or another appropriate specialist), radiologist, or surgeon documents that the initial study lacked the quality needed for diagnosis. In such instances, a repeat or complementary diagnostic procedure is permissible under the Medical Treatment Guidelines (MTG).

Acknowledging that the clinical course or treatment progress may warrant repeat imaging studies and other tests, it may be justifiable to repeat diagnostic procedures (e.g., imaging studies) during the course of care to reassess or stage the pathology in cases of symptom progression or findings, before surgical interventions and/or therapeutic injections when clinically indicated, and post-operatively to monitor the healing process. It is important to note that serial imaging, including x-rays and particularly CT scans, increases cumulative radiation dose and associated risks.

Given that a diagnostic imaging procedure may offer similar or distinct information compared to other procedures, a prudent selection of the procedure(s) for a single diagnostic evaluation, a complementary procedure in conjunction with other procedure(s), or a proper sequential order in multiple procedures will ensure maximum diagnostic accuracy, minimize adverse effects on patients, and enhance efficiency by avoiding unnecessary duplication or redundancy.

A.14 Surgical Interventions

The consideration of surgery should always be rooted in the expected functional outcome, as the notion of “cure” through surgical treatment alone is generally misleading. Surgical interventions must be guided by a positive correlation among clinical findings, the clinical course, and the results of imaging and other diagnostic tests. The synthesis of these factors should lead to a specific diagnosis, positively identifying the underlying pathological condition(s). To justify surgery for treating pain, a clear correlation between the pain symptoms and objective evidence of its cause is imperative. Shared decision-making with the patient is strongly recommended in all cases. Patients should have the opportunity to comprehend the advantages and disadvantages of surgery, consider potential rehabilitation as an alternative where applicable, be informed about evidence-based outcomes, and understand the specific surgical experience.

A.15 Pre-Authorization

All diagnostic imaging, testing procedures, non-surgical and surgical therapeutic procedures, and other therapeutics within the criteria of the Medical Treatment Guidelines are considered authorized, except for procedures listed in section 324.3(1)(a) of Title 12 NYCRR, which are not included in the list of pre-authorized procedures. Providers seeking to perform one of these procedures must request pre-authorization from the carrier before proceeding. Additionally, pre-authorization is required for second or subsequent procedures, involving the repeat performance of a surgical procedure due to the failure of or incomplete success from the same surgical procedure performed earlier, if the Medical Treatment Guidelines do not specifically address multiple procedures.

A.16 Psychological/Psychiatric Evaluations

For certain patients, mental health evaluations are crucial to establish, secure, or confirm a diagnosis. The scope and duration of evaluations and interventions by mental health professionals may vary, depending on whether the underlying clinical issue in the claim is inherently a mental health concern, if there is a mental health issue secondary or consequential to the medical injury or illness at issue in the claim, or if there is a pre-existing, unrelated mental health issue exacerbated by or hindering the recovery from the medical injury or illness in question.

Psychological function tests or psychometric testing, when deemed necessary, can be valuable components of the psychological evaluation for identifying associated psychological, personality, and psychosocial issues. While these instruments may suggest a diagnosis, it’s important to note that neither screening nor psychometric tests can independently make a diagnosis. The diagnosis should only be established after a thorough analysis of all available data, including information from a comprehensive history and clinical interview.

Preference for Language Fluency and Interpreter Services

A professional fluent in the patient’s primary language is strongly preferred. In cases where such a provider is unavailable, the services of a professional language interpreter must be provided.

Frequency Guidelines:

1. Pre-existing Mental Health Issues: When assessing a pre-existing, unrelated mental health issue worsened by or hindering recovery from a work-related medical injury or illness, a one-time visit for the initial psychiatric/psychological encounter should be sufficient. Subsequent care would typically be continued by the previous treating provider.

2. Psychometric Testing: If psychometric testing is indicated during the initial encounter, the time for such testing should not exceed an additional three hours of professional time.

3. Central Mental Health Issue in the Claim: For conditions where a mental health issue is a central part of the initial claim or is secondary or consequential to the work-related medical injury or illness, more extensive diagnostic and therapeutic interventions may be clinically indicated. Detailed guidelines for such mental health conditions are outlined in the Medical Treatment Guidelines.

A.17 Personality/Psychological/Psychosocial Intervention

After a psychosocial evaluation recommends intervention, it is crucial to implement the intervention as promptly as possible. This intervention can be utilized independently or in conjunction with other treatment modalities. For all psychological/psychiatric interventions, there must be a comprehensive assessment and treatment plan incorporating measurable behavioral goals, specific interventions, and time frames.

General Time Frames for Intervention:

  • Time to produce effect: Two to eight weeks.
  • Optimum duration: Six weeks to three months.
  • Maximum duration: Three to six months.
  • Counseling is intended to enhance functional recovery, not to cause delays.

