ACOEM Practice Guidelines Forearm, Wrist, and Hand

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ACOEM Practice GuidelinesForearm, Wrist, and Hand

• C. David Rowlett, M.D., M.S.

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Learning Objectives

• Understand the history and rationale for
  development of clinical practice guidelines in
  general, and the ACOEM Occupational Medicine
  Practice Guidelines in particular.
• Identify and employ criteria to classify medical
  evidence to support evidence-based
  recommendations or decisions.
• Locate and apply information regarding hand,
  wrist, and forearm in the Guidelines in order to
  optimize injury management.

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Outline of Presentation

• What is the Context of this Presentation?
• What is the Basic Issue Practice Guidelines
  Address?
• What is Evidence-Based Medicine?
• What is the Role of Clinical Practice Guidelines?
• Why Does ACOEM Produce Practice Guidelines?
• How were the Practice Guidelines Produced?
• How do I Use the ACOEM Practice Guidelines
• (using Forearm, Wrist, and Hand as an Example)?
• How Do I Incorporate CPG into My Practice?

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1.0 What is the Context of this Presentation?

• First and Foremost
• As a User of Practice Guidelines
• My Professional Experience
• Have worked both as an Engineer OM physician
• This has provided both my Perspective and my
  Bias

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1.1 What is the Context of this Presentation?

• Unapologetic Procedural Bias
• Nuclear Industry Demands Procedural Bias
• Guidelines enhance the quality of an endeavor
  through procedural adherence.
• Real Issue How do we change clinicians
  behaviors?
• Not peddling Cookbook Medicine
• (Even with the procedures
• I cant fly a 747)

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2.0 What is the Basic Issue Practice Guidelines
Address?

• Information Overload
• Medical Knowledge is now doubling every 10 years!
• (Am I half or a fourth the doc I once was ?!?)
• When you go fishing for information
• You often get more than you bargained for!

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2.0a What is the Basic Issue Practice Guidelines
Address?

• Information Overload Sheer Volume chief issue
• Really Two Problems Volume and Noise
• Quote attributed to the Dean of Cornell Medical
  College
• Half of what we will teach you is wrong. The
  problem is, we dont know which half!
• Joseph Bernstein, MD Evidence Based
  Medicine,
• J Am Acad Orthop Surg 20041280-88

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2.1 What is the Basic Issue Practice Guidelines
Address?

• Information Overload Volume and Noise
• Another Example
• Source Margin, Richard A. Swenson, MD (Medical
  Futurist and AOHC Keynote speaker, 1997)

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2.2 What is the Basic Issue Practice Guidelines
Address?

• Consequence of Information Overload
• Where is the Life we have lost in living?
• Where is the wisdom we have lost in knowledge?
• Where is the knowledge we have lost in
  information?
• T. S. Elliot, Choruses from the Rock, 1934

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2.3 What is the Basic Issue Practice Guidelines
Address?

• T. S. Elliot was the first to point out the
  latent danger of an information rich society
• It may be wisdom poor. This is due to the
  inevitable noise and consequent uncertainty
  introduced by the volume of information
  available.
• Medicine is not alone in grappling with this
  problem.
• Its instructive to look at the parallels in the
  information science communitys literature.

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2.4 What is the Basic Issue Practice Guidelines
Address?

• DIKW Hierarchy Data-Information-Knowledge-Wisdo
  m

Must have a rational way to move along DIKW
Hierarchy Evidence Based Medicine/Practice
Guidelines is one way.
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3.0 What is Evidence-Based Medicine?
(Appendix of 2nd Edition)

• Also known as Evidence-Based Practice
• Frequently cited definition
• "Evidence-based medicine is the conscientious,
  explicit and judicious use of current best
  evidence in making decisions about the care of
  individual patients. The practice of
  evidence-based medicine means integrating
  individual clinical expertise with the best
  available external clinical evidence from
  systematic research."
• Sackett D.L et al.
• BMJ 1996 31271-80

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3.0b Evidence-Based Medicine Is it New?

