Code of Colorado Regulations
1100 - Department of Labor and Employment
1101 - Division of Workers' Compensation
7 CCR 1101-3 R17 Ex 05 - Rule 17, Exhibit 5 - CUMULATIVE TRAUMA CONDITIONS MEDICAL TREATMENT GUIDELINES
Current through Register Vol. 47, No. 17, September 10, 2024
A. INTRODUCTION
This document has been prepared by the Colorado Department of Labor and Employment, Division of Workers' Compensation (Division) and should be interpreted within the context of guidelines for physicians/providers treating individuals qualifying under Colorado's Workers' Compensation Act as injured workers with cumulative trauma conditions.
Although the primary purpose of this document is advisory and educational, these guidelines are enforceable under the Workers' Compensation Rules of Procedure, 7 CCR 1101-3. The Division recognizes that acceptable medical practice may include deviations from these guidelines, as individual cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of professional care.
To properly utilize this document, the reader should not skip nor overlook any sections.
B. GENERAL GUIDELINES PRINCIPLES
The principles summarized in this section are key to the intended implementation of all Division of Workers' Compensation guidelines and critical to the reader's application of the guidelines in this document.
The practitioner should understand all of the physical demands of the patient's job position before returning the patient to full duty and should request clarification of the patient's job duties. Clarification should be obtained from the employer or, if necessary, from including, but not limited to, an occupational health nurse, occupational therapist, vocational rehabilitation specialist, an industrial hygienist, or another professional.
* Consensus means the judgment of experienced professionals based on general medical principles. Consensus recommendations are designated in the guidelines as "generally well-accepted," "generally accepted," "acceptable/accepted," or "well-established."
* "Some evidence" means the recommendation considered at least one adequate scientific study, which reported that a treatment was effective. The Division recognizes that further research is likely to have an impact on the intervention's effect.
* "Good evidence" means the recommendation considered the availability of multiple adequate scientific studies or at least one relevant high-quality scientific study, which reported that a treatment was effective. The Division recognizes that further research may have an impact on the intervention's effect.
* "Strong evidence" means the recommendation considered the availability of multiple relevant and high-quality scientific studies, which arrived at similar conclusions about the effectiveness of a treatment. The Division recognizes that further research is unlikely to have an important impact on the intervention's effect.
All recommendations in the guideline are considered to represent reasonable care in appropriately selected cases, irrespective of the level of evidence or consensus statement attached to them. Those procedures considered inappropriate, unreasonable, or unnecessary are designated in the guideline as "not recommended."
C. DEFINITIONS AND MECHANISMS OF INJURY
Cumulative trauma related conditions (CTC) of the upper extremity comprise a heterogeneous group of diagnoses which include numerous specific clinical entities including disorders of the muscles, tendons and tendon sheaths, nerves, joints and neurovascular structures.
The terms "cumulative trauma disorder", "repetitive motion syndrome", "repetitive strain injury", "myofascial pain" and other similar nomenclatures are umbrella terms that are not acceptable, specific diagnoses. The health care provider must provide specific diagnoses in order to appropriately educate, evaluate, and treat the patient. Examples include: de Quervain's disease, cubital tunnel syndrome, and lateral/medial epicondylitis (epicondylalgia). Many patients present with more than one diagnosis, which requires a thorough upper extremity and cervical evaluation by the health care provider. Furthermore, there must be a causal relationship between work activities and the diagnosis (See Section D.3 Initial Diagnostic Procedures, Medical Causation Assessment). The mere presence of a diagnosis that may be associated with cumulative trauma does not presume work-relatedness unless the appropriate work exposure is present.
Mechanisms of injury for the development of cumulative trauma related conditions have been controversial. However, repetitive awkward posture, force, vibration, cold exposure, and combinations thereof are generally accepted as occupational risk factors for the development of cumulative trauma related conditions.
Evaluation of cumulative trauma related conditions require an integrated approach that may include ergonomics assessment, clinical assessment, past medical history and psychosocial evaluation on a case-by-case basis.
The normal working age population may have non-specific pain complaints that require minimum treatment and may be considered part of the normal aging process. When pain continues or a complete history indicates a potential for other diagnoses, a medical workup may be necessary to screen for other diseases. However, in cases where there is no specific diagnosis and corresponding work related etiology, the work-up should generally be performed outside of the workers' compensation system.
D. INITIAL DIAGNOSTIC PROCEDURES
The Division recommends the following diagnostic procedures be considered, at least initially, the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Standard procedures that should be utilized when initially diagnosing a work-related upper extremity complaint are listed below.
History-taking and physical examination are generally accepted, well-established and widely used procedures that establish the foundation for subsequent stages of diagnostic and therapeutic procedures. When findings of clinical evaluations and those of other diagnostic procedures are not complementing each other, the objective clinical findings should have preference. The medical records should reasonably document the following:
Patient-reported outcomes, whether of pain or function, are susceptible to a phenomenon called response shift. Response shift refers to changes in self-evaluation, which may accompany changes in health status. Patient self-reports may not coincide with objective measures of outcome, due to reconceptualization of the impact of pain on daily function and internal recalibration of pain scales. Response shift may obscure treatment effects in clinical trials and clinical practice, and it may lead to apparent discrepancies in patient-reported outcomes following treatment interventions. While methods of measuring and accounting for response shift are not yet fully developed, understanding that the phenomenon exists can help clinicians understand what is happening when some measures of patient progress appear inconsistent with other measures of progress.
Assess the individual's ability to perform job duties. This frequently includes a job site evaluation including an ergonomic assessment as well as the patient's description of the job duties. Job title alone is not sufficient information. The clinician is responsible for documenting specific information regarding repetition, force, other risk factors, and duration of employment. Refer to risk factors as listed in Section D.3.d Risk Factors Definitions Table and Section D.3.e Diagnosis-Based Risk Factors Table. A formal job site evaluation may be necessary. A formal job site evaluation may not be necessary when the physician is intimately familiar with the job position and associated work activities and there are no new job alterations.
Information should be obtained regarding other employment, sports, recreational, and avocational activities that might contribute to or be impacted by the cumulative trauma condition. Activities such as video gaming, smartphone use, crocheting/needlepoint, baseball/softball, playing musical instruments, home computer operation, golf, tennis, and gardening are included in this category. Duration of these activities should be documented. In most cases, the duration of these activities will be less than three hours per day, the minimum necessary to meet the causation standard. Therefore, these activities will not be considered major contributions to the medical condition.
Behavioral adaptations to symptoms should be documented.
The evaluation of any upper extremity complaint should begin at the neck and upper back and then proceed down to the fingers and include the contralateral region. It should include evaluation of vascular and neurologic status, and describe any dystrophic changes or variation in skin color or turgor. A description of the patient's general posture (e.g., neck rotation, shoulder depression, spine kyphosis), and body mass index [BMI] should be documented. Additional physical exam components may be necessary based on past medical history.
