The guidelines established by the New York State Workers Compensation Board are intended to assist healthcare practitioners in providing appropriate treatment for shoulder therapies.
Tailored for medical professionals, these guidelines from the Workers Compensation Board help in identifying the right level of care for individuals undergoing shoulder therapies.
It’s important to emphasize that these guidelines are not a substitute for clinical expertise or professional experience. The final decision on care should be a collaborative one, involving the patient and their healthcare provider in consultation.
Therapeutic Exercise: Rehabilitation
Rehabilitation resulting from a work-related injury should be centered on restoring the functional ability necessary for the patient to resume daily and work activities and return to work, aiming to bring the injured worker as close as possible to their pre-injury status. Active therapy involves internal efforts by the patient to complete specific exercises or tasks, while passive therapy consists of interventions not requiring the patient’s exertion, dependent on modalities delivered by a therapist.
Generally, passive interventions are seen as a means to facilitate progress in an active therapy program, leading to objective functional gains. Emphasis should be on active interventions over passive ones. Patients should be advised to continue both active and passive therapies at home as an extension of the treatment process to maintain improvement levels. Additionally, assistive devices may be included in the rehabilitation plan as an adjunctive measure to facilitate functional gains.
Therapy Active:
- Therapy Active
- Physical / Occupational Therapy
- Recommended – to improve function, including range of motion and strength.
- Frequency/Dose/Duration: Frequency of visits is usually individualized based on the severity of the limitation. Two to three visits per week for two weeks are often used to initiate an exercise program. The total number of visits may be as few as two to three for mild patients or up to 12 to 15 with documentation of objective functional improvement.
- As part of the rehabilitation plan, patients should be instructed to continue both active and passive therapy at home as an extension of the treatment process to maintain improvement.
- Indications: All postoperative and conservatively managed patients.
- Indications for Discontinuation: Resolution of pain, intolerance, lack of efficacy, or noncompliance.
- Therapeutic Exercise
- Therapeutic exercise where the therapist instructs the patient in a supervised clinic and home program to increase the strength of the supporting shoulder musculature. Motions and muscles to be strengthened include shoulder internal and external rotators, abductors, and scapula stabilizers. Isometrics are performed initially, progressing to isotonic exercises as tolerated.
- Recommended – in select patients as clinically indicated.
- Frequency: Typically two to three times/week for eight to 12 weeks as noted below.
- Weeks 1-3: Isometrics in sling.
- Weeks 3-8: Progressive isotonic exercises.
- Weeks 8-12: Begin overhead activities when the rotator cuff strength is normalized, and full active elevation has been achieved.
- Physical / Occupational Therapy
Therapy: Ongoing Maintenance Care
A continuous maintenance program involving physical therapy or occupational therapy might be warranted under specific circumstances, post determination of Maximum Medical Improvement (MMI), especially when linked to the preservation of functional status.
- While the existing scientific evidence doesn’t universally support the routine use of this intervention, there are situations where maintenance therapy modalities could be deemed necessary to sustain functional status. This becomes pertinent when a previous objective deterioration of function has been observed and documented in the medical record.
- It is essential to identify specific objective goals that can be measured to substantiate the ongoing need for maintenance care.
- Successive and progressively longer trials of therapeutic withdrawal should be undertaken to evaluate whether therapeutic goals can be upheld without clinical interventions.
- Within the first year and subsequently on an annual basis, a trial without maintenance treatment should be initiated.
- Managing chronic shoulder symptoms should involve an ongoing patient self-management plan conducted regularly by the patient. Additionally, a self-directed pain management plan should be established and activated by the patient if symptoms worsen, and function declines.
- If there is documented deterioration in the ability to maintain function, reinstatement of ongoing maintenance may be considered.
Frequency: The maximum frequency is up to ten visits per year, post determination of MMI, contingent upon objectively documented maintenance of functional status. No deviation from the maximum frequency is allowed. Ongoing Maintenance Care is a constituent of the Functional Maintenance Care recommendations outlined in the New York Non-Acute Pain Medical Treatment Guidelines. For further details, please refer to the New York Non-Acute Pain Medical Treatment Guidelines.
Superficial Heat and Cold
Superficial heat and cold therapies are thermal applications employed in various ways to either decrease or elevate body tissue temperature. This is done to alleviate pain, inflammation, and/or effusion resulting from injury or induced by exercise. It can be applied acutely along with compression and elevation. Indications encompass acute pain, edema, hemorrhage, the need to raise pain threshold, diminish muscle spasm, and encourage stretching/flexibility. This may involve the use of portable cryotherapy units. The application can be performed in conjunction with other active therapies or self-administered by the patient.
- Time to produce effect: Immediate.
- Frequency: Two to five times per week.
- Optimum duration: Three weeks as the primary approach, or up to two months if used intermittently as an adjunct to other therapeutic procedures, or even longer for adhesive capsulitis (Refer to Section D.2, Adhesive Capsulitis.)
- Maximum duration: Two months.
Transcutaneous Electrical Nerve Stimulation (TENS)
TENS treatment should involve at least one instructional session for proper application and use. Indications cover muscle spasm, atrophy, and control of concurrent pain in the office setting. Essential TENS unit parameters should include pulse rate, pulse width, and amplitude modulation. Consistent, measurable, functional improvement must be documented, and determination of the likelihood of chronicity should precede the provision of a home unit. TENS treatment is recommended in conjunction with active physical therapy.
- Time to Produce Effect: Immediate.
- Frequency: Variable.
- Optimum Duration: 3 sessions.
- Maximum Duration: 3 sessions. Purchase or provide with a home unit if effective.
Therapeutic Ultrasound With or Without Electrical Stimulation
Therapeutic ultrasound with or without electrical stimulation utilizes sonic generators to deliver acoustic energy for therapeutic thermal and/or non-thermal soft tissue treatment. Indications encompass scar tissue, adhesions, collagen fiber, muscle spasm, and the need to extend muscle tissue or accelerate soft tissue healing.
- Time to produce effect: Six to 15 treatments.
- Frequency: Three times/week.
- Optimum duration: Four weeks, or longer for adhesive capsulitis. (Refer to Section D.2, Adhesive Capsulitis.)
Electrical Therapeutic Modality
Electrical Therapeutic Modality can be utilized as an adjunct for recovery. To justify its use, documentation regarding functional gains must be provided.
- Time to produce effect: Eight to 12 sessions.
- Frequency: Three times/week.
- Optimum duration: Four weeks.
Return to Work
Returning to work may be considered, but with restrictions on overhead activity, lifting, or repetitive motion with the involved arm until cleared by the primary treating physician for heavier activities. Determining task tolerance should be individualized based on the diagnosis and job demands in each case.
