# Presentation: 693706

## ACOEM Practice GuidelinesForearm, Wrist, and Hand

*C. David Rowlett, M.D., M.S.*

##  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.

##  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?**

##  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...**
**	**

##  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 clinician’s behaviors?”**
**Not peddling “Cookbook Medicine”**
**(Even with the procedures...**
**	*****I can’t fly a 747)***
**	**

## 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!*

## 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 don’t know which half!”*
- 		* Joseph Bernstein, MD: Evidence Based Medicine,
- 		J Am Acad Orthop Surg 2004;12:80-88

## 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) **

## 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

##  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” community’s literature.

##  2.4 What is the Basic Issue Practice Guidelines Address?

- “DIKW” Hierarchy: _D_ata-_I_nformation-_K_nowledge-_W_isdom

- Must have a rational way to move along DIKW Hierarchy:
- Evidence Based Medicine/*Practice Guidelines **is one way.*

##  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; 312:71-80**

##  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**

## 3.1 How do you do...“Evidence-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.

##  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.

**Notes:**
Evidence is compared with current clinical practice and consensus to ask --
Does is support current practice?
If not, is change warranted ?  Why ?
Literature is rated
Based upon “quality of the evidence”
Recommendations crafted
Integrate clinical expertise with the best available external clinical evidence from systematic research
Multidisciplinary input critical

##  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)

**Notes:**
Evidence is compared with current clinical practice and consensus to ask --
Does is support current practice?
If not, is change warranted ?  Why ?
Literature is rated
Based upon “quality of the evidence”
Recommendations crafted
Integrate clinical expertise with the best available external clinical evidence from systematic research
Multidisciplinary input critical

## 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...”
**	****	****	****	****	**

## 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: Worker’s Compensation
- Documented Process to Assess Outcomes

##  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

##  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...”

## 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**

##   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.

##   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-serving...but its not. The issue is how we change clinician behaviors.)

##  5.4 Are All Guidelines Evidence-Based?

- "The ***absence of evidence*** is not the ***evidence of absence***."
- 	Carl Sagan

## 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?)

##  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”

##   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

##  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?)

##  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

##   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 Wisdom”...Consensus (?) +/-

##   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

## 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 confounder’s effect is what we are actually measuring).

## 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

##  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

##  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

##  6.7c Grading the Evidence (3)

- Epidemiologist’s *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

##  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

## 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*

##  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*

##  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

## 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)

## 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

## 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?...

##  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)

##  7.3b Chapters 8-15 Organization (2)

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

##    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 Chapter’s 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)

##  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

##  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?

##  7.7 Physical Exam: 	Forearm, Wrist & Hand

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

##  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

## 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

## 7.8b Diagnostic Criteria Example: CTS 

## 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”

## 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?

##  7.9c Work Relatedness/Causation (3)

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

##  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

**Notes:**
Fractures
Progressive neurological deficits
Infection requiring drainage
Etc.

## 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

## 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)

##  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

## 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

## 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

## 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

## 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

##  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

## 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

## 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 Gamekeeper’s thumb
- Early NCV for severe clinical CTS
- Classic Presentation and thenar atrophy
- Serologies for persistent joint effusions

##  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)

## 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”...
- Don’t have to be a statistician.
- Don’t have to be an epidemiologist.
- “Watchmakers aren’t the only ones wearing watches.”

## 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...

## 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

## 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](http://www.cochrane.org/)_
- Oxford Center Evidence Based Medicine (Free):
-  _[http://www.cebm.net/](http://www.cebm.net/)_
- AMA Center for Health Evidence (Free):
-  _[http://www.usersguides.org](http://www.usersguides.org/)_
- ACP Journal Club (subscription):
- _[http://www.acpjc.org](http://www.acpjc.org/)_

## Questions?