World Wide Catalog 1995 Summer/World_Wide_Catalog_InfoMagic_Summer_1995.iso/pages/wwwoshaf.gov/ergo/ergo_c.txt

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APPENDIX C:  MEDICAL MANAGEMENT GUIDELINES
Introduction
Access to Health Care Providers
Job Familiarity
Health Care Provider Assessment
  History
  Physical Examination
  Diagnosis/Assessment
Treatment
  (1) Reduction of Exposure to Workplace Risk Factors
       a) Modifying Present Job
       b) Temporary Job Transfer
       c) Complete Removal from the Work Environment
  (2) Other Treatment
       a) Immobilization Devices
       b) Assessment and Reduction of Other Activities Outside
of Work
Written Musculoskeletal Disorder Management Plan
Periodic Follow-up Evaluations
Attachment 1.A.:  Sample History of Present Illness Recording
Form
Attachment 1.B.: Example of Completed History of Present Illness
Recording Form
Attachment 2:  Physical Examination Recording Form for the Neck
and Upper Extremity
Attachment 3.A.:  Sample Musculoskeletal Disorder Management
Plan
Attachment 3.B.:  Example of Completed Musculoskeletal Disorder
Management Plan
Table 1:  Decision Logic for Musculoskeletal Disorder Management
Plan

Appendix C: Medical management guidelines

Introduction
This appendix serves as a general guidance document for
employers and health care providers to provide medical
management for employees with work-related musculoskeletal
disorders as specified in the standard.  Nothing in the
standard, or in this appendix, supersedes or in any manner
affects any workers' compensation law, or enlarges,
diminishes, or affects in any other manner the common law
or statutory rights, duties, or liabilities of employers
and employees under any law with respect to injuries,
diseases, or death of employees arising out of, or in the
course of, employment.

Additionally, this appendix does not prescribe specific
medical treatments or dictate when an injured worker can
return to work.   Rather, it provides general guidelines
that the health care provider and the employer should use
in structuring appropriate medical management for the
affected employee.

An assumption is made in this appendix that in most
workplaces, the employer is contracting for the services of
a health care provider who is not located in the workplace.
However,  the information and guidance in this appendix
also applies to workplaces with on-site health care
providers.

Regardless of where the health care provider is located,
where workers' compensation law gives the employer the
authority to select the health care provider, the employer
is responsible for selecting health care providers who are
knowledgeable in the assessment and treatment of work-
related musculoskeletal disorders.  Criteria or
considerations for the employer to use in selecting a
knowledgeable health care provider include:
     * Specialized training and experience in ergonomics
     and the treatment of work-related musculoskeletal
     disorders;
     * Current working knowledge of the worksite and the
specific industry;
     * Willingness to periodically tour the worksite;
     * Willingness to communicate with the employer and
     employees (Louis, 1987,  Journal of Hand Surgery; and
     Haig, et.al., 1990, Journal of Occupational Medicine);
     * Willingness to consider conservative therapy prior
to surgery; and
     * History of successful treatment of work-related
musculoskeletal disorders.
(Reference ACOEM survey results dated August 9, 1994; AAOHN
survey results dated August 31, 1994; and AOEC survey
results dated September 30, 1994)

For the purposes of this standard, the term
"musculoskeletal disorder" refers to any of the following
when they are caused or aggravated by exposure to risk
factors in the workplace and are not the result of acute or
instantaneous events (e.g., slips or falls):  clinically
diagnosed musculoskeletal disorders, objective signs (e.g.,
swelling), or persistent symptoms.  A persistent symptom is
defined in the standard as a symptom which has persisted
for at least 7 calendar days from onset, or is interfering
with the employee's ability to perform the job.

 The goals of medical management are to:
     1) Reduce or eliminate musculoskeletal symptoms and
     conditions associated with work-related risk factors;
     2) Prevent, eliminate, or reduce duration and severity
     of functional impairment from these symptoms or
     conditions; and
     3) Prevent, eliminate, or reduce duration and severity
     of disability associated with these symptoms or
     conditions.