A neurological examination typically includes bilateral assessments of pinprick, 2 point sensation as applicable, motor strength and reflexes. These assessments of the upper extremities including a vascular assessment will provide information regarding polyneuropathic processes such as diabetic neuropathy. Vibratory sense and Achilles reflexes are frequently lost in diabetic neuropathy. Decreased response to cold temperature or pain response to cold temperature has been related to radicular findings in the spine as discriminated from axial pain. To confirm a reported hypoalgesic area, some examiners may choose to complete multiple tests that may be done with the patient's eyes closed:
Refer to the following Physical Examination Findings Reference Tables for details.
|
DIAGNOSIS |
SYMPTOMS |
SIGNS (Required Findings) |
|
Aggravated Osteoarthritis of the Wrist |
Pain usually in the carpometacarpal joints; or in metacarpophalangeal joints. |
At least one of the following: * Positive grind test resulting in pain; crepitus; * Subluxation of the metacarpal may be induced in advanced cases; * Swelling; * Reduced motion; * Angular deformities; * Tenderness with palpation of thumb metacarpophalangeal or carpometacarpal joint. |
|
de Quervain's Disease |
Tenderness over the first dorsal extensor compartment (anatomical snuff box). |
At least one of the following: * Pain worsened by resisted thumb abduction and/or extension with or without resistance; * Positive Finkelstein's test. |
|
Epicondylitis-Lateral (Epicondylalgia) |
Elbow pain over the lateral epicondyle increased with gripping. |
Tenderness to palpation at/near lateral epicondyle and pain over the lateral epicondyle and/or extensor mass of the forearm with one of the following maneuvers: |
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* Active or resisted wrist extension; * Active or resisted middle finger extension; * Active or resisted supination. |
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Epicondylitis-Medial (Epicondylalgia) |
Elbow pain over the medial epicondyle. |
Tenderness to palpation at/near medial epicondyle and pain over the medial epicondyle and/or flexor mass of the forearm with one of the following maneuvers: * Active or resisted wrist flexion; * Active or resisted pronation. |
|
Extensor Tendon Disorders of the Wrist |
Pain localized to the affected tendon(s) worsened by wrist or finger extension. |
Pain and/or tenderness with active or resisted wrist/digit extension, specific to the extensor mechanism involved. |
|
Flexor Tendon Disorders of the Wrist |
Pain/tenderness localized to affected tendons. |
Reproduction of pain with active or resisted wrist/digit flexion or ulnar deviation specific to the flexor mechanism involved. |
|
Triangular Fibrocartilage Complex Tear (TFCC) |
Symptoms mainly on ulnar side of the wrist. |
Tenderness over the TFCC complex and localized pain, clicking, or findings of abnormal motion with one of the following movements: * Forced supination and pronation with axial pressure on an ulnar deviated wrist; * The patient pushes up from a seating position using the hand, and/or * Ballottement of the distal ulna with the wrist supinated causes abnormal motion as compared to the asymptomatic side. |
|
Trigger Finger |
Difficulty flexing the finger with a catching or triggering sensation. |
One of the following: * Tenderness at the A-1 pulley with finger flexion; * Triggering of the digit; * Difficulty flexing and extending the finger with a palpable nodule. |
|
DIAGNOSIS |
SYMPTOMS |
SIGNS (Required Findings) |
|
Carpal Tunnel Syndrome |
Specific paresthesias in 2 of the following digits: thumb, index, and middle finger. |
At least one of the following: * Positive Phalen's sign; |
|
Shaking of the hand (to relieve symptoms) and nocturnal symptoms are common. |
* Positive Tinel's sign over the carpal tunnel; * Positive closed fist test; * Positive compression test; * Thenar atrophy may be present later in course; * Weakness of abductor pollicis brevis; * Sensory loss to pinprick, light touch, two-point discrimination or Semmes-Weinstein monofilament tests in a median nerve distribution. No loss of sensation in the central palm. |
|
|
Cubital Tunnel Syndrome |
Paresthesias or dull, aching sensations in the 4th and 5th digits (ring and small fingers) and discomfort near the medial aspect of the elbow. |
Paresthesias or dull, aching in the 4th and 5th digits and at least one of the following exam findings: * Diminished sensation of the fifth and ulnar half of the ring fingers, which may sometimes include sensory loss to pinprick, light touch, two-point discrimination or Semmes-Weinstein monofilament tests in an ulnar nerve distribution; * Positive elbow flexion/ulnar compression test; * Later stages manifested by: intrinsic atrophy and ulnar innervated intrinsic weakness; Wartenberg's sign; Froment's sign. |
|
Guyon Canal (Tunnel) Syndrome |
Paresthesias in the 4th and 5th digits (ring and small fingers) without proximal ulnar complaints. |
At least one of the following exam findings: * Positive Tinel's at hook of hamate; * Numbness or paresthesias of the palm surface of the ring and small fingers; * Decreased strength of the adductor pollicis, abductor digiti minimi, and/or lumbricals. |
|
Posterior Interosseous Nerve Entrapment (PIN) |
Weakness of finger and thumb extension |
Weakness or inability to extend fingers, thumb or wrist in neutral or ulnar deviation; |
|
Pronator Syndrome |
Pain/paresthesias in the median nerve distribution distal to the elbow. |
Paresthesias in the median nerve distribution and at least one of the following reproduces median nerve symptoms: |
|
Pronator Syndrome, continued |
* Resisted pronation with elbow flexed at 90 degrees or elbow extended; * Positive Tinel's at the proximal edge of the pronator teres muscle over the median nerve. |
|
|
Radial Tunnel Syndrome |
Pain over the lateral posterior forearm. May occur in conjunction with and must be distinguished from lateral epicondylitis. May include paresthesias over the dorsal radial hand and wrist. |
The following two elements are required: * Tenderness over the radial nerve near the proximal edge of the supinator muscle; * Resisted supination or resisted middle finger extension with the forearm pronated and extended reproduces symptoms. |
Laboratory tests are generally accepted, well-established and widely used procedures. Patients should be carefully screened at the initial exam for signs or symptoms of diabetes, hypothyroidism, arthritis, and related inflammatory diseases. The presence of concurrent disease does not refute work-relatedness of any specific case. This frequently requires laboratory testing. In one study of patients with cumulative trauma conditions (other than carpal tunnel syndrome) who have been seen by specialists, 3% were diagnosed with diabetes, 6% with hypothyroidism, and 9% with a chronic inflammatory disease including spondyloarthropathy, arthritis, and systemic lupus erythematosus. Up to two thirds of the patients were not aware of their concurrent disease. When a patient's history and physical examination suggest infection, metabolic or endocrinologic disorders, tumorous conditions, systemic musculoskeletal disorders (e.g., rheumatoid arthritis or ankylosing spondylitis), or problems potentially related to medication (e.g., renal disease and non-steroidal anti-inflammatory medications), then laboratory tests, including, but not limited to the following can provide useful diagnostic information:
The Division recommends that the workers' compensation carrier cover initial lab diagnostic procedures to ensure that an accurate diagnosis and treatment plan is established. When the authorized treating provider has justification for the test, insurers should cover the costs. Laboratory testing may be required periodically to monitor patients on chronic medications.
