Feedback and Response Regarding ACOEM’s Practice
RSDSA Comments on ACOEM’s Practice Guidelines
In 2010, the American College of Occupational and Environmental Medicine (ACOEM) will be publishing the third edition of Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. The guidelines, according to ACOEM, are intended to help improve or restore the health of those workers who incur occupationally-related illness or injuries and are the only “evidence-based guidelines that focus on returning employees to work within 90 days of an injury or illness.”
Nevertheless, there is a lot of concern among members of the RSDSA Board of Directors on how these guidelines affect people with complex regional pain syndrome (CRPS). Peter Moskovitz, MD, submitted the following comments to the ACOEM on behalf of the board:
The Reflex Sympathetic Dystrophy Syndrome Association (RSDSA), as a not-for-profit organization dedicated to the awareness, education, advocacy, and research for CRPS, also known as reflex sympathetic dystrophy (RSD), would like to make the following comments on the American College of Environmental and Occupational Medicine Guidelines.
In 2007, the ACOEM published the second edition of the Occupational Medicine Practice Guidelines1 (the Guidelines). They are an evidence-based review similar to a Cochrane Collaboration. The Guidelines are written as a set of graded recommendations for, or against, the use of various diagnostic and treatment modalities for low back pain, chronic pain disorders, and elbow complaints. Guidelines for the diagnosis and treatment of CRPS are specifically included.
Other academic and professional organizations (American Academy of Orthopaedic Surgeons, North American Spine Society, and Trauma Related Neuronal Dysfunction [TREND] Research Consortium) have convened committees based on the Cochrane model to develop evidence-based guidelines for musculoskeletal, neuro-mechanical, immune, and neuropathic conditions. The ACOEM’s Guidelines appear to have been written without referencing any of them. The ACOEM’s “independent” approach may be due to the intended use of their Guidelines for injured and ill workers, but RSDSA sees no reason to differentiate between the treatment of people whose CRPS developed after work-related injury and those whose did not. The principles of appropriate and necessary medical practice are the same.
The ACOEM Overuses the Term “Guidelines”
One classification of recommendations that grade the value of diagnostic or therapeutic interventions divides them into five categories: (1) standards for an intervention, (2) guidelines for…, (3) choices, (4) guidelines against…, and (5) standards against…. Here a “standard” is used in the medical sense and not the more commonly used legal sense—in most jurisdictions, a legal “standard of care” is what a majority of comparably educated, trained and experienced practitioners would do under the same circumstances. A medical “standard” for an intervention is one for which the evidence is so strong that there must be a contraindication against its use. When the evidence for a medical intervention is weak, then the support for a recommendation for, or against, the use of the medical intervention no longer qualifies as a “guide” to clinical practice. Using an intervention for which there is inadequate evidence is a “choice.” Here, good clinical judgment and informed consent are the best guides to medical practice. The Guidelines for chronic pain conditions contain many more choices than guidelines and, although the confusion might be a common error, there is no excuse for it.
The Guidelines are Insensitive to the Many Ways in Which a Painful Condition Presents
The Guidelines, in their ambitious attempt to develop guidelines for a wide variety of injuries and impairments, do not consider varieties of medical conditions. To subdivide types and sorts of CRPS, or any other painful condition, would dilute the scant evidence that exists on the etiology, diagnosis, and treatment of CRPS. Since there are several taxonomies of CRPS, proper clinical guidelines would choose one and defend the choice. Existing clinical guidelines for the diagnosis and treatment of CRPS2-4 are sensitive to the variety of manifestations of the disease, whereas the Guidelines incorrectly propose treating CRPS as a singular disorder.
CRPS patients are variable in their initial clinical presentation to a medical practitioner. Moreover, the time course and progression of CRPS symptoms are often distinct to the patient. The term “complex” is reflected in the complexity of a practitioner’s efforts to understand the onset and course of this highly debilitating pain disorder. Physicians and physical therapists often develop specialized treatment plans for individual patients based upon symptom history, regions of the body affected by CRPS, and past responses to various types of medical intervention. In specialized CRPS treatment centers, multimodal treatment plans are based upon a given physician’s past experience with managing CRPS symptoms, as well as consulting and collaborating with other healthcare professionals (e.g., neurologists, anesthesiologists, pain psychologists, physical therapists). The treatment plan is dependent on the physical and psychological condition of the patient, and designed to match the patient’s individual therapeutic needs.
The Guidelines Reinforce Normative Judgment
By presenting CRPS as a singular pain disorder, the Guidelines invite clinicians to treat all persons suffering from CRPS alike. Appropriate and necessary interventions, on the other hand, are based on the spectrum of the diagnosis. For CRPS, the Guidelines declare ranges for the “recommended target for disability duration,”1 but they are without reference to medical literature or advice, other than being the consensus of the 18-member Evidence-based Practice Chronic Pain Panel.
Normative Judgments Are Inappropriate as Criteria for Coverage Decisions
In clinical practice, evidence-based guidelines and normative expectations help practitioners in the initial assessment and care planning. The narrative recommendations of the panel of experienced and respected clinicians who wrote and edited the Guidelines have “the ring” of good sense and they provide the “help” that give a rational context in which the practitioner views each patient’s particular predicament. After the practitioner has the appropriate and necessary evidence about the specific patient, normative judgments do not apply. The Guidelines are helpful, but not prescriptive.