• Use of objective evidence for clinical decisions
  not new
• Current form and name (EBM) came from Canadian
  physicians (most at McMaster)
• Tools and thinking derive from clinical
  epidemiology

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3.1 How do you doEvidence-Based Medicine ?

• EBM is a process in which you
• Formulate answerable clinical questions.
• Gather medical evidence.
• Appraise the evidence for validity.
• Implement the valid evidence using your clinical
  judgment about your patient.
• Evaluate the process (iteratively).
• Or, you do 4-5 follow guidelines in which
  steps 1-3 have been done for you.

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3.2 What are Evidence-Based Practice Guidelines
and How Are They Used?

• Two Types
• Clinical Practice Guidelines (Patient Care)
• Administrative Guidelines (Utilization Review)
• Both entail formulation of strategies to ensure
  consistent application of best practices.
• Our focus primarily Clinical Practice Guidelines.

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3.3 What are Evidence-Based Practice Guidelines
and How Are They Used?

• Two Steps
• Development of Systematic reviews
• Evidence search
• Study analysis, grading, synopsis
• Summaries/ Evidence Tables
• Use of systematic reviews to formulate usable
  recommendations for
• Patient care (CPGs)
• Payers of Care (Utilization Review)

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4.0 What is the Role of Clinical Practice
Guidelines (CPGs) in OM?

• Systematically developed statements to assist
  practitioner and patient to decide about
  appropriate health care for specific clinical
  circumstances
• National Institute of Medicine, 1990
• Evidence component systematically developed
• Instructional component assist practitioner
  and patient

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4.1 Impetus for Clinical Practice Guidelines
(CPGs)?

• Research and Concerns about
• Variances in Practice (far greater than variance
  in disease prevalence)
• Appropriateness of Testing (leading to Treatment)
• Cost-Effectiveness of both Testing and Treatment
• Demand for Benchmarks and Standards
• Insurers
• Employers
• States Workers Compensation
• Documented Process to Assess Outcomes

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4.2 ACOEM Approach in Developing Clinical
Practice Guidelines (CPGs)

• Keyed to Presenting Complaint
• Geared to Comprehensive Patient Care
• Meaning of Complaint, Dx, Causation
• Work Environment Considerations
• Person-Job fit
• Psychosocial Factors
• Past History
• Risks for Delayed Recovery, Exacerbation also
  Addressed

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5.0 But Why Does ACOEM Produce Practice
Guidelines?

• Mission Promote the health and safety of workers
  and workplaces through education, research,
  guiding public policy, and enhancing quality of
  practice.
• Ethical code Practice on a Scientific Basis
  with integrity

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5.1 What Can We Expect if We Practice on a
Scientific Basis?

• "The aim of science is not to open the door to
  infinite wisdom, but to set a limit to infinite
  error."
• Bertolt Brecht, Life of Galileo

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5.2 Purposes of Guidelines (1)

• Describe appropriate care based on the best
  available scientific evidence and/or broad
  consensus.
• Reduce inappropriate variations in practice.
• Provide a more rational basis for referral.

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5.3 Purposes of Guidelines (2)

• Promote efficient use of resources.
• Help define quality of care.
• Highlight shortcomings of existing literature and
  suggest appropriate future research.
• Provide a focus for continuing education.
• (Last item may sound self-servingbut its not.
  The issue is how we change clinician behaviors.)

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5.4 Are All Guidelines Evidence-Based?

• "The absence of evidence is not the evidence of
  absence."
• Carl Sagan

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5.4b What Do We Really Know About What We Know?

• For any given disease state, we need population
  data
• Prevalence Incidence
• Etiology/Causation
• Prognosis
• Treatment
• Cost
• (Are you in the tail of the normal distribution?)

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5.5 If Quality Evidence is Lacking?

