First occupational medicine guidelines released this month

Will they become the standard of care?

The long-awaited practice guidelines for occupational medicine are being released this month, and an advance copy obtained by Occupational Health Management suggests they are the beginning of the standardization that many professionals have been seeking.

Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers is a 400-page text that took two years to compile. It has the official approval of the American College of Occupational and Environment Medicine (ACOEM) in Arlington Heights, IL, and represents the first set of practice guidelines specifically devoted to occupational health.

That specificity is what will make the guidelines so valuable, says Melissa D. Tonn, MD, MBA, MPH, medical director with Worklink, the occupational health program of Memorial Sisters of Charity hospital in Houston.

"Other practice guidelines are available, but these will focus on return-to-work issues and underlying social issues," Tonn says. "They alert you to the red flags you want to look out for and how to know if a case is going bad."

The ACOEM practice guidelines should become the standard of care in occupational medicine, Tonn says, serving as a standard reference for what is considered appropriate care in all clinical situations common to occupational medicine. More than just a general guideline, the ACOEM text provides specific advice concerning what testing and treatment options are ill-advised and unnecessary.

Tonn plans to use the guidelines to help train family practice residents in occupational medicine because they emphasize the unique aspects of the specialty.

"The practice guidelines provide a reference for what to look for in certain cases and what the expected duration should be for different problems," she notes.

The issue still to be decided is just how "standard" these guidelines will become. Establishing a standard of care is a long and sometimes circuitous process, but having a major organization like the ACOEM publish formal guidelines is a huge step in that direction. If the guidelines are presented as the generally accepted way to provide occupational medicine, and if providers accept them as such, it may be inevitable that insurers would take advantage of them for reimbursement decisions. That could mean the guidelines will, in effect, become requirements for those expecting payment.

Insurance sources are reluctant to assess the ACOEM guidelines, or the value of any occupational medicine guidelines, before their publication, but they have hinted that they may welcome them. The guidelines are unlikely to have an immediate influence on reimbursement decisions, but insurance representatives tell OHM they will be watching closely to see how well the guidelines are accepted.

Available for a fee

The guidelines will be released sometime this month, says Curtis Vouwie, president and publisher of OEM Health Information in Beverly Farms, MA. OEM is publishing the guidelines in conjunction with ACOEM. The loose-leaf binder will sell for about $150 to ACOEM members and $180 for nonmembers.

ACOEM and OEM spent two years compiling the guidelines, which consist of accepted protocols and strategies in occupational health. Once compiled, the draft was reviewed and approved by ACOEM members and experts.

Preview copies of the guidelines were displayed at recent occupational health conferences and received a positive response, Vouwie reports. He and Tonn predict the practice guidelines will be of interest to both novices in occupational health and experienced practitioners.

There are 17 chapters altogether, including nine chapters that provide an overview of occupational health philosophies, such as the initial approach to assessment and work relatedness.

The next eight chapters cover practice guidelines on these topics:

• neck and upper back complaints;

• shoulder complaints;

• elbow complaints;

• forearm, wrist, and hand complaints;

• lower back complaints;

• knee complaints;

• ankle and foot complaints;

• acute eye complaints.

The practice guidelines will be updated periodically with new chapters, with the first available as early as this summer. The new additions will be priced separately.

Chapters address issue from start to finish

The draft copy of the practice guidelines obtained by OHM indicates the chapters will provide a solid framework from which to address occupational health problems. Considerable space is devoted to addressing the aspects that make an occupational health approach to the problem differ from the way a general practitioner might address the problem.

In the section on forearm, wrist, and hand complaints, the practice guideline begins with an abstract of the problem and a list of these principal recommendations:

• The initial assessment of patients with acute hand and wrist problems focuses on the detection of indications of potentially serious disease, termed "red flags," and the determination of an accurate diagnosis.

• In the absence of red flags, work-related forearm, hand, and wrist complaints can be safely and effectively managed by occupational or primary care providers. The injury is expected to heal with little intervention. The focus is on monitoring for complications, facilitation of the healing process, and facilitation of return to work in modified duty.

• Relief of discomfort can be accomplished most safely by temporary immobilization and systemic nonprescription analgesics.

• Patients recovering from acute forearm, hand, and wrist injuries or infections are encouraged to return to modified work as their condition permits.

• If symptoms persist beyond four weeks, referral for subspecialty care may be indicated.

• Nonphysical factors such as psychosocial, workplace, or socioeconomic problems should be addressed in an effort to resolve delayed recovery.

The chapter goes on to divide hand and wrist complaints into four categories. Potentially serious hand and wrist conditions include fractures, acute dislocation, infection, neurovascular compromise or injury, and tumor. Mechanical disorders include derangements of the hand or wrist related to acute trauma, such as ligament or tendon strain.

The degenerative disorders category covers the consequences of aging, repetitive use, or a combination thereof, such as arthritis, tendinitis, or tenosynovitis. The last category is nonspecific disorders, such as those occurring in the hand or wrist and suggesting neither internal derangement or referred pain.