General Principles of Medical Causation Assessment
The clinician must determine if it is medically probable (greater than 50% likely or more likely than not) that the need for treatment in a case is due to a work-related exposure or injury. Treatment for a work-related condition is covered when:
The medical causation assessment for cumulative trauma conditions is not a substitute for a legal determination of causation/compensability by an Administrative Law Judge. Legal causation is based on the totality of medical and non-medical evidence, which may include age, gender, pregnancy, BMI, diabetes, wrist depth/ratio, and other factors based on epidemiologic literature.
The steps in a medical causation assessment for cumulative trauma conditions are:
Step 1: Make a specific and supportable diagnosis. Remember that cumulative trauma, repetitive strain and repetitive motion are not diagnoses. Examples of appropriate diagnoses include: specific tendinopathies, strains, sprains, and mono-neuropathies. Refer to Section F Specific Musculoskeletal Disorders and Section G Specific Peripheral Nerve Disorders for the specific findings of common cumulative trauma conditions. Less common cumulative trauma conditions not listed specifically in these Guidelines are still subject to medical causation assessment.
Step 2: Determine whether the disorder is known to be or is plausibly associated with work. The identification of work-related risk factors is largely based on comparison of the patient's work tasks with risk factors (as described in Section D.3.a Foundations for Evidence of Occupational Relationships and Section D.3.b Using Risk Factors to Determine Causation).
Step 3: Interview the patient to find out whether risk factors are present in sufficient degree and duration to cause or aggravate the condition. Consider any recent change in the frequency or intensity of occupational or non-occupational tasks. In some cases, a formal job site evaluation may be necessary to quantify the actual ergonomic risks. Refer to Section E.6.c Job Site Evaluations.
Step 4: Complete the required match between the risk factors identified in Section D.3.d Risk Factors Definitions Table and the established diagnosis using the system described in Section D.3.b. Remember that preexisting conditions may be aggravated by, or contribute to, exposures lower than those listed on the table. Those preexisting conditions must be determined by the authorized treating physician based on physiologic plausibility.
Step 5: Determine whether a temporal association exists between the workplace risk factors and the onset or aggravation of symptoms.
Step 6: Identify non-occupational diagnoses, such as rheumatoid arthritis, obesity, diabetes, as well as avocational activities, such as golf and tennis. This information can affect the medical causation assessment. It may be applicable when exposure levels are low and the case does not meet evidence-based criteria.
All results described in this section are a result of a thorough review of the epidemiologic literature available at the time of these Guidelines. One limitation of an epidemiological literature review is that studies rely most heavily upon healthy worker populations and may not reflect the worker population with other concurrent disease or comorbidities. No single epidemiological study fulfills all the criteria for medical causation. Consequently, individual variability lies outside the scope of epidemiological studies and must be addressed by a physician who takes into account not only force, posture, and repetition but also other premorbid risk factors.
The clinician is responsible for documenting specific information regarding the force, posture, repetition, and other risk factors as listed in Section D.3.d Risk Factors Definitions Table. Job title alone is not sufficient to determine the risk factors. A job site evaluation is usually necessary.
Many studies have been completed in industrial settings and focus on cumulative trauma conditions or upper extremity complaints in relationship to work exposures. The studies vary in several ways that directly affect the interpretation of their results. Studies that provide the strongest evidence have 1) an accepted clinical exam confirming the diagnosis and 2) work exposures validated by direct observation or questionnaires that were correlated with direct observation. Well-done, prospective, longitudinal studies (cohort studies) are preferred. However, for uncommon disorders, these studies may not be able to identify all factors contributing to causation. These Guidelines consider other large prevalence and incidence studies which meet minimum quality criteria and use reliable questionnaires for self-reported exposure.
Many studies report symptoms rather than diseases. These studies are useful for ergonomic research or as pilot studies but do not directly affect the evidence level for causation. They are mentioned, when useful, as indirect evidence. If multiple well-done symptom studies show no increase in symptomatology with specific activities, it follows that there is very little chance that the studied exposure causes disease.
In addition, there are a few studies which address less common musculoskeletal diagnoses or peripheral nerve conditions other than carpal tunnel syndrome, such as posterior interosseous nerve entrapment and pronator syndrome. In these cases, these Guidelines rely upon studies which report the risks for related conditions.
Many of the original studies identifying diagnosable cumulative trauma conditions were performed in manufacturing industries and meat, fish and poultry processing companies. In these industries, most workers are exposed to highly repetitive mono-task jobs which frequently involve a forceful grip, awkward postures, vibration, and cold environments. The evidence for increased disorders when these multiple risk factors are present is compelling. Research attempting to define clear, threshold exposure limits for increased risk from isolated tasks and/or intermittent exposures has less consistent results.
The quality of keyboarding studies is highly variable. Most of the studies rely on self-report. Self-report appears to approximately double the actual time spent using the keyboard. Some studies show distortion highest in the medium range of use. There appears to be less inflation for self-reported mouse use. Fortunately, a few studies have provided more objective keyboard use data.
The group of studies now available provides good evidence that keyboarding in a reasonable ergonomic posture (wrist with 30 degrees or less of extension and 15 degrees or less of radial deviation) up to 7 hours per day under usual conditions is very unlikely to cause carpal tunnel syndrome or other upper extremity disorders. This conclusion is based on studies of carpal tunnel pressure under a variety of typing and wrist positions as well as a number of studies of workers who keyboard on a regular basis. Clinicians may determine in a particular case that there is a relationship based on the ergonomic conditions or on excessive typing, such as more than 7 hours per day of essentially uninterrupted keyboard use or full-day court reporting.
There is some evidence that mouse use appears to be associated with carpal tunnel syndrome and related symptoms with 4 hours or greater of continuous use per day. Studies of pressure within the carpal tunnel indicated that pressures may rise to levels which could affect the median nerve when the mouse is being dragged or clicked. Again, the actual ergonomics of the work place should be considered for each individual patient before making a final causation decision.
