Monday, September 08, 2008

American College of Occupational and Environmental Medicine

The American College of Occupational and Environmental Medicine (ACOEM) has released an extensive update to its evidence-based practice guidelines.

The revised Chronic Pain chapter contains the following enhancements: 

  • Over 200 recommendations focusing on diagnostic and other testing and treatments for several chronic pain conditions, including complex regional pain syndrome (CRPS), neuropathic pain, trigger points/myofascial pain, chronic persistent pain, and chronic low back pain.
  • An extensive in-depth review of pharmacologic interventions (prescription, over-the-counter, complementary and alternative) used to treat patients with chronic pain, including a comprehensive appendix on guidance for the use of opioids.
  • Strong evidence indicating that best practices for treatments of various chronic pain conditions should differ.
  • Detailed recommendations regarding the use of appliances, skilled allied health provided medical therapies, and electrical therapies.
  • Description of the uses and limitations of injection therapies.
  • Discussion of spinal cord stimulation for CRPS and other painful conditions.
  • Detailed review of psychological services and rehabilitation for delayed recovery, including biofeedback, work conditioning/work hardening/early intervention programs, and interdisciplinary pain rehabilitation programs.
  • Evidence that in the absence of a curative intervention, teaching and learning coping skills will result in superior outcomes and are consequently highly advisable.
  • Incorporation of patient education information, including the criticality of maintaining activities, avoiding disuse and focusing on function.
  • Discussion of the use of progressive exercise programs to facilitate maximal medical improvements, increased functional status, return to limited work, or in best cases, return to unrestricted work as cornerstone therapies.
  • Recommendations for clinicians to address psychosocial and workplace factors that may be impeding patient recovery to facilitate functional improvement.
  • Emphasis on the need for the clinical evaluation to provide a comprehensive picture of the physical, psychological and socio-environmental factors that may be contributing to pain and the use of descriptions of current functional activities rather than pain ratings, to quantify the impact of pain.
  • A focus on functional restoration including an active exercise program and behavioral program as patients do best when returned to functional status sooner, including through use of work conditioning, work hardening, graded exercise programs and participatory ergonomic and return to work programs.
  • A comprehensive appendix which covers treatment options for patients with tender points/fibromyalgia, although this is not considered an occupational disorder.
  • A table which summarizes the recommendations by chronic pain disorder.
  • Algorithms for the different chronic pain conditions which offer quick and accurate guidance for cases with different progressions, circumstances, or outcomes.
  • An extensive volume of literature relied upon to develop the evidence-based recommendations contained in the chapter—1,557 references including 546 randomized controlled trials.

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