Specific to PTSD Psychological Intervention:

  • Optimum duration: Three to six months.
  • Maximum duration: Nine to twelve months.

For certain patients, extended supervision and treatment may be necessary. If further treatment is indicated, the authorized treating practitioner should provide documentation every four weeks during the first six months of treatment, projecting a realistic functional prognosis and detailing the nature of the psychological factors. For treatment lasting six to twelve months, documentation should be provided every four to eight weeks, and for long-term treatment beyond twelve months, every eight to twelve weeks. Continuous communication among all parties is essential to ensure seamless, continuous, and uninterrupted treatment.

A.18 Functional Capacity Evaluation (FCE)

A Functional Capacity Evaluation (FCE) is a thorough assessment, either comprehensive or more restricted, that examines various aspects of function in relation to a patient’s ability to return to work.

This evaluation encompasses areas such as endurance, lifting (both dynamic and static), postural tolerance, specific range-of-motion, coordination and strength, worker habits, employability, as well as psychosocial, cognitive, and sensory perceptual aspects related to competitive employment. Components of this evaluation may include musculoskeletal screening, cardiovascular profile/aerobic capacity, coordination assessment, lift/carrying analysis, job-specific activity tolerance, maximum voluntary effort, pain assessment/psychological screening, non-material and material handling activities, cognitive and behavioral assessment, visual examination, and sensory perceptual factor evaluation.

In most cases, the question of whether a patient can return to work can be answered without the need for an FCE. An FCE may be considered at the time of Maximum Medical Improvement (MMI), following reasonable prior attempts to return to full duty during the course of treatment, especially when the treating physician faces difficulty making a clear determination on work status at case closure. However, an FCE is not warranted early in a treatment regime for any reason, including supporting a therapeutic plan.

When an FCE is used to determine a return to a specific job site, it is the responsibility of the treating physician to understand and consider the job duties. FCEs cannot be used in isolation to determine work restrictions. The authorized treating physician must interpret the FCE in light of the individual patient’s presentation, medical information, and personal perceptions. It’s essential to note that FCEs should not be the sole criteria for diagnosing malingering.

A.19 Return To Work

In the context of these guidelines, “return to work” is defined as engaging in any work or duty that the patient can perform safely, even if it differs from the patient’s regular work. Determining the return to work status is an integral aspect of medical care and should be incorporated into the treatment and rehabilitation plan. Typically addressed at each outpatient visit, a description of the patient’s status and task limitations forms part of any treatment plan, serving as the basis for restricting work activities when necessary. Striving for an early return to work is a key objective in treating occupational injuries. These guidelines emphasize progressing patients along a continuum of care and return to work, recognizing that the likelihood of successfully reintegrating an injured worker into the workforce diminishes the longer the worker remains out of work.

A.20 Job Site Evaluation

The treating physician has the option to communicate with the employer or their representative, whether in person, via video conference, or by telephone, to gather information about the patient’s pre-injury job. This may encompass details about the physical demands of the job, such as exertional requirements, repetitive activities, load lifting, static or awkward postures, environmental exposures, psychological stressors, and other factors that could impede re-entry, pose a risk of re-injury, or disrupt the recovery process.

If returning to the patient’s previous job tasks or setting is deemed unfeasible due to clinically determined restrictions on the patient’s activities, inquiries should be made about modified duty work settings that align with the patient’s condition and proposed work activities or demands. It’s important to note that, under certain circumstances, more than one job site evaluation may be indicated.

While an on-site inspection of job settings and activities would ideally provide the most information, it’s recognized that this may not be feasible in many cases. In situations where job videos/CDs/DVDs are available from the employer, they can offer valuable insights. Video conferences, conducted from the worksite and preferably from the workstation or work area, can also provide useful information.

Frequency of Contacts:

  • 1st contact: When the patient is in a functional state, enabling them to perform some work.
  • 2nd contact: When the patient has progressed to a state where they are capable of handling enhanced functional demands in a work environment.

The physician should thoroughly document the details of these conversations.


A.21 Guideline Recommendations and Medical Evidence

The Workers’ Compensation Board and its Medical Advisory Committee have not independently evaluated or vetted the scientific medical literature used in support of the guidelines but have relied on the methodology used by the developers of various guidelines referenced herein.

A.22 Experimental/Investigational Treatment

Medical treatment that is experimental/investigational and not approved for any purpose, application, or indication by the FDA is not permitted under these guidelines.

A.23 Injured Workers as Patients

In these guidelines, injured workers are referred to as patients, recognizing that in certain circumstances, there may be no doctor-patient relationship.

A.24 Scope of Practice

These guidelines do not address the scope of practice or change the scope of practice.

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