There is a large variety in assessment strategies for lower quality studies. Examples include:
Most studies were unable to truly assess repetition alone. Indirect evidence from a number of studies supports the conclusion that task repetition up to 6 hours per day unaccompanied by other risk factors is not causally associated with cumulative trauma conditions. Risk factors likely to be associated with specific CTC diagnostic categories include: extreme wrist or elbow postures; force including regular work with hand tools greater than 1 kg or tasks requiring greater than 50% of an individual's voluntary maximal strength; work with vibratory tools at least 2 hours per day; or cold environments.
The variability in study design presented a challenge for creating physiologically reasonable hour limits for the specific primary and secondary risk factors. These Guidelines define risk factor cutoff measures by selecting the strongest studies for specific risks and extrapolating measures. For example, 3/4 of a day exposure was translated to a 6 hour exposure. Exposure measures and groups extrapolated in this manner constitute the primary risk factor definitions used in these Guidelines.
Regarding secondary risk factors, the previous version of these Guidelines used a 4 hour exposure cutoff for determining physiologically acceptable limits based on:
No studies examined the relationship between the development of ganglion cysts and work activities. However, work activities, such as bending or twisting of the wrist repetitively, may cause an aggravation of existing ganglion cysts that interferes with function.
Aggravation of a pre-existing medically established diagnosis must be determined on an individual case basis. A comparison of the worker's specific job duties with usual activities of daily living and the occupational risk factors should contribute to the discussion.
Non-occupational exposures
Most studies demonstrate an association of cumulative trauma conditions with older age; high BMI; the presence of other upper extremity musculoskeletal diagnoses; related diseases such as auto-immune conditions, diabetes, hypothyroidism and rheumatologic diseases; and psychosocial issues including relationships with supervisors. The influence of these non-occupational risk factors varies according to the specific diagnoses involved. These additional factors may contribute to the disorder and may impact legal causation, but they do not negate the actual evidence from the defined risk factors supporting a specific work related condition.
Use Section D.3.d Risk Factors Definitions Table and Section D.3.e Diagnosis-Based Risk Factors Table with the following directions to formulate the causation of diagnoses established as cumulative trauma conditions.
The physician should perform the following:
Step 1. Determine the diagnosis.
Using the history, physical examination and supporting studies, a medical diagnosis must be established. Refer to Section F Specific Musculoskeletal Diagnosis and Section G Specific Peripheral Nerve Diagnosis. Less common cumulative trauma conditions not listed specifically in these Guidelines are still subject to medical causation assessment.
Step 2. Clearly define the job duties of the worker.
Do not rely solely on the employer's description of job duties. The worker's description of how they actually perform the duties is extremely important. Job site evaluations are always appropriate, but they are sometimes unnecessary when the physician can identify the job duty that appears to be causing the symptoms and provide a method for ergonomically correcting the activity. Job site evaluations performed to identify risk factors should always include appropriate ergonomic alterations. It may not be possible to recommend ergonomic alterations in industrial settings where the employer is incapable of making changes or ergonomic changes are not feasible.
Step 3. Compare the worker's duties with the Primary Risk Factor Definition Table.
Hours are calculated by adding the total number of hours per day during which the worker is exposed to the defined risk. Breaks, time performing other activities, and inactive time are not included in the total time. When the employee meets the definition for a sole Primary Risk Factor and the risk factor is physiologically related to the diagnosis, it is likely that the worker will meet causation for the cumulative trauma condition. When the Primary Risk Factor identified is not physiologically related to the diagnosis, causation will not be established at this point. The provider then needs to consider Step 4.
Step 4. Compare the worker's risk factors identified in Step 2 with the Secondary Risk Factor definitions on the Risk Factor Definition Table. If secondary risk factors are identified, proceed to the Diagnosis Based Risk Factor Table.
When no Primary Risk Factors are present but one or more Secondary Risk Factors are found on the Risk Factor Definitions Table, proceed to the Diagnosis Based Risk Factor Table. Elements in this table are listed under the strength of evidence headings. This includes a category for strength of evidence for risks that have been demonstrated not to be related to the diagnosis. Consult the diagnostic category pertaining to the worker. For a number of less common diagnoses, little direct research has been done that meets the quality standards. Therefore, the risk factors for these diagnoses use the risk factors from physiologically related, better researched diagnostic titles. Initially, check the evidence statements for or against causation based on the secondary risks identified previously. If the Diagnosis Based Risk Factor table establishes a match between the Secondary Risk Factor(s) and other job duties using the evidence based columns for the established diagnosis, the case is likely work-related. If none of the evidence categories match the worker, causation based solely on epidemiological evidence from research has not been established.
Step 5. If an evidence-based medical causation relationship, based on Steps 1-4, has not been established and the worker has one Secondary Risk Factor from Section D.3.d Risk Factors Definitions Table, the physician may consult the last column of Section D.3.e Diagnosis-Based Risk Factors Table entitled "Additional Risk Factors." This category describes medically accepted physiological risk factors for the diagnosis and risk factors which demonstrated an association with the diagnosis in lower quality studies that did not meet the standards of evidence. Some of the additional risk factors have less clear definitions due to lack of definition in the lower quality studies. These risk factors were added only when the medical professionals on the multi-disciplinary task force agreed they were physiologically plausible. When a Secondary Risk Factor has been identified that does not meet the evidence based definitions Section D.3.e Diagnosis-Based Risk Factors Table, physicians may use the other "Additional Risk Factors," as appropriate, to establish the presence of combined risk factors. The worker must have met at least one of the Secondary Risk Factor definitions from the Risk Factors Definition Table and that risk factor must be physiologically related to the diagnosis, in order to use the "Additional Risk Factors" in the Diagnosis Based Risk Factor Table. Additional Risk factors that duplicate the conditions in the Secondary Risk Factor identified for the case may not be used. Any conclusions using this methodology are not strictly evidence-based and therefore the physician should include a discussion of why the Additional Risk Factors are pertinent in the particular case.