Under this standard, the primary effort of the employer
must be primary prevention - to reduce or eliminate
workplace risk factors, and to detect problem jobs before
the risk factors lead to symptoms and the need for medical
treatment.  Workplace risk factors include, but are not
limited to:  repetitive, forceful or prolonged exertions;
frequent or heavy lifting; pushing, pulling or carrying of
heavy objects; a fixed or awkward work posture; contact
stress; localized or whole-body vibration; and cold
temperatures.  These workplace risk factors can be
intensified by work organization characteristics, such as
inadequate work-rest cycles, excessive work pace and/or
duration, unaccustomed work, lack of task variability,
machine-paced work and piece rate.

In contrast, medical management  focuses on the prevention
of functional impairment and disability in a symptomatic
employee who presents for medical care.  In these
situations, where medical management is needed, this
appendix serves as a guide.

Currently there is no scientific evidence that validates
the use of pre-assignment medical examinations, job
simulation tests or other screening tests as a valid
predictor of which employees are likely to develop
musculoskeletal disorders (Frymoyer, J.W., 1992,
Bailliere's Clinical Rheumatology; Werner, R.A., et.al.,
1994, Arch Phys Med Rehabil; Cohen, J.E., et.al., 1994,
Journal of Occupational Medicine).  While OSHA is aware
that some of these tests may currently be used, at this
time OSHA does not support or encourage their use.  OSHA
has not approved any of these musculoskeletal disorder
screening tests.  In addition, no pre-assignment screening
tests or initial medical examinations are required in this
standard (Franzblau, A., et.al., 1993, Journal of
Occupational Rehabilitation).




Access to Health Care Providers
The standard specifies that the employer make available an
assessment to an employee at the earliest possible date but
no later than 5 work days after the signs or persistent
symptoms of a work-related musculoskeletal disorder are
reported.  A persistent symptom is defined in the standard
as a symptom which has persisted for at least 7 calendar
days from onset, or is interfering with the employee's
ability to perform the job.  This is not meant to imply
that employers should wait 7 calendar days from onset of
the employee's symptoms before referring the employee to a
health care provider.  There are foreseeable circumstances
where immediate evaluation by a health care provider would
be warranted.  For example, an employee who reports to the
supervisor that he/she is experiencing severe low back pain
with numbness and tingling radiating down his/her leg, an
inability to sleep due to the pain and obvious difficulty
walking should immediately be referred to the health care
provider.  Or, an employee may describe symptoms that have
been present for three weeks at the time he or she reports
symptoms.  This employee must be referred to a health care
provider at the time of initial reporting.  Furthermore,
referral prior to 7 calendar days is prudent since early
intervention is usually more effective than late
intervention (Ryan, 1985, The Australian Secretary; and
Ranney, 1993, Ergonomics; Kiefhaber, T.R. and Stern, P.J.,
1992, Clinics in Sports Medicine; Day, 1987, Seminars in
Occupational Medicine; Kaplan, S.J., et.al., 1990, Journal
of Hand Surgery (British Volume); Kruger, V.L., et.al.,
1991, Arch Phys Med Rehabil; Gelberman, R.H., et.al., 1980,
The Journal of Bone and Joint Surgery; Frymoyer, J.W.,
1992, Bailliere's Clinical Rheumatology).  Where health
care providers are available at the workplace, an initial
assessment should be performed and documented in the
employee's medical record at the time the employee reports
symptoms.

The standard also specifies that assessment and treatment
be performed by a person educated and trained in the
delivery of health care services who is operating within
the scope of their license, registration, certification, or
legally authorized practice.  The scope of practice of
health care providers varies from state to state.  It is
imperative, therefore, that the legal scope of practice
unique to each state be considered prior to any decision to
hire or contract for services.

Job Familiarity
The employer is required by the standard to establish a
contact person(s)  who is familiar with the jobs and risk
factors in the workplace to communicate with the health
care provider.  The contact person is required to
communicate and coordinate with the health care provider so
that appropriate job placement of the employee occurs
during the recovery period.