• Goal EBM as the foundation for all CPGs
• Adequate Evidence may not exist
• Costs to develop information
• Gaps inevitably exist between what we want to
  know and what we do know
• Fill in the gaps with structured, logical
  consensus
• Bottomline
• In God we trust all others bring evidence.
• If there is no evidence Delphi approach

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5.5b If No Proven Treatments

• Guidelines can be evidence based only to the
  extent that there is appropriate scientific
  literature Frequently, recommendations are
  premised on the apparent reasonableness of the
  intervention, the degree to which it puts the
  patient at risk for harm, and the apparent
  cost-effectiveness of the intervention.
• ACOEM CPG pg 491-2

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6.0 How were the ACOEM Practice Guidelines
Produced?

• Methodology similar to other Systematic Reviews
  e.g. Cochrane
• Identify the Clinical Issue(s)
• Answerable Set of Clinical Questions
• Review Current Practice re Clinical Issue
• Majority opinion (general consensus)
• Alternative options (valid, but different?)

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6.0b How were the ACOEM Practice Guidelines
Produced?

• Search for Evidence to support or refute various
  diagnostic therapeutic options
• Systematic Review (Evidence Tables)
• Categorize Rank the QUALITY of Evidence
• In Absence of Evidence
• Document What is Lacking
• Determine Consensus Practice and Its Rationale
• Distill into actionable guidance with sufficient
  background information GUIDELINES

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6.1 How is Quality of Evidence Defined ?

• Sound study design ? ?
• Sound statistical analysis ? ?
• Reputation of the author(s) /-
• Experience with subject matter.
• Respect for their prior work.
• Advocated Position or Conventional
  WisdomConsensus (?) /-

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6.2 Assess Study Design

• Experimental (RCT gold standard)
• Observational (uncontrolled)
• Analytic
• Cohort (retrospective prospective)
• Case-control
• Prevalence (cross-sectional)
• Descriptive
• Case reports and case series
• Metanalyses and review articles
• If done well best study short of RCT

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6.5 A Key Problem Causality

• Noncausal relationships are erroneously
  reported as causal when there is a third, or
  confounding, factor associated with both the
  exposure (or treatment) and the outcome of
  interest (the confounders effect is what we are
  actually measuring).

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6.6 Statistical Analysis and Hypothesis Testing

• Way of looking at data to assess the likelihood
  that the difference observed is real (as
  opposed to occurring by chance)
• Tools p values, regression coefficient,
  t-tests, confidence limits, odds/likelihood
  ratios
• Findings are relative and NOT absolute
• A finding of statistical significance does NOT
  rule out the possibility of error
• Statistical significance ? clinical significance

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6.7 Grading the Evidence (1)

• A Strong research-based evidence multiple,
  relevant, high quality scientific studies
• B Moderate research based evidence one
  relevant high quality scientific study or
  multiple adequate scientific studies
• C Limited research based evidence at least one
  adequate scientific study
• D Information does not meet inclusion criteria
  for research-based evidence

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6.7b Grading the Evidence (2)

• A There are a NUMBER of good studies that
  clearly support (or refute) the intervention
• B There is at least ONE good, or multiple
  adequate studies that support it.
• C There is a minimum of ONE adequate scientific
  study (the rest inadequate)
• D There are no good supportive studies or the
  studies are SO contradictory as to clearly not
  support the value of the intervention

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6.7c Grading the Evidence (3)

• Epidemiologists Pyramid of Evidence
• Randomized controlled trial-BEST EVIDENCE
• Prospective cohort study
• Retrospective cohort study
• Case-control study
• Case series
• Case report
• Expert opinion (Delphi)
• Personal observation-LEAST VALID

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6.8 Translating Rated Evidence

• Rated Evidence from Systematic Review
• Becomes the basis for Guidelines
• Need to weigh certain factors
• Risk, efficacy and costs of the intervention
• Compared to other interventions
• Compared to doing nothing at all
• Natural history of the problem in the absence of
  intervention