Algorithmic Steps for Medical Causation Assessment continued
*In the case of an aggravation or exacerbation of a pre-existing condition, the provider will need to make an individualized causation decision based on the presence of other accompanying conditions.
|
Category |
As a Primary Risk Factor |
Secondary Risk Factor |
|
Force and Repetition/Duration |
6 hrs. of: use of 2 pounds pinch force or 10 pounds hand force 3 times or more per minute. |
3 hrs. of: use of 2 pounds pinch force or 10 pounds hand force 3 times or more per minute. |
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6 hrs. of: lifting 10 lbs > 60x per hour. |
3 hrs. of: lifting 10 lbs > 60x per hour. |
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6 hrs. of: use of hand held tools weighing 2 lbs or greater. |
3 hrs. of: use of hand held tools weighing 2 lbs or greater. |
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|
Awkward Posture and Repetition/Duration |
4 hrs. of: Wrist flexion > 45 degrees, extension > 30 degrees, or ulnar deviation > 20 degrees. |
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6 hrs. of: Elbow - flexion > 90 degrees. |
3 hrs. of: Elbow - flexion > 90 degrees. |
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4 hrs. of: Supination/pronation with task cycles 30 seconds or less or posture is used for at least 50% of a task cycle. |
3 hrs. of: Supination/pronation of 45° with power grip or lifting. |
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Computer Work |
Note: Up to 7 hours per day at an ergonomically correct workstation is not a risk factor. Refer to Section H. 6.e Ergonomic Considerations Table for definition of ergonomic risk factors. > 4 hrs. of: Mouse use. |
|
|
Use of handheld vibratory power tools and Duration |
6 hrs. for more common types of vibration exposure. |
2 hrs. when accompanied by other risks. |
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Cold Working Environment |
Ambient temperature of 45F or less for 4 hrs. or more, such as handling frozen foods that are 10 degrees. This risk factor does not stand alone. It is used in combination with other secondary risk factors. Refer to the following Diagnostic-Based Risk Factors Table. |
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DIAGNOSIS-BASED RISK FACTORS |
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Hours are calculated by totaling the cumulative exposure time to the risk over an 8 hour day. Breaks or periods of inactivity or performing other types of work tasks are not included. Unless the hours are specifically stated below, "combination" of factors described below uses the Secondary Risk Factor Definitions from the Risk Factor Definition Table. |
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|
DIAGNOSIS |
Evidence FOR Specific Risk Factors |
Evidence AGAINST Specific Risk Factors |
Non-Evidence-Based Additional Risk Factors to Consider. These factors must be present for at least 4 hours of the work day, and may not overlap evidence risk factors.¹ |
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Strong Multiple high quality studies |
Good One high quality study or multiple adequate studies |
Some One adequate study |
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Aggravated Osteoarthritis of the Thumb, Carpometacarpal (CMC) and Wrist |
No Quality Evidence Available |
Work studies support repetitive thumb movement 20 times per minute in women contributing to CMC arthritis. Awkward Posture (depending on the joint involved). Repetition of activities affecting the joint involved for 4 hrs. Prior Injury. |
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|
Carpal Tunnel Syndrome |
Combination of force, repetition, and vibration.2,4 |
Wrist bending or awkward posture for 4 hrs. |
High repetition defined as task cycle times of less than 30 seconds or performing the same task for more than 50% of the total cycle time.5 |
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Carpal Tunnel Syndrome, continued |
Combination of repetition and force for 6 hours. Combination repetition and forceful tool use with awkward posture for 6 hours. Combination force, repetition, and awkward posture. Combination of 2 pound pinch or 10 pound hand force 3 times or more per minute for 3 hours. |
Mouse use more than 4 hours. Combination cold and forceful repetition for 6 hours - Frozen food handling. |
Good evidence -Keyboarding less than or equal to 7 hrs. in good ergonomic position IS NOT RELATED. Good evidence-Repetition alone less than or equal to 6 hrs. IS NOT RELATED. |
Tasks using a hand grip. Extreme wrist radial/ulnar positions or elbows in awkward postures. |
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|
Cubital Tunnel Syndrome |
Combination forceful tool use, repetition and probably posture for 6 hrs- Holding a tool in position with repetition. |
Wrist bending and/or full elbow flexion/extension, repetition for 4 hours, vibration.3 Repetitive pronation of forearm.³ Sustained pressure at the cubital tunnel. |
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DeQuervain's Disease |
Combination force, repetition, & posture.2,4 |
Wrist in ulnar deviation.³ Repetitive thumb abduction and extension.3 Wrist bending in extreme postures.3 Precise hand motions e.g., dental hygienists. Repetitive hitting. |
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Epicondylitis Lateral |
Combination - awkward posture (forearm supination past 45 degrees) and forceful lifting.2 Combination force and possible awkward posture - study used repetition and turning and screwing. Combination forearm pronation 45° or greater with power grip or lifting for 3 hours per day. |
Combination of wrist bending for 4 hours and rotation the forearm for 2 hours. Combination repetition and awkward posture including static posture. |
Some evidence keyboard use IS NOT RELATED. |
Wrist posture in extension and repetitive supination of the forearm and/or elbow extension.³ |
|
|
Epicondylitis Medial |
Combination - force & repetition,4 force and wrist and hand repetition. |
Combination of wrist bending for 4 hours and rotation the forearm for 2 hours. |
Some evidence keyboard use IS NOT RELATED. |
Wrist posture in flex and repetitive pronation and/or elbow extension.³ |
|
|
Extensor tendon disorders of the Wrist |
Combination - force & repetition,4 force and wrist and hand repetition.2 Combination - forceful exertion and repetition 6 hours. Combination force, repetition, & posture.2, 4 |
Sustained tool use. Awkward posture.³ No relationship to keyboard use is expected in a good ergonomic workstation. Wrist bending in extreme postures.3 Repetitive hitting. |
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Flexor tendon disorders of the Wrist |
Combination force, repetition, & posture.2, 4 |
Sustained tool use. Awkward posture.3 No relationship to keyboard use is expected in a good ergonomic workstation. Wrist bending in extreme postures.3 Repetitive hitting. |
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|
Guyon Canal |
No Quality Evidence Available. |
Ulnar wrist posture and flexion. Direct pressure on the wrist. |
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Posterior Interroseous Nerve Entrapment |
Refer to lateral epicondylitis section above for indirect evidence. No specific evidence available. |
Ulnar wrist posture and flexion. Direct pressure on the wrist. |
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|
Pronator Syndrome |
Refer to medial epicondylitis section above for indirect evidence. No specific evidence available. |
Ulnar wrist posture and flexion. Direct pressure on the wrist. |
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|
Trigger Finger |
Hand tool use - 6 hours. |
Repeated digital flexion. |
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|
Radial Tunnel Syndrome |
Repetition and force - force of 1 kg with cycle time < 1 minute or awkward posture (static posture) elbow > 90 degrees. |
Repetitive Supination. Extension of the elbow from 0 to 45 degrees. |
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|
Triangular Fibrocartilage Compression |
No Quality Evidence Available. |
Usually from traumatic hyperextension which may become symptomatic over time. Wrist posture in extension and repetitive supination of the forearm and/or elbow extension. For occupational, usually unilateral with ulnar wrist pain while supinating and extending the wrist as part of the regular work duty. |
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|
1. Physiological risk factors are those generally agreed upon by the medical community to cause the specific condition described. Other risk factors described are those identified in lower quality studies that are possibly related. These are consensus risk factors. 2. Combined factors refer to the Secondary Risk Factor definitions found in the Risk Factor Definition Table. 3. Caution: These additional risk categories may not be used when awkward posture, using a similar definition, has been cited as a Secondary Risk Factor. 4. Evidence rated as strong by National Institute for Occupational Safety and Health (NIOSH) 1997 criteria are placed in the "good" category because the NIOSH strong evidence definition matches the Colorado "good" level of evidence requiring multiple adequate studies. 5. Due to small case size and a definition of low force/high repetition jobs that likely included many jobs qualifying for a force risk from the "Risk Definitions" table, this study does not support repetition as a sole risk factor. |
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Cumulative trauma staging is used to rate permanent impairment of specific disorders when no other rating is available in the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment, 3rd Edition Revised. Specific diagnoses must be provided prior to the assignment of an impairment rating. Remember that the terms "cumulative trauma disorder," "repetitive motion syndrome," "repetitive strain injury," and similar nomenclatures are umbrella terms that are not acceptable diagnoses. Cumulative Trauma Conditions can be staged only after taking a thorough history and performing an appropriate physical examination (see Section D.1 History-Taking and Physical Examination). The factors included in the Cumulative Trauma Condition Staging Matrix are:
A = History and Physical Examination.