Red flags critical part of guidelines

The ACOEM guidelines emphasize the need to look for red flags that can signal serious underlying medical conditions. The absence of red flags "rules out the need for special studies, referral, or inpatient care during the first four weeks when spontaneous recovery is expected," as long as related workplace factors are addressed.

Seven categories of red flags are listed for hand and wrist complaints. With fractures, for instance, the occupational health provider is urged to look for a history of significant trauma, a history of deformities with or without spontaneous or self-reduction, swelling, and joint pain. On physical examination, the provider might find significant swelling, deformity with displaced fracture, point tenderness, hematoma, or ecchymosis.

The guidelines suggest including questions in the medical history that pertain specifically to occupational health. For hand and wrist complaints, the guidelines recommend these questions:

• How do these symptoms limit you?

• Can you do hand work? For how long?

• What stops you from working? Are the symptoms worse at work?

• Can you grasp? How much? Are you dropping things?

• Are the symptoms worse at night? Do they wake you up?

• What do you think is the cause of the problem?

• What have you tried to make it better? Did it work?

The guide goes on to outline the particular physical tests that should be conducted in the initial exam, and if no red flags are present, the diagnostic criteria are used to determine which musculoskeletal disorder is present. The diagnostic criteria are structured to guide the clinician from the simplest diagnosis, such as ligament strain, to DeQuervain’s tenosynovitis and carpal tunnel syndrome.

Acetaminophen is first-line medication

Work relatedness is an important issue in the guidelines, with the chapters providing advice on how to determine if a particular patient’s problem is a result of workplace causes. The clinician should weigh all the possible contributors to the problem, and a predominance of workplace factors means the ailment is work-related.

"A cluster of cases in a work group could suggest a greater probability of associated work design or management factors," the guidelines state. "Repetitive work, especially pinch grasping and possibly keyboard work, is currently thought to contribute to tendinitis and nonspecific wrist or hand pain. Workstations have been associated much less commonly with complaints that may be consistent with carpal tunnel syndrome and DeQuervain’s tenosynovitis and ulnar compression at the wrist."

In discussing treatment options, the guideline advises using acetaminophen as the first choice medication, followed by nonsteroidal anti-inflammatory drugs like aspirin and ibuprofen. Nonprescribed physical methods, such as stretching and exercise, are the next recommended options. Prescribed pharmaceutical and physical methods are next.

Guidelines warn against unproven treatment

Perhaps the most influential sections of the guidelines will be those in which clinicians are warned against using some popular but unproven treatment modalities. For the first time, occupational health physicians will have ACOEM-approved statements which declare whether certain treatments are effective in certain situations.

In the hand and wrist section, for instance, early passive range-of-motion exercises are advised for all hand and wrist injuries other than unstable fractures and acute dislocations. Physical therapy is beneficial in educating patients about effective exercise programs, but the guide notes that "this requires very few visits to the therapist."

The ACOEM guidelines also point out that "manipulation has not been proven effective in hand/wrist pain" and "physical modalities such as massage, diathermy, cutaneous laser treatment, ultrasound, TENs units, and biofeedback have no proven efficacy in the treatment of acute hand or wrist symptoms." Home applications of heat and cold may be used before or after exercises and are as effective as those provided by a therapist, the guidelines state.

Invasive techniques such as needle acupuncture and injection procedures have "no proven value," with the exception of corticosteroid injection into specific tendon sheaths or possibly the carpal tunnel. But even in those cases, corticosteroid injections should be avoided until conservative therapy of eight to 12 weeks has proven ineffective.

Iontophoresis and phonophoresis have no proven efficacy, the guidelines state.

Specifics offered on disability duration

The guidelines go on to outline activity modifications appropriate for each type of injury, along with typical duration of disability with or without modified duty. For all the hand and wrist injuries, the guidelines list zero to three days disability duration with modified duty and seven to 14 days without modified duty.

The patient should be monitored by a midlevel practitioner or physical or hand therapist every three to five days for counseling on correct body mechanics, medication use, activity modification, and other concerns. "Care should be taken to answer questions and make these sessions interactive so that the patient is duly involved in his or her recovery," ACOEM advises. "Follow-up by the physician should occur when a release to modified, increased, or full duty is needed or after appreciable healing or recovery can be expected, on average. Physician follow-up might be expected every four to seven days if the patient is off work and seven to 14 days if the patient is working."

Latter sections in the chapter outline the ability of various techniques to identify and define pathology, plus when to consider surgical options. An extensive summary at the end of each chapter notes the source of the recommendations for that section.

[Editor’s note: To order a copy of the practice guidelines, contact OEM Press, 8 West St., Beverly Farms, MA 01915-2226. Telephone: (800) 533-8046. Fax: (508) 921-0304. Web site: www.oempress.com.]