General Guideline Principles for Non-Specific
Hand/Wrist/Forearm Pain for workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Non-Specific Hand/Wrist/Forearm Pain.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Non-Specific Hand, Wrist and Forearm Pain

In the absence of distinct trauma, non-specific pain in the hands, wrists, and forearms frequently occurs. Instead, it frequently happens in environments with demanding physical jobs or undefined exposures.

The majority of cases will clear up on their own, but focused diagnostic testing should be taken into consideration if there is no improvement after several weeks of therapy. It’s fairly uncommon for non-specific pain to last longer than two months.

In addition to psychological disorders, proximal pathology related to the spine (such as radiculopathy, spinal tumours, and infections) should also be considered when making a diagnosis, especially when severe symptoms are present or when there is a pattern of recurring unexplained illnesses.

In the absence of discrete trauma, patients frequently describe how their pain or other symptoms gradually started to appear. The forearm is where symptoms most frequently occur, and they are frequently poorly localised.

Diagnostic Studies of Non-Specific Hand/Wrist/Forearm Pain

1. Diagnostic Studies of Non-Specific Hand/Wrist/Forearm Pain of Rheumatological Studies for Arthralgias

   Diagnostic Studies of Non-Specific Hand/Wrist/Forearm Pain of Rheumatological Studies for Arthralgias are recommended for the evaluation of a select group of patients who have tenosynovitis or persistent, unexplained arthralgias.

   Indications – persistent arthralgias or tenosynovitis with no known cause.

   Frequency/Duration – As some patients, especially those with less severe diseases, tend to develop positive antibodies after months or years, it may be necessary to conduct additional studies after some time has passed.

    

2. Arthrocentesis for Joint Effusions

   Arthrocentesis for Joint Effusions is recommended in the evaluation of infections and crystalline arthropathies in unexplained joint effusions.

   Indications – Joint effusions that are unclearly diagnosed, such as those caused by crystalline arthropathies or suspected infections

    

3. Electrodiagnostic

   Electrodiagnostic is recommended to assess patients who experience paresthesias or other neurological symptoms and have generalised hand, wrist, or forearm pain.

   Indications – persistent pain and tingling, especially signs of radiculopathies and entrapment neuropathies. Providers are advised that abnormal electrodiagnostic studies are common in asymptomatic populations and that abnormal results should be interpreted in relation to clinical findings.

   Frequency/Dose – Usually carried out at least 3 weeks after the start of the symptoms.

    

4. X-Rays

   X-Rays are recommended to assess cases of persistent, non-specific hand, wrist, or forearm pain.

   Indications – persistent, vague pain in the hands, wrists, or arms.

Medications of Non-Specific Hand/Wrist/Forearm Pain

Ibuprofen, naproxen, or other NSAIDs from an earlier generation are suggested as first-line treatments for the majority of patients. For patients who are not candidates for NSAIDs, acetaminophen (or the analogue paracetamol) may be a viable alternative, even though the majority of research indicates it is only marginally less effective than NSAIDs. There is proof that NSAIDs are less dangerous and just as effective at treating pain as opioids, such as tramadol.

1. Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Non-specific hand/wrist/forearm Pain

   Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Non-specific hand/wrist/forearm Pain are recommended for the treatment of generalised hand, wrist, and arm pain that is either acute, subacute, or chronic.

   Indications –NSAIDs are advised as a treatment for non-specific acute, subacute, or chronic pain in the hands, wrists, or forearms. First, try over-the-counter (OTC) medications to see if they work.

   Frequency/Duration: Many patients might find it reasonable to use as needed.

   Indications for Discontinuation: the symptom’s resolution, the medication’s ineffectiveness, or the emergence of side effects that require stopping.

    

2. NSAIDs for Patients at High Risk of Gastrointestinal Bleeding

   NSAIDs for Patients at High Risk of Gastrointestinal Bleeding are recommended for patients at high risk of gastrointestinal bleeding to take misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors concurrently.

   Indications:Cytoprotective drugs should be taken into consideration for patients with a high-risk factor profile who also have indications for NSAIDs, especially if a longer course of treatment is planned. Patients who have a history of gastrointestinal bleeding in the past, the elderly, diabetics, and smokers are at risk.

