Evaluating Covid-19 Injury Claims With a Focus on Workers' Compensation.

: COVID-19 illness can cause multiorgan illness. Some States have passed legislation granting a rebuttable presumption of causation by workplace exposure in certain occupations. This paper summarizes methodology for evaluating claimants utilizing known science and as well as information from the American Medical Association Guides resources.

Using Electronic Health Records and Clinical Decision Support to Provide Return-to-Work Guidance for Primary Care Practitioners for Patients With Low Back Pain.

OBJECTIVE: The aim of this study was to describe the process by which a group of subject matter experts in the area of return to work developed a resource tool to provide clinical decision support (CDS) for primary care clinicians. METHODS: A common musculoskeletal disorder, low back pain (LBP), was selected, pertinent literature reviewed, and specific recommendations for action in the clinical setting developed. RESULTS: Primary care practitioners (PCPs) are routinely expected to create work activity prescriptions. The knowledge base for a CDS tool that could be embedded in electronic health records has been developed. CONCLUSION: Improved clinical support should help prevent and manage work limitations associated with LBP not caused by work. The proposed decision support should reduce administrative burden and stimulate PCPs to explore the role of occupation and its demands on patients.

ACOEM practice guidelines: opioids for treatment of acute, subacute, chronic, and postoperative pain.

DESCRIPTION: The American College of Occupational and Environmental Medicine's guidelines have been updated to develop more detailed guidance for treatment of acute, subacute, chronic, and postoperative pain with opioids. METHODS: Literature searches were performed using PubMed, EBSCO, Cochrane Review, and Google Scholar without publication date limits. Of 264,617 articles' titles screened and abstracts reviewed, 263 articles met inclusion criteria. Of these, a total of 157 were of high and moderate quality addressing pain treatment. Comprehensive literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel to develop evidence-based guidance. RECOMMENDATIONS: No quality evidence directly supports histories, physical examinations, and opioid treatment agreements, although they are thought to be important. No quality trials were identified showing superiority of opioids, compared with nonsteroidal anti-inflammatory and other medications for treatment of chronic, noncancer pain. The use of opioid-sparing treatments associated with lower doses of postoperative opioids is also associated with better long-term functional outcomes. Selective use of opioids is recommended for patients with acute and postoperative pain. Consensus recommendations also include consideration of carefully conducted trials of chronic opioid treatment for highly select patients with subacute and chronic pain and to maintenance opioid prescriptions only if documented objective functional gain(s) results. A strong and reproducible dose-response relationship identifies a recommended morphine equivalent dose limit of no more than 50 mg/day. Higher doses should be prescribed only with documented commensurately greater functional benefit(s), comprehensive monitoring for adverse effects, informed consent, and careful consideration of risk versus benefit of such treatment. Chronic opioid use should be accompanied by informed consent, a treatment agreement, tracking of functional benefits, drug screening, and attempts at tapering.

ACOEM practice guidelines: opioids and safety-sensitive work.

OBJECTIVE: ACOEM has updated the treatment guidelines concerning opioids. This report highlights the safety-sensitive work recommendation that has been developed. METHODS: Comprehensive literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel to develop evidence-based guidance. A total of 12 moderate-quality studies were identified to address motor vehicle crash risk, and none regarding other work among opioid-using patients. RESULTS: Acute or chronic opioid use is not recommended for patients who perform safety-sensitive jobs. These jobs include operating motor vehicles, other modes of transportation, forklift driving, overhead crane operation, heavy equipment operation and tasks involving high levels of cognitive function and judgment. CONCLUSION: Quality evidence consistently demonstrates increased risk of vehicle crashes and is recommended as the surrogate for other safety-sensitive work tasks.

Commentary: The spine and vibration: whole lotta shaking going on.

Commentary on: Holguin N, Martin JT, Elliott DM, Judex S. Low-intensity vibrations partially maintain intervertebral disc mechanics and spinal muscle area during deconditioning. Spine J 2013;13:428-36 (in this issue).

Factors associated with obstructive sleep apnea among commercial motor vehicle drivers.

OBJECTIVE: Identify factors associated with obstructive sleep apnea (OSA) risk during commercial driver medical examinations. METHODS: A case-control study was conducted at an occupational health clinic by reviewing the commercial driver medical examinations medical records performed from January 2007 to December 2008. The magnitude of association with OSA was estimated with logistic regression. RESULTS: Among 1890 commercial motor vehicle drivers, 51 were confirmed positive for OSA by polysomnography after initial screening by Joint Task Force guidelines, yielding estimated positive predictive values of 78.5% for the screening criteria. Multivariable logistic regression showed that body mass index ≥ 30 (odds ratio: 26.86), hypertension (odds ratio: 2.57), and diabetes (odds ratio: 2.03) were independently associated with OSA. CONCLUSION: Medical examiners' use of objectively measurable risk factors, such as obesity, history of hypertension, and/or diabetes, rather than symptoms, may be more effective in identifying undiagnosed OSA in commercial drivers during the commercial driver medical examinations.