B = Response to Modification of Specific Aggravating Factors.
C = Activities of Daily Living.
It is expected that objective signs on physical examination will correlate with subjective symptoms. The signs and symptoms are staged in the Cumulative Trauma Staging Matrix as:
Stage 1 = Minimal.
Stage 2 = Mild.
Stage 3 = Moderate.
Stage 4 = Severe.
Stages 3 and 4 frequently may be associated with other secondary symptoms of chronic pain such as sleep alteration or depression.
When using the Staging Matrix for impairment rating at maximum medical improvement (MMI), assignment of the patient to a stage should be based primarily on limitations in ADLs and history and physical examination findings. The response to modification of specific aggravating activities may be used to aid the rater in choosing a number within the available rating range.
The staging number chosen from the "Impairment Grades at MMI" row is to be used as a multiplier in conjunction with the AMA Guides to the Evaluation of Permanent Impairment, 3rd Edition Revised, Chapter 3 and Table 17 to determine the impairment rating for each specific diagnosis. The primary presenting joint that corresponds to each specific established diagnosis should be rated. Descriptions of painful conditions without clear physiologic findings may not be rated using this chart. Examples include pain in the elbow or other upper extremity joint and myofascial pain disorder.
The staging matrix is only used to rate a cumulative trauma condition diagnosis when there is no impairment rating under range of motion, specific diagnosis, and/or peripheral nerve injuries in the AMA Guides, 3rd Edition Revised. All impairment ratings from this table are provided in upper extremity terms and must be multiplied by the upper extremity total impairment rating for the appropriate joint found in Table 17 on page 48 of the AMA Guides, 3rd Edition Revised. The upper extremity rating is then converted to whole person. The table is not intended to distinguish between permanent partial disability paid under §§ 8-42-107(2) and -107(8), C.R.S. This information is also available in the Impairment Rating Tips Desk Aid #11.
Cumulative Trauma Staging Matrix
|
Stage 1 (Minimal) |
Stage 2 (Mild) |
Stage 3 (Moderate) |
Stage 4 (Severe) |
|
|
History and Physical Examination |
1 to 2 symptoms with signs identified on history and supported by physical examination with consistency of subjective and objective findings |
2 or more symptoms with signs identified and supported by physical examination with consistency of subjective and objective findings |
3 or more symptoms with signs identified and supported by the physical examination with consistency of subjective and objective findings |
3 or more symptoms with signs identified and supported by physical examination with consistency of subjective and objective findings |
|
AND |
AND |
AND |
AND |
|
|
Response to Modification of Specific Aggravating Factors |
Symptoms and/or signs improve or resolve with modification of specific aggravating activity |
Symptoms and/or signs may improve but will not resolve completely with modification of specific aggravating activity |
Symptoms and/or signs do not improve with modification of the specific aggravating activity but may improve with elimination of the specific aggravating activity |
Symptoms and/or signs do not improve with modification or elimination of the specific aggravating activity |
|
AND |
AND |
AND |
AND |
|
|
Activities of Daily Living (ADLs) |
Minimal problems with ADLs |
Noticeable aggravation by more difficult ADLs |
Significant interference with most ADLs |
Severe limitations of ADLs |
|
Impairment Grades at MMI (See Note below to obtain Multiplier) |
0-10% |
11-20% |
21-30% |
31-40% |
E. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES
One diagnostic imaging procedure may provide the same or distinct information as another procedure. Therefore, the prudent choice of a single diagnostic procedure, a complement of procedures, or a sequence of procedures will optimize diagnostic accuracy, maximize cost effectiveness (by avoiding redundancy), and minimize potential adverse effects to patients.
All diagnostic imaging procedures have a significant percentage of specificity and sensitivity for various diagnoses. None is specifically characteristic of a certain diagnosis. Clinical information obtained by history-taking and physical examination should be the basis for selection and interpretation of imaging procedure results.
Practitioners should be aware of the radiation doses associated with various procedures and provide appropriate warnings to patients. Coloradans have a background exposure to radiation, and unnecessary CT scans or X-rays increase the lifetime risk of cancer death.
When a diagnostic procedure, in conjunction with clinical information, provides sufficient information to establish an accurate diagnosis, the second diagnostic procedure will become a redundant procedure. At the same time, a subsequent diagnostic procedure can be a complementary diagnostic procedure if the first or preceding procedures, in conjunction with clinical information, cannot provide an accurate diagnosis. Usually, preference of a procedure over others depends upon availability, a patient's tolerance, and/or the treating practitioner's familiarity with the procedure.
This section does not include automated electrodiagnostic testing such as neurometers and portable automated electrodiagnostic devices. These testing devices are not adequate to determine peripheral neuropathies, radiculopathies, or unusual nerve compression syndromes and should not be used. Neurometers and portable electrodiagnostic testing devices may not be used to make a diagnosis and are not recommended in treatment settings. Refer also to Section E.5.a.i Electroneurometer and Section E.5.a.ii Portable Automated Electrodiagnostic Devices.
Because EDX studies may be negative early in the clinical course, they should be delayed until the patient has been symptomatic for 3 to 6 weeks. Refer to Sections F and G on specific diagnoses for details.
When polyneuropathy is suspected, it is prudent to perform electrodiagnostic testing in the lower extremities.