   Frequency/Dose/Duration: H2 blockers, misoprostol, sucralfate, and proton pump inhibitors are advised. dosage recommendations from the manufacturer. It is generally accepted that there are no significant differences in effectiveness for preventing gastrointestinal bleeding.

   Indications for Discontinuation: ITolerance, the emergence of negative effects, or the stopping of NSAID use.

    

3. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

   The advantages and disadvantages of NSAID therapy for pain should be discussed with patients who have a history of cardiovascular disease or who have multiple cardiovascular risk factors.

    

4. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
   • NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

     NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended as far as adverse cardiovascular effects go, acetaminophen or aspirin as first-line therapy seem to be the safest options.

      

   • NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

     NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended If necessary, non-selective NSAIDs are preferred to COX-2-specific medications. To reduce the chance that an NSAID will negate the protective effects of low-dose aspirin in patients receiving it for primary or secondary cardiovascular disease prevention, the NSAID should be taken at least 30 minutes after or eight hours before the daily aspirin.

      

5. Acetaminophen for Treatment of Non-specific hand/wrist/forearm Pain

   Acetaminophen for Treatment of Non-specific hand/wrist/forearm Pain is recommended for the treatment of generalised hand, wrist, and arm pain, especially in patients who have NSAID contraindications.

   Indications:Acute, subacute, chronic, and post-operative patients with non-specific hand, wrist, and forearm pain.

   Dose/Frequency: As per the manufacturer’s recommendations; can be used as required. Over four gm/day, there is evidence of hepatic toxicity.

   Indications for Discontinuation: pain, side effects, or intolerance are gone.

    

6. Opioids of Non-Specific Hand/Wrist/Forearm Pain

   Opioids are not recommended for generalised hand, wrist, or forearm pain that is either acute, subacute, or chronic.

Treatments of Non-Specific Hand/Wrist/Forearm Pain

1. Relative Rest

   Relative Rest are recommended in certain instances of sudden, vague hand, wrist, or forearm pain, especially when there are significant ergonomic exposures (high force or high force combined with other risk factors).

   Reason for Recommendation: Relative rest may be beneficial for patients with high ergonomic exposures.

    

2. Splinting

   Splinting is recommended for treatment of select patients with acute or subacute non-specific hand, wrist, or forearm pain.

   Splinting is not recommended for ongoing use

   Rationale for Recommendation – Splinting, while occasionally helpful, perpetuates debility. It is generally not recommended for chronic use.

   Rehabiliation Rehab (supervised formal therapy) needed after a work-related injury should be concentrated on regaining the functional ability needed to meet the patient’s daily and work obligations and enable them to return to work, with the goal of returning the injured worker to their pre-injury status to the extent that is practical.

   Active therapy calls for the patient to put forth an internal effort to finish a particular exercise or task. The interventions known as passive therapy rely on modalities that are administered by a therapist rather than the patient exerting any effort on their part.

   Passive interventions are typically seen as a way to speed up an active therapy programme and achieve concurrently objective functional gains. Interventions that are active should be prioritised over those that are passive.

   To maintain improvement levels, the patient should be advised to continue both active and passive therapies at home as an extension of the therapeutic process.

   To facilitate functional gains, assistive devices may be used as an adjunctive measure in the rehabilitation plan.

Therapy – Active of Non-Specific Hand/Wrist/Forearm Pain

Therapeutic Exercise

Therapeutic Exercise are recommended for treatment of acute, subacute, or chronic non-specific hand, wrist, or forearm pain.

Frequency/Dose/Duration –With documentation of ongoing objective functional improvement, the total number of visits may be as low as two to three for patients with mild functional deficits or as high as 12 to 15 for those with more severe deficits.

If there is evidence of functional improvement toward specific objective functional goals, more than 12 to 15 visits may be necessary when there are persistent functional deficits (e.g., increased grip strength, key pinch strength, range of motion, advancing ability to perform work activities). A home exercise programme should be created as part of the rehabilitation strategy and carried out alongside the therapy.

Therapeutic Exercise is recommended for a select group of patients whose non-specific hand, wrist, or arm pain is acute, subacute, or chronic and does not go away after receiving initial care.

Therapy: Passive of Non-Specific Hand/Wrist/Forearm Pain

Self-application of Ice or Heat

Self-application of Ice or Heat is recommended for the treatment of nonspecific acute or subacute hand, wrist, or arm pain.

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