At the time of the initial assessment, the employer must
ensure that the health care provider has the name and
telephone number of the contact person for the workplace, a
copy of the medical management section from the regulatory
text of the standard, and the risk factor checklist for the
employee's job, or other materials that describe the job
and workplace risk factors.  The employer is required to
complete a risk factor checklist for any employee who
reports a work-related musculoskeletal disorder and for
each employee in a job with daily exposure during the
workshift to certain specified risk factors.

The checklist is a quick screening tool for identifying
workplace risk factors that can cause or aggravate
musculoskeletal disorders and the approximate duration of
exposure to each risk factor.  These workplace risk factors
are briefly described on the checklist form.  The checklist
is used by the employer to determine which jobs must be
further analyzed or changed to reduce risk of neck, upper
limb, lower limb and back disorders at work.  It can be
used by the health care provider to understand the general
conditions of the job.  In some cases, the checklist may
not be specific enough to determine whether the job is
appropriate for restricting specific muscle-tendon use
during the recovery period.  (Note:  For more detail on the
risk factor checklist, the health care provider should ask
the employer's contact person for a copy of Appendix A of
the standard.)

The contact person should also furnish the health care
provider with job descriptions and relevant visuals which
will familiarize the health care provider with the specific
requirements of the employee's regular job.  In addition,
employers shall provide health care providers with the
opportunity to conduct periodic walkthroughs of the
workplace in order to become familiar with the employer's
jobs and the risk factors present (Kasdan, Edit, 1991,
Occupational Hand and Upper Extremity Injuries and
Diseases, Chapter 35).

Walkthroughs allow the health care provider to:
     1) Gain insight and remain knowledgeable about
     operations and work practices;
     2) Participate in the identification of potential
restricted duty jobs;
     3) Maintain close contact with the employee; and
     4) Make more informed decisions about work placement.

Where a walkthrough is not possible, or until one can be
scheduled, the health care provider can gain valuable
information through the employee's risk factor checklist
and detailed job descriptions, job analyses, and visuals,
such as photographs or videotapes accompanied by
descriptions or narrations.  This information will
supplement a careful occupational history obtained from the
employee.



Health Care Provider Assessment
The standard requires that the assessment  include at least
a relevant occupational and
health history and a physical examination and tests
appropriate to the reported signs or symptoms (Putz-
Anderson, 1988, Cumulative Trauma Disorders. A Manual for
Musculoskeletal Diseases of the Upper Limbs, Chapter 6 and
Appendix B).  Specific attention should be paid to the
following:
     History:
     History of present illness, with particular attention
to:
          -- characterization of  symptoms as to onset,
          location, symptom quality, radiation, intensity,
          duration and frequency
          -- history of the course of the condition
          including the job the employee  was performing
          when symptoms were first noticed (prior job if
          recently changed jobs), the amount of time spent
          on that job, and jobs or tasks that exacerbate
          symptoms
          -- history of prior or current treatments
     Medical history, with particular attention to:
          -- systemic illnesses or conditions
          -- history of trauma, with particular attention
to the affected body part
          -- prior musculoskeletal condition to same,
adjacent, or other body part
          -- recreational activities

     Employee description of job activities:
          -- characterization of  required tasks with
          respect to known workplace risk factors for
          musculoskeletal disorders and duration of the
          exposure, such as  hours per day, days per week
          and shift work.  Workplace risk factors include
          repetitive, forceful or prolonged exertions;
          frequent or heavy lifting or lifting in awkward
          postures (e.g. twisting, trunk flexion or lateral
          bending); pushing, pulling or carrying of heavy
          objects; a fixed or awkward work posture; contact
          stress; localized or whole-body vibration; cold
          temperatures, and others;
          -- any recent changes in the job, such as longer
          hours, increased pace,  new tasks or equipment,
          or new work methods which may have caused the
          current illness.

     See attachment 1.A. for a sample history form and
     attachment 1.B. for an example of a completed history
     form.


     Physical Examination:
     The standard requires that the physical examination
     include at least inspection, palpation and range of
     motion.   The examination should also include
     evaluation of sensory, motor and reflex function, and
     any applicable provocative testing.  Attachment 2 is a
     suggested recording form for the examination of the
     neck and upper extremity.