Radiographic imaging of the upper extremities is a generally accepted, well-established and widely used diagnostic procedure when specific indications based on history and/or physical examination are present. It should not be routinely performed for cumulative trauma injuries. It may be useful when clinical findings suggest a fracture, arthritis, avascular necrosis or ligament or cartilage injuries involving the carpals or pain persists after initial treatment. The mechanism of injury and specific indications for the radiograph should be listed on the request form to aid the radiologist and x-ray technician. For additional specific clinical indications, see Section F Specific Musculoskeletal Diagnosis, Testing and Treatment and Section G Specific Peripheral Nerve Diagnosis, Testing and Treatment.
MRI may show increased T2-weighted signal intensity of the common extensor tendon in lateral epicondylitis, but this is common in the asymptomatic contralateral elbow and not sufficiently specific to warrant the use of MRI as a diagnostic test for epicondylitis. MRI may be helpful to diagnose triangular fibrocartilage complex tears and other suspected ligament or bone pathology when clinical findings suggest these diagnoses. Its routine use for cumulative trauma conditions is not recommended.
CT is generally accepted and provides excellent visualization of bone. It is rarely needed for cumulative trauma conditions. When clinical findings suggest possible bone pathology it may be used to further evaluate bony masses and suspected fractures not clearly identified on radiographic window evaluation. Instrument scatter reduction software provides better resolution when metallic artifact is of concern.
Diagnostic Sonography is an accepted diagnostic procedure to rule out mass lesions. It is rarely appropriate for cumulative trauma condition diagnoses. However, it may be used to rule out ganglions, other space occupying lesions, and tendon injuries. It should not be used to diagnosis carpal tunnel syndrome. The performance of sonography is operator dependent, and is best when done by a specialist in musculoskeletal radiology.
Joint aspiration is a generally accepted, well-established and widely used procedure when specifically indicated and performed by individuals properly trained in these techniques. It is rarely indicated for cumulative trauma conditions but may be needed when history and/or physical examination are of concern for a septic joint, gout, or bursitis as well as for some acute injuries. Persistent or unexplained effusions may be examined for evidence of infection, rheumatologic, or inflammatory processes. The presence of fat globules in the effusion strongly suggests occult fracture.
These are generally accepted and well-established diagnostic procedures with selective use in the cumulative trauma conditions population but with more widespread use in subacute and chronic pain populations. Diagnostic testing procedures may be useful for patients with symptoms of depression, delayed recovery, chronic pain, recurrent painful conditions, disability problems, and for pre-operative evaluation. These procedures also have a possible predictive value for post-operative response. Psychological testing should provide differentiation between pre-existing depression versus injury caused depression, as well as post-traumatic stress disorder. Formal psychological or psychosocial evaluation should be performed on patients not making expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests. In addition to the customary initial exam, the evaluation of the injured worker should specifically address the following areas:
* Employment history;
* Interpersonal relationships - both social and work;
* Leisure activities;
* Current perception of the medical system;
* Results of current treatment;
* Perceived locus of control; and
* Childhood history, including abuse and family history of disability.
This information should provide clinicians with a better understanding of the patient, thus allowing for a more effective rehabilitation. The evaluation will determine the need for further psychosocial interventions. In those cases, a Diagnostic Statistical Manual for Mental Disorders (DSM) diagnosis should be determined and documented. An individual with a PhD, PsyD, or Psychiatric MD/DO credentials should perform initial evaluations, which are generally completed within 1 to 2 hours. When issues of chronic pain are identified, the evaluation should be more extensive and follow testing procedures as outlined in the Division's Chronic Pain Disorder Medical Treatment Guidelines.
* Frequency: 1 time visit for evaluation. If psychometric testing is indicated as a portion of the initial evaluation, time for such testing should not exceed an additional 2 hours of professional time.
These tests are not used to establish a diagnosis. They may be used to follow the progress of the patient, depending on their diagnosis or to conduct research.
Pinch and grip strength measurements are not generally accepted as a diagnostic tool for cumulative trauma conditions. Strength is defined as the muscle force exerted by a muscle or group of muscles to overcome a resistance under a specific set of circumstances. Pain, the perception of pain secondary to abnormal sensory feedback, and/or the presence of abnormal sensory feedback affecting the sensation of the power used in grip/pinch may cause a decrease in the force exerted and thereby not be a true indicator of strength. When a bell-shaped curve is present, these measures provide a method for quantifying strength that can be used to follow a patient's progress and to assess response to therapy. In the absence of a bell-shaped curve, clinical reassessment is indicated. These measurements may also be useful to determine an individual's fitness for duty or as a reassessment after therapy and/or surgery.
QST may be used as an assessment tool to monitor the patient's progress throughout treatment. Results of tests and measurements of sensory integrity are integrated with the history and review of systems findings and the results of other tests and measures. QST tests the entire sensory pathway, limiting its ability to localize a deficit precisely. It depends on the patient's report of perception and may not be objective. Cutaneous conditions may alter sensory thresholds.
QST may be useful for peripheral polyneuropathy but not for isolated nerve injury or compression syndromes. Although it is not useful diagnostically, it may be used post-operatively for surgically treated mononeuropathies.
These are generally well-accepted and are performed as part of a skilled assessment of the patient's capacity to return to work, his/her strength capacities, physical work demand classifications, and tolerance. The procedures in this subsection are listed in alphabetical order.
These may include isotonic, isometric, isokinetic and/or isoinertial measurements of movement; range of motion; endurance; or strength. Values obtained can include degrees of motion, torque forces, pressures, or resistance. Indications include determining validity of effort, effectiveness of treatment, and demonstrated motivation. These evaluations should not be used alone to determine return-to-work restrictions.
* Frequency: One time for evaluation, one for mid-treatment assessment, and one at final evaluation.
This is a comprehensive or modified evaluation of the various aspects of function as they relate to the worker's ability to return to work. Areas such as endurance, lifting (dynamic and static), postural tolerance, specific range of motion, coordination and strength, worker habits, employability, as well as psychosocial aspects of competitive employment may be evaluated. Reliability of patient reports and overall effort during testing is also reported. Components of this evaluation may include:
Most studies examining FCEs were performed utilizing cases involving chronic low back pain. There is some evidence that an FCE fails to predict which injured workers with chronic low back pain will have sustained return to work. Another cohort study concluded that there was a significant relation between FCE information and return to work, but the predictive efficiency was poor. There is some evidence that time off work and gender are important predictors for return to work, and floor-to-waist lifting may also help predict return to work. However, the strength of that relationship has not been determined.
A full review of the literature reveals no evidence to support the use of FCEs to prevent future injuries. There is some evidence in chronic low back pain patients that (1) FCE task performance is weakly related to time on disability and time for claim closure, and (2) even claimants who fail on numerous physical performance FCE tasks may be able to return to work. These same issues may exist for lower extremity injuries.
Full FCEs are rarely necessary. In many cases, a work tolerance screening or return to work performance will identify the ability to perform the necessary job tasks. There is some evidence that a short form FCE reduced to a few tests produces a similar predictive quality compared to the longer 2-day version of the FCE regarding length of disability and recurrence of a claim after return to work.