Long-term outcomes of lumbar fusion among workers' compensation subjects: a historical cohort study.

STUDY DESIGN: Historical cohort study. OBJECTIVE: To determine objective outcomes of return to work (RTW), permanent disability, postsurgical complications, opiate utilization, and reoperation status for chronic low back pain subjects with lumbar fusion. Similarly, RTW status, permanent disability, and opiate utilization were also measured for nonsurgical controls. SUMMARY OF BACKGROUND DATA: A historical cohort study of workers' compensation (WC) subjects with lumbar arthrodesis and randomly selected controls to evaluate multiple objective outcomes has not been previously published. METHODS: A total of 725 lumbar fusion cases were compared to 725 controls who were randomly selected from a pool of WC subjects with chronic low back pain diagnoses with dates of injury between January 1, 1999 and December 31, 2001. The study ended on January 31, 2006. Main outcomes were reported as RTW status 2 years after the date of injury (for controls) or 2 years after date of surgery (for cases). Disability, reoperations, complications, opioid usage, and deaths were also deter-mined. RESULTS: Two years after fusion surgery, 26% (n = 188) of fusion cases had RTW, while 67% (n = 483) of nonsurgical controls had RTW (P ≤ 0.001) within 2 years from the date of injury. The reoperation rate was 27% (n = 194) for surgical patients. Of the lumbar fusion subjects, 36% (n = 264) had complications. Permanent disability rates were 11% (n = 82) for cases and 2% (n = 11) for nonoperative controls (P ≤ 0.001). Seventeen surgical patients and 11 controls died by the end of the study (P = 0.26). For lumbar fusion subjects, daily opioid use increased 41% after surgery, with 76% (n = 550) of cases continuing opioid use after surgery. Total number of days off work was more prolonged for cases compared to controls, 1140 and 316 days, respectively (P < 0.001). Final multi-variate, logistic regression analysis indicated the number of days off before surgery odds ratio [OR], 0.94 (95% confidence interval [CI], 0.92-0.97); legal representation OR, 3.43 (95% CI, 1.58-7.41); daily morphine usage OR, 0.83 (95% CI, 0.71-0.98); reoperation OR, 0.42 (95% CI, 0.26-0.69); and complications OR, 0.25 (95% CI, 0.07-0.90), are significant predictors of RTW for lumbar fusion patients. CONCLUSION: This Lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a WC setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor RTW status.

Correlation between screening for obstructive sleep apnea using a portable device versus polysomnography testing in a commercial driving population.

OBJECTIVE: To compare the accuracy of portable monitoring for obstructive sleep apnea (OSA) with polysomnography (PSG) in commercial drivers. METHODS: A consecutive case series of drivers were screened for OSA using recent validated consensus conference criteria at a single occupational medicine clinic; those screening positive were tested with a portable OSA screening device while awaiting PSG. RESULTS: Three hundred forty-six drivers were screened and 34 completed PSG and portable monitoring. Comparing the portable device to PSG at a definition of OSA as an apnea hypopnea index (AHI) >or=15, positive predictive value is 0.64 with a 0.87 negative predictive value. Positive likelihood ratio is 4.20. Linear regression model found statistically significant relationship (P = 0.0004) between the portable device and PSG AHI values. CONCLUSION: Although not perfect, portable monitoring may be useful in further stratifying risk in drivers who have a high probability of having OSA.

Consensus criteria for screening commercial drivers for obstructive sleep apnea: evidence of efficacy.

OBJECTIVE: To validate the recently published consensus criteria for screening commercial drivers for obstructive sleep apnea (OSA). METHODS: A large, consecutive case series of commercial drivers was screened for OSA at a single occupational medicine clinic and those screening positive were referred for overnight polysomnography. RESULTS: One hundred ninety (13%) of 1443 individuals having commercial motor vehicle driver examinations screened positive for OSA. None of these would have been detected if the only screening were the questions on the current Commercial Driver Medical examination form. One hundred thirty-four underwent polysomnography, and of those 94.8% had OSA, which is the best estimate of the positive predictive value of these consensus criteria in a population of truck drivers. CONCLUSION: The proposed screening criteria have a high positive predictive value in this population. This study lends support for the requirement to screen for OSA in commercial drivers.

Failure to communicate: how terminology and forms confuse the work ability/disability evaluation process.

OBJECTIVE: To describe the current confusion in physician communication of patient work ability to insurers and employers. BACKGROUND: Many medical conditions cause patients difficulty with resuming their normal work activities. Employers and insurers frequently ask physicians for information on patient's work ability. METHODS: A narrative review of the current status of physician communication to employers and insurers. RESULTS: Physicians frequently fail to understand the terms risk, capacity, and tolerance. Also, the forms sent to physicians by insurers and employers are themselves a problem. CONCLUSION: Physicians need to be educated in work ability assessment, and the forms used for communication need to be standardized.