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6.8b ACOEM CPG Recommendations

• In each chapter, Tables show recommendations
  based on the strength of the evidence
• Many conventionally utilized treatments (and
  tests) are rated as C (optional) or D (not
  recommended)
• In many cases absence of a firm determination
  reflects insufficient data
• Cannot recommend for or against
• Distinction sometimes small between optional and
  not recommended interventions
• Weigh pros and cons based upon individual
  situational characteristics, considerations,
  priorities
• Information in first 7 chapters critical

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6.9 ACOEM CPGs History (1)

• Common Health Problems and Functional Recovery in
  Workers, 1st Ed. (the Guidelines) 1994-1996
• Evidence search and Evidence analysis
• Recommendations
• Extensive multi-specialty peer review, pilot
  testing
• Board review and approval
• Publication March 1997
• Robert Wood Johnson Foundation - funded
  implementation and improvement project

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6.9b ACOEM CPGs History (2)

• Common Health Problems and Functional Recovery in
  Workers, 2nd Ed.
• Updated literature search and review
• Six drafts
• Discussion
• Practice Guidelines committee
• Specialty representatives
• Peer review within ACOEM
• Specialty/professional review x 2
• Board approval
• Publication December 2003

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7.0 How do I Use the Practice Guidelines(Ex
Forearm, Wrist, Hand)

• Structure of the ACOEM CPGs
• Algorithms and Tables
• First Seven Chapters
• General issues
• Approach to the Patient
• Second Half of the Book
• Specific Conditions
• Appendix (EBM)

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7.1 Contents I - Foundations of Occupational
Medicine Practice

• Tables Algorithms
• Ch 1. Prevention
• Ch 2. General Approach to Initial Assessment..
• Ch 3. Initial Approaches to Treatment
• Ch 4. Work-Relatedness
• Ch 5. Disability Management Prevention
• Ch 6. Pain, Suffering Restoring Function
• Ch 7. IMEs Consultations

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7.2 Contents II - Presenting Complaints
(Conditions With Wide Variation in Treatment)

• Ch 8. Neck and Upper Back
• Ch 9. Shoulder
• Ch 10. Elbow
• Ch 11. Forearm, Wrist and Hand
• Ch 12. Low back
• Ch 13. Knee
• Ch 14. Ankle and Foot
• Ch 16. Eye
• Ch 15. Stress-related Conditions
• Appendix EBM What Does it Mean?

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7.3 Chapters 8-15 Organization (1)

• Sections Keyed to Topics in Chapters 1-7
• General Approach Basic Principles
• Initial Assessment
• Medical History
• Physical exam
• Diagnostic Criteria
• Work-Relatedness (continued)

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7.3b Chapters 8-15 Organization (2)

• (Continued)
• Initial Care
• Work Activity Alteration
• Follow-Up Visits
• Special Studies and Treatment Considerations
• Surgical Considerations

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7.4 Example Ch 11 Forearm, Wrist Hand

• General Approach Keyed to Chapter 2 Material
• Face Sheet for each Chapter Master Algorithm
• Time Sequenced (initial, 7 d, 4-6 wks, 6-8 wks)
• References Chapters Specific Algorithms
• Early Assessment of Red Flags
• Indicator of Potentially Serious Disease
• If Present, Consider Early Referral
• Often Surgical Disease
• Absence of Red Flags Manage without Referral
• Quality of Evidence Ch 11 Table 11-6
• Evidence for most interventions C or D level
• B level evidence NSAIDs, early CTR (NCV)

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7.5 Initial Assessment (Ch 2)

• Do focused but complete history and physical
  evaluation
• Past medical and work history
• Neurologic exam for musculoskeletal complaints
• Understand mechanism of injury
• Critical to understanding causality
• Error determining causation difficult to rescind

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7.6 Medical History Forearm, Wrist Hand

• Chapter 2 Material
• Open Ended Questions
• What are your symptoms?
• Do you have pain, numbness, tingling, weakness,
  or limited range?
• How do these symptoms limit you?
• When did your limitations begin?
• What do you hope that we accomplish during this
  visit?