     Diagnosis/Assessment:
     For each employee referred for an assessment,  the
     health care provider should make a specific diagnosis
     consistent with the current International
     Classification of Diseases or the health care provider
     should summarize the findings of their assessment.
     Terms such as "repetitive motion disorder",
     "cumulative trauma disorder", and "overuse syndrome"
     should not be used as a substitute for a specific
     diagnosis or assessment.  These terms are not
     diagnoses, but statements of causation (Ranney, 1993,
     Ergonomics).



Treatment:
 A musculoskeletal disorder management plan should include
both a plan for medical treatment and a plan for return to
work.  The medical treatment plan addresses issues such as
anti-inflammatory medication,  physical therapy and
occupational therapy.  The return to work plan addresses
issues such as whether restrictions are needed during the
recovery period and how long they will be needed.    The
employer has a contact person who is knowledgeable about
the employee's job requirements and their associated risk
factors.  The contact person is responsible for
communicating and coordinating with the health care
provider so that appropriate job placement of the employee
occurs during the recovery period (Kasdan, Edit, 1991,
Occupational Hand and Upper Extremity Injuries and
Diseases, Chapters 34 and 35).  Written plans ensure that
the health care provider, the employee, and the employer
all understand the steps recommended to promote recovery,
and ensures that the employer understands what his or her
responsibility is for returning the employee to work.  (See
the "Written Musculoskeletal Disorder Management Plan"
section  below for more discussion of the written plan.)

     (1)  Reduction of Exposure to Workplace Risk Factors:
     Reduction of exposure to workplace risk factors that
     cause or contribute to musculoskeletal disorders is a
     mainstay of successful treatment of these disorders
     and is the most effective way to rest the symptomatic
     area (Upfal, 1994, Occupational Hazards).  The
     standard requires the employer to review the
     employee's job with regard to risk factor exposures
     when the employee is referred for the initial
     assessment by the health care provider.  Where
     required by the standard, the employer must implement
     control measures which reduce or prevent employee
     exposure to the identified workplace risk factors.
     The discussion that follows will highlight current
     expert opinion on principles for reduction of
     exposure.

     Reduction in exposure to risk factors on the job
     during the recovery period can be achieved by placing
     restrictions on the employee, thereby limiting the
     manner in which an employee performs a job or work
     tasks.  This may be accomplished by modifying the
     present job, by temporary job transfer, or by complete
     removal from work.  Training or retraining of the
     employee on work methods, such as the proper method of
     keying at a video display unit to avoid hyperextension
     of the wrists, will supplement other exposure
     reduction modalities (Kasdan, Edit, 1991, Occupational
     Hand and Upper Extremity Injuries and Diseases,
     Chapter 33).  The health care provider is responsible
     for determining the appropriate restrictions of the
     affected employee during the recovery period.  The
     employer's contact person is responsible for working
     with the health care provider to ensure that any
     medical restrictions are taken into account in job
     modification or transfer (Upfal, 1994, Occupational
     Hazards).

     A variety of factors determine the length of time an
     employee is placed on restrictions.  These include
     specific diagnosis, severity of the disorder, duration
     and frequency of symptoms, response to treatment, the
     frequency and duration of exposure to relevant risk
     factors involved in the original job, and how quickly
     that original job can be changed, if necessary.

          a) Modifying Present Job
          Modifying the present job to reduce risk factors
          is the preferable option.  Modified duty allows
          the employee to remain in his or her present job,
          but limits physical stresses on the symptomatic
          area.  Examples of modified duty include
          performing a job at a reduced speed, performing
          only some of the job tasks or limiting the number
          of hours per day the employee performs certain
          job tasks.

          b) Temporary Job Transfer
          Employee exposure to workplace risk factors can
          be reduced through temporary job transfer.  The
          new job should be carefully assessed by the
          employer in collaboration with the health care
          provider to be sure that the symptomatic area
          will not be exposed to relevant risk factors.  If
          the employee is removed from a job requiring high
          force or high repetitions, the health care
          provider should consider a gradual reentry phase
          back into that job.


