• Forearm, wrist, and hand complaints. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 34 p. [101 references]

This is the current release of the guideline.

This guideline updates a previous version: Harris, J, ed. Occupational Medicine Practice Guidelines: American College of Occupational and Environmental Medicine. Beverly Farms, MA: OEM Press; 1997.

Forearm, wrist, and hand complaints

Diagnosis
Evaluation
Management
Treatment

Family Practice
Internal Medicine
Orthopedic Surgery
Physical Medicine and Rehabilitation
Preventive Medicine
Surgery

Advanced Practice Nurses
Physician Assistants
Physicians
Utilization Management

• To provide information and guidance on generally accepted elements of quality care in occupational and environmental medicine
• To improve the efficiency with which the diagnostic process is conducted, the specificity of each diagnostic test performed, and the effectiveness of each treatment in relieving symptoms and achieving cure
• To present recommendations on assessing and treating adults with work-related forearm, wrist, or hand complaints

Adults with potentially work-related forearm, wrist, or hand complaints seen in primary care settings

Note from the National Guideline Clearinghouse (NGC): The following general clinical measures were considered. Refer to the original guideline document for information regarding which specific interventions and practices under these general headings are recommended, optional, or not recommended by the American College of Occupational and Environmental Medicine.

1. History and physical exam
2. Patient education
3. Medication
4. Physical treatment methods
5. Injections
6. Rest and immobilization
7. Activity and exercise
8. Detection of neurologic abnormalities
9. Radiography
10. Other imaging procedures
11. Surgical considerations
12. Psychosocial factors

Missed work days

Searches of Electronic Databases

Note from the National Guideline Clearinghouse (NGC): The American College of Occupational and Environmental Medicine contracted the Work Loss Data Institute to provide medical library research services.

Disability-Duration Data

This edition includes disability-duration data that have been extracted from National Health Interview Survey data. Only data from interviews with individuals without workers' compensation claims has been included.

Not stated

Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)

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 of patients with forearm, wrist, or hand disorders).

D = Reviewer or consensus interpretation of evidence not meeting inclusion criteria for research-based evidence.

Review
Review of Published Meta-Analyses

Contributors reviewed at least one chapter each and reviewed the relevant medical literature that had been published since the creation of the original Guidelines in 1997.

Expert Consensus

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Following the chapter and literature review, participants provided written or verbal comments to the American College of Occupational and Environmental Medicine's Practice Guidelines Committee.

Verbal comments were in the form of participation in multi-specialty conference calls, during which the issues raised in each chapter were extensively discussed. Draft chapters were prepared and distributed by the American College of Occupational and Environmental Medicine to all chapter reviewers. Follow-up multi-specialty teleconferences were then held as appropriate, during which time the draft was again reviewed.

Recommendations are followed by evidence classification (A-D) identifying the type of supporting evidence. Definitions for the types of evidence are presented at the end of the "Major Recommendations" field.

Summary of Recommendations for Evaluating and Managing Forearm, Wrist, and Hand Complaints (refer to the original guideline document for more detailed information)

Definitions:

Levels of Evidence

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 of patients with forearm, wrist, or hand disorders).

D = Reviewer or consensus interpretation of evidence not meeting inclusion criteria for research-based evidence.

The following clinical algorithms are provided in the original guideline document:

• American College of Occupational and Environmental Medicine Guidelines for care of acute and subacute occupational forearm, wrist, and hand complaints
• Initial evaluation of occupational forearm, wrist, and hand complaints
• Initial and follow-up management of occupational forearm, wrist, and hand complaints
• Evaluation of slow-to-recover patients with occupational forearm, wrist, and hand complaints (symptoms >4 weeks)
• Surgical considerations for patients with anatomic and physiologic evidence of nerve root compression and persistent forearm, wrist, and hand symptoms
• Further management of occupational forearm, wrist, and hand complaints

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Improved efficiency of the diagnostic process
• Effective treatment resulting in symptom alleviation and cure

Risks and complications of surgical procedures and imaging studies (e.g., infection, radiation)

• The American College of Occupational and Environmental Medicine (ACOEM) provides this segment of guidelines for practitioners and notes that decisions to adopt particular courses of actions must be made by trained practitioners on the basis of the available resources and the particular circumstances presented by the individual patient. Accordingly, the ACOEM disclaims responsibility for any injury or damage resulting from actions taken by practitioners after considering these guidelines.
• The guidelines for modification of work activities and disability duration (see original guideline document)  are general guidelines based on consensus or population sources and are never meant to be applied to an individual case without consideration of workplace factors, concurrent disease or other social or medical factors that can affect recovery.  The parameters for disability duration are ''consensus optimal'' targets as determined by a panel of ACOEM members in 1996, and reaffirmed by a panel of ACOEM members in 2002. In most cases persons with one non-severe extremity injury can return to modified duty immediately. Restrictions should take into consideration the opposite extremity also to prevent strain injuries to the uninjured extremity. Additional limitations of the frequency or pressure of keyboard use or pinch grasp may be warranted.

An implementation strategy was not provided.

Getting Better

Effectiveness
Patient-centeredness

• Forearm, wrist, and hand complaints. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 34 p. [101 references]

Not applicable: The guideline was not adapted from another source.

1997 (revised 2004)

American College of Occupational and Environmental Medicine - Medical Specialty Society

American College of Occupational and Environmental Medicine

American College of Occupational and Environmental Medicine Practice Guidelines Committee

Chapter Lead: C. David Rowlett, MD, MS

Committee Members: Jennifer H. Christian, MD, MPH, FACPM; Philip I. Harber, MD, MPH, FACOEM, FCCP; John P. Holland, MD, MPH, FACOEM; Kathryn L. Mueller, MD, MPH, FACEP, FACOEM; Douglas J. Patron, MD, MSPH; Bernyce M. Peplowski, DO, MS; and Jack Richman, MD, CCFP, DOHS, FACOEM

Timothy J. Key, MD, MPH, FACOEM, as Responsible Officer and ACOEM President Elect, and Edward A. Emmett, MD, MS, FACOEM, Chair of the ACOEM Council on Occupational and Environmental Medical Practice, contributed to the development of the guidelines as well.

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Harris, J, ed. Occupational Medicine Practice Guidelines: American College of Occupational and Environmental Medicine. Beverly Farms, MA: OEM Press; 1997.

None available

None available

This NGC summary was completed by ECRI on May 31, 2006. The information was verified by the guideline developer on November 3, 2006.

The American College of Occupational and Environmental Medicine, the signator of this license, represent and warrant that they are the publisher of the guidelines and/or possess all rights necessary to grant the license rights to AHRQ and its agents.