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7.7 Physical Exam Forearm, Wrist Hand

• Regional Exam
• Examine forearm, wrist, hand as a unit
• Swelling, tenderness, redness, deformity
• Radial Sx consider DeQuervains
• Neurovascular Screening
• Cervical exam C6 radiculopathy
• CTS Katz Diagram, Semmes-Weinstein Monofilament,
  Night Pain (Best PPV)
• Assessing Red Flags

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7.7b Red Flags Forearm, Wrist Hand

• Table 11-1 Hx PE for Common Red Flags
• Hx Trauma Fracture and/or Dislocation
• Infection
• Tumor
• Inflammation
• Neurologic Compromise (Rapidly Progressing)
• Vascular Compromise
• Osteoarthritis
• Severe CTS

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7.8 Dx Criteria Forearm, Wrist Hand

• Both Causation and Treatment depend on an
  Accurate Diagnosis
• Identify
• Unique mechanism
• Unique symptoms
• Unique signs
• Tests and Results
• Meet most or all Dx Criteria in Table 11-2

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7.8b Diagnostic Criteria Example CTS
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7.9 Work Relatedness/Causation (1)

• Specific description of job and incident
• Biological plausibility
• Temporal relationship
• Consistent with published studies
• Subjective linkage not adequate
• No diagnosis of exclusion

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7.9b Work Relatedness/Causation(2)

• For Discrete Event
• Look at temporal issues, mechanism of injury, and
  specificity of association
• Usually can then determine causality
• What about Repetitive stress/strain?
• Same approach, but difficult to determine injury
  vs. intolerance as these multifactorial
  processes routinely occur in the absence of
  trauma
• Is there pre-existing disease?

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7.9c Work Relatedness/Causation (3)

• False Attribution of Disease
• Difficult to Correct
• Need for Apportionment?
• Recurrence
• Acceleration
• Exacerbation

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7.10 Initial Care

• Treatment should be known to improve the the
  Natural Hx (untreated recovery) of the diagnosed
  condition
• Benefits should exceed risks
• Conservative treatment 4-6 wks
• Most problems recover in days to weeks
• Risk of invasive Rx exceeds benefit early on
• Exceptions
• Red Flag conditions

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7.10b Initial Care (see Table 11-4)

• Pain Relief/Comfort usually paramount
• Acetaminophen
• OTC NSAIDs (i.e. Ibuprofen)
• Work Modification/Physical Modalities
• Modify workstation, job tasks, work hours
• Stretching
• Hand/wrist exercises
• Cold for 48 hrs, heat thereafter
• Maintain conditioning aerobic exercise

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7.11 Work Activity Alteration (see Table 11-5)

• Disability Duration Target (No Red Flags)
• With Modified Duty 0-3 days
• Without Modified Duty 7-14 days
• General Activity prescription
• Consider age and type work
• Limit immobilization
• Resumption of activity as Sx lessen
• Pacing restrictions (egg timer)

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7.11b Work Activity Alteration Return to
Work Benefits (Ch5)

• Prompt, appropriate return to work
• Prevents deconditioning, disabling inactivity
• Reduces disability
• Reinforces self esteem, self image
• Provides social support
• Conveys respect for worker
• Improves therapeutic outcome
• Two Options
• Progressive accommodation in usual job
• Modified duty elsewhere

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7.12 Follow-Up Care Must Manage Pain to
Increase Function

• Pharmacologic
• NSAIDs
• Opioids
• Antidepressants
• Injections
• Steroids

• Physical
• Home Exercise
• Physical therapy
• Modalities
• Activity Based Functional Rehab
• Chiropractic
• Modalities
• Manipulations

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7.12 b Follow-Up Care Pain Control Unproven
Effectiveness (Ch 6)