           c) Complete Removal from the Work Environment
          Complete removal from the work environment should
          generally be reserved for severe conditions and
          in workplaces where the only available jobs have
          risk factors which would adversely impact
          recovery of  the symptomatic area.  Research has
          documented that the longer the employee is off
          work, the less likely he/she is to return
          (Vallfors, 1985, Scandinavian Journal of
          Rehabilitation Medicine; Upfal, 1994,
          Occupational Hazards; Kasdan, Edit, 1991,
          Occupational Hand and Upper Extremity Injuries
          and Diseases, Chapters 34 and 35).

     (2) Other Treatment:
     While reduction of exposure to risk factors should be
     combined with appropriate medical treatment, minimal
     guidance is provided here concerning specific medical
     treatment, including use of analgesia, occupational
     and physical therapy, anti-inflammation medication, or
     surgery.  The health care provider is expected to
     provide these therapeutics on the basis of best
     available knowledge at the time that care is provided
     and to closely monitor the employee's progress to
     evaluate effectiveness of the prescribed treatment.

     It must be noted that the effectiveness of Vitamin B-6
     for treatment of musculoskeletal disorders has not
     been established (Stransky, et.al, 1989, Southern
     Medical Journal; Spooner, et.al, 1993, Canadian Family
     Physician).  Additionally, at this time there is no
     scientifically valid research that establishes the
     effectiveness of Vitamin B-6, anti-inflammatory
     medications such as aspirin, hot wax, or
     immobilization devices worn on or attached to the
     wrist or back as effective methods for preventing the
     occurrence of musculoskeletal disorders.  Exercises
     that involve stressful motions or an extreme range of
     motions, or that reduce rest periods, may be harmful.

          a) Immobilization Devices
          Immobilization devices, such as splints or
          supports, may help rest the symptomatic area
          during sleep.  Immobilization devices should be
          prescribed judiciously and monitored carefully (
          Kasdan, Edit, 1991, Occupational Hand and Upper
          Extremity Injuries and Diseases, Chapter 33).
          Prolonged use may cause muscle atrophy.  It
          should be noted that wearing flexible wrist
          splints during rest or repetitive work activities
          does limit range of motion but has no significant
          effect on carpal tunnel pressure (Rempel et al,
          1994 Journal of Hand Surgery).

          Under most circumstances, wrist splints should
          not be worn at work for the treatment of
          musculoskeletal disorders.  Struggling against a
          splint can exacerbate the medical condition due
          to the increased force needed to overcome the
          splint.  Working with a splint may also cause
          other joint areas, such as the elbow and
          shoulder, to be exposed to additional risk
          factors and to become symptomatic.  If a wrist
          splint is prescribed to be worn at work during
          the recovery period, the health care provider
          should ensure that the splint is properly fitted
          and that work restrictions are appropriately
          assigned to ensure that the employee is not
          struggling against the splint.

          The prophylactic use of devices worn on or
          attached to the wrist or back is not recommended.
          (Reference letter from AOTA dated October 31,
          1994; letter from ACOEM dated November 3, 1994;
          Memorandum from ASHT dated December 20, 1994)  In
          fact, devices worn on or attached to the wrist or
          back are not considered personal protective
          equipment in the standard.  Wrist splints have
          not been found to prevent distal upper extremity
          musculoskeletal disorders, and may cause the
          onset of symptoms in an employee who uses them
          under the conditions described above (Rempel,
          1994, Journal of Hand Surgery).  At this time,
          there is no rigorous scientific evidence that
          back belts or back supports prevent injury, and
          their use is not recommended for prevention of
          low back problems (CDC/NIOSH, July 1994,
          "Workplace Use of Back Belts"; Upfal, 1994,
          Occupational Hazards; Mitchell, L.V., et.al.,
          1994, Journal of Occupational Medicine).  Where
          the employee is allowed to use a device that is
          worn on or attached to the wrist or back, the
          employer, in conjunction with a health care
          provider,  should inform each employee of the
          risks and potential health effects associated
          with their use in the workplace, and train each
          employee in the appropriate use of these devices
          (McGill, S.M., 1993, American Industrial Hygiene
          Journal).

          b) Assessment and Reduction of Other Activities
     Outside of Work
          The health care provider should also evaluate
          whether activities outside of work contribute to
          or aggravate the musculoskeletal disorder, and
          recommend modifications of those activities
          during the recovery period.

 Written Musculoskeletal Disorder Management Plan
The employer is required by the standard to obtain from the
health care provider a   copy of the musculoskeletal
disorder management plan as soon as possible but not later
than 3 work days after each assessment until the employee
is released from care. The employer is also required  to
ensure that the health care provider gives the affected
employee a copy of the plan at the time of each assessment.
To ensure medical confidentiality, the management plan
shall not reveal specific findings or diagnoses unrelated
to workplace exposure to risk factors.
At a minimum, the musculoskeletal disorder management plan
shall include the results of the assessment, restrictions,
and follow-up required.  The health care provider should
discuss the details of the plan with the employee at the
time of the visit.

  The health care provider, in developing these plans,
should specify:
     -- diagnosis/assessment;
     -- the treatments to be used, including any treatment
     needed during work hours, and the frequency and
     duration;
      -- description of restricted work activity and
     duration (e.g., No lifting >10 pounds from below the
     knees for more than one hour in an 8-hour work shift
     until next appointment); and
     --  follow-up including the next appointment and other
     scheduled appointments.
The health care provider should communicate and collaborate
with the employer's contact person to ensure that the
employee's musculoskeletal disorder management plan is
understood and to ensure proper job placement during the
recovery period (Kasdan, Edit, 1991, Occupational Hand and
Upper Extremity Injuries and Diseases, Chapters 34 and 35).
The health care provider should  return the employee to
his/her original job when risk factor modification or
appropriate treatment allows the employee to safely remain
in that job (Johns, R.E., et.al., 1994, Journal of
Occupational Medicine).
Table 1 outlines the decision logic the health care
provider can use to establish the musculoskeletal disorder
management plan.   Attachment 3.A. is a sample
musculoskeletal disorder management plan and attachment
3.B. is an example of a completed musculoskeletal disorder
management plan.

Periodic Follow-Up Evaluations
Most musculoskeletal disorders improve with conservative
management.  Regardless of whether the employee has
continued to work or has been completely removed from the
work environment during the recovery period, primary health
care providers should monitor the symptomatic employee to
document improvement, or lack thereof, and re-evaluate the
employee who has not improved.  The timeframe for this
follow-up depends on the symptom type, duration and
severity.  A clinical exam or telephone contact with the
employee should be made once a week, followed by a complete
re-evaluation within ten calendar days from the last
examination if the employee's symptoms are not improving.
Where health care providers are available at the workplace,
monitoring of the symptomatic employee should occur every
3-5 working days depending on the clinical severity of the
disorder, and the results of the assessment must be
documented in the employee's medical record (Wiesel,
S.W.,et.al., 1984, SPINE; Wiesel, S.W., et.al., 1994,
Clinical Orthopaedics and Related Research).
TABLE 1
DECISION LOGIC FOR MUSCULOSKELETAL DISORDER MANAGEMENT PLAN
(1) Can the employee return to his/her current job without
restrictions after this visit?
(2) If not, can the employee return to his/her current job
with restrictions that reduce risk factors, such as:
     -- decreased pace of work
     -- increased rest time
     -- elimination of some of the elements of the work,
     (e.g., "No lifting over 10 pounds from below the knees
     for more than one hour in an 8 hour work shift," or "
     No use of a vibrating hand tool")
(3) If the first two options are not possible, either
because of the severity of the condition or the specific
requirements of the job, can the employee be moved to
another job that reduces exposure to relevant risk factors?
The health care provider should make recommendations
regarding the restrictions of the employee and work with
the employer's contact person to match these restrictions
to a specific job.
(4) Is complete removal from work necessary?
(5) Once any restrictions are prescribed, what are the
expected lengths of time for these restrictions, and when
will this plan be re-evaluated?