• Protracted use of opiates
• No earlier recovery (Liberty Mutual Research
  Institute, 2004)
• May deplete receptors, increase pain perception
• Protracted NSAID use
• May prevent complete healing, remodeling
• Increased risk of complications
• Protracted physical therapy or chiropractic

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7.12 d Follow-up Delayed Recovery Yellow Flags
(Ch 5)

• Injury
• Patient Factors (2 gain)
• Work Site Factors (CBA)
• System Factors (WC)
• Delayed Recovery

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7.12 i Follow-up Prevention of Chronic Cases

• Explore beliefs, expectations
• Provide accurate information about pathology and
  expected recovery
• Resume aerobic activity ASAP
• Avoid deconditioning, loss of function
• Reintegrate into workplace quickly
• Taper use of medications
• Track function not pain

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7.12 j Follow-up Pain Management Approach

• Pain is a symptom, not a disease
• Cannot be measured objectively
• Focus on functional recovery, not pain
• Function possible, no pain state may not be
• Psychological responses to pain
• Anxiety, helplessness, escape/avoidance,
  depression, increased pain behaviors
• Opiates do not lead to (earlier) recovery 1
• Time-limited, goal-oriented plan

1. Liberty Mutual Research Institute, 2004
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7.13 Special Studies

• Studies are not a substitute for good Hx PE
• Testing should affect the course of treatment or
  should not be done (indications?)
• Clarify Dx (or anatomy) prior to an intervention
• False positives often arise
• Early testing usually not helpful
• There are exceptions that merit early testing

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7.13b Special Studies (Ch 11)

• Exceptions Early Testing Indicated
• Films or Bone scan for Snuffbox tenderness
• R/O Scaphoid Fx
• Films if Laxity at 1st MCP joint
• R/O Gamekeepers thumb
• Early NCV for severe clinical CTS
• Classic Presentation and thenar atrophy
• Serologies for persistent joint effusions

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7.14 Surgical Considerations

• Diagnosis must be secure
• Treatment failure should prompt re-evaluation
• Repeat Hx and PE (sometimes a different picture
  emerges)
• Compliance adequate trial of conservative care?
• Is this Delayed Recovery or Chronic Pain
• Consider additional studies
• Bone scan for occult fractures
• Serologies for persistent joint effusions
• Consider referral
• OT (CHT)
• PMR or Hand Surgeon (Ortho or Plastics)

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8.0 How Do I Incorporate EBM Principles and
CPG into My Practice?

• Must do more than abide EBM, must embrace it!
• Realize EBM does not require higher math
• Dont have to be a statistician.
• Dont have to be an epidemiologist.
• Watchmakers arent the only ones wearing
  watches.

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8.0 b How Do I Incorporate EBM Principles and
CPG into My Practice?

• Throw Most of Your Journals Away
• (Except JOEM)
• Learn to Use the EBM process
• Formulate answerable questions
• Gather evidence
• Appraise the evidence
• Implement the valid evidence
• Evaluate the process
• Or Use Systematic Reviews or Guidelines
• From one of Several Sources

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8.0 c How Do I Incorporate EBM Principles and
CPG into My Practice?

• Best evidence comes from Systematic Reviews (such
  as Cochrane Library) and/or EBM journals
• More likely (than personal research and critical
  appraisal) to be Valid
• Saves Time for the busy clinician
• Avoids error and duplication of effort

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8.0 d How Do I Incorporate EBM Principles and
CPG into My Practice?

• Suggested Resources
• ACOEM Practice Guidelines Glass et al
• Evidence Based Medicine. Straus et al
• Cochrane Collaboration (Free)
• http//www.cochrane.org
• Oxford Center Evidence Based Medicine (Free)
• http//www.cebm.net/
• AMA Center for Health Evidence (Free)
• http//www.usersguides.org
• ACP Journal Club (subscription)
• http//www.acpjc.org

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Questions?