When an FCE is being used to determine return to a specific job site, the provider is responsible for fully understanding the physical demands and the duties of the job the worker is attempting to perform. A job site evaluation is usually necessary. A job description should be reviewed by the provider and FCE evaluator prior to this evaluation. FCEs cannot be used in isolation to determine work restrictions. It is expected that the FCE may differ from both self-report of abilities and pure clinical exam findings in chronic pain patients. The length of a return to work evaluation should be based on the judgment of the referring physician and the provider performing the evaluation. Since return to work is a complicated multidimensional issue, multiple factors beyond functional ability and work demands should be considered and measured when attempting determination of readiness or fitness to return to work. FCEs should not be used as the sole criteria to diagnose malingering.
* Frequency: Once, when patient is unable to return to the pre-injury position and further information is desired to determine permanent work restrictions.
Prior authorization is required for repeat Functional Capacity Evaluations.
Ergonomic alterations should be done early to assure that appropriate changes are accomplished early in the treatment program. Whenever a case is identified as a work-related cumulative trauma condition, job alterations are an expected treatment. These may be in the form of:
A formal job site evaluation is a comprehensive analysis of the physical, mental and sensory components of a specific job. It may be important initially to determine causation. These components may include, but are not limited to:
* Frequency: 1 time with additional visits as needed for follow-up per job site.
Once an authorized practitioner has determined that a patient will not be able to return to his/her former employment and can prognosticate final restrictions, a timely vocational assessment can be implemented. The vocational assessment should provide valuable guidance in the determination of future rehabilitation program goals. It should clarify rehabilitation goals, which optimize both patient motivation and utilization of rehabilitation resources. The effectiveness of vocational rehabilitation may be enhanced when performed in combination with work hardening or work conditioning. If prognosis for return to former occupation is poor, except in the most extenuating circumstances, vocational assessment should be implemented within 3 to 12 months post-injury. Declaration of maximum medical improvement should not be delayed solely due to lack of attainment of a vocational assessment.
* Frequency: 1 time with additional visits as needed for follow-up.
Work Tolerance Screening (Fitness for Duty) is a determination of an individual's tolerance for performing a specific job as based on a job activity or task. It may include a test or procedure to specifically identify and quantify work-relevant cardiovascular demands, physical fitness, and postural tolerance. It may also address ergonomic issues affecting the patient's return-to-work potential. May be used when a full Functional Capacity Evaluation is not indicated.
F. SPECIFIC MUSCULOSKELETAL DIAGNOSIS, TESTING & TREATMENT PROCEDURES
Cumulative trauma related conditions comprise a number of specific diagnoses with diagnostic findings and treatment. Cumulative trauma disorder itself is not a diagnosis and cannot be treated or evaluated until the specific diagnosis is identified. Refer to Section C Definitions and Mechanisms of Injury for details.
Cumulative trauma conditions often involve several diagnoses and conservative treatment of all applicable diagnoses should be treated simultaneously. See Section G for peripheral neuropathies.
When a patient presents with pain at the base of the thumb, tests for de Quervain's, flexor carpi radialis tendonitis, and scaphoid pathology should all be considered.
There is some evidence that home-based hand exercises with phone call follow-up and monitoring plus hand osteoarthritis (HOA) information is more effective than only giving HOA information in improving hand functionality in women with HOA. Self-application of heat or ice and ergonomic changes of the job site are recommended.
Refer to medication discussions in Section H.7 Medications and Medical Management for further details.
Whenever a case is identified as a work-related cumulative trauma condition, job alterations are an expected treatment. These may be in the form of:
* Time to Produce Effect: 1 to 2 injections. If the first injection is unsuccessful and symptoms continue, the second injection should be performed by a specialist with expertise in the anatomy of the upper extremity.
* Optimum Maximum Frequency: 3 injections in 1 year spaced at least 4 to 8 weeks apart.
* Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections. Refer to Section H.4 Injections for further information on steroid injections.
One study demonstrated a 70% reduction in the number of patients desiring surgery after 7 months when they were provided with 3 sessions of hand therapy explaining the use of splints; accessories such as fitted scissor, book support, pen handles; and modification of their work environment. It is strongly suggested that all patients receive hand therapy support and job site alterations before considering surgery.
Early stage arthritis with functional deficits may be amenable to debridement and thermal capsular shrinkage. For later stages, synthetic material and interposition materials may have more complications than biologicals.
There is currently a lack of convincing evidence that any operative intervention for osteoarthritis of the base of the thumb is more or less effective than any other operative intervention.
The most common current procedures for thumb carpometacarpal arthritis are trapeziectomy with or without suspension procedures, including ligament reconstruction and/or tendon interposition. There is good evidence that these procedures have similar outcomes at 1 year. There is uncertainty regarding the risk of adverse events between simple trapeziectomy and trapeziectomy combined with other procedures. However, a lower risk of complications with simple trapeziectomy cannot be ruled out. Osteotomies may be additional procedures in some cases and fusions are occasionally performed, usually in younger active patients.
Ligament and tendon procedures are thought to protect the other carpal joints from earlier deterioration and allow greater stability for the thumb. Most patients have not been followed long enough to compare rates of subsequent arthritis and resulting functional deficits between those having a simple trapeziectomy and those with suspension procedures. In one follow up study, there was an increase in x-ray joint changes without a clinical impact.
Complications from wrist arthroscopy are approximately 4.7%, including ulnar or posterior interosseous nerve damage. Total wrist arthroplasty is not currently recommended due to long-term problems with dislocation or compartment loosening. If it is being considered, then prior authorization and a second opinion by a hand surgeon are required.
Whenever a case is identified as a work-related cumulative trauma condition, job alterations are an expected treatment. These may be in the form of:
Observational studies suggest that steroid injections may be beneficial even when splints are not used. However, there is insufficient evidence to favor steroid injections over thumb spica splinting. There is some evidence that in the setting of de Quervain's disease, functional benefits of a corticosteroid injection are enhanced by a thumb spica cast which reduces stress on the abductor pollicis longus and extensor pollicis brevis tendons. There is inadequate evidence to show that a thumb spica cast, compared to other splinting methods, is necessary to achieve this added benefit. There is not clear evidence that steroid injections are more effective than splinting alone.
These injections are best performed by a specialist. Ultrasound guided injections may assist when a separation is present between the extensor pollicis brevis and the abductor pollicis longus although there is insufficient evidence to routinely recommend this treatment.
Post injection, the hand is usually placed at rest for several days and a splint may be used.
* Time to Produce Effect: 1 to 2 injections. If the first injection is unsuccessful and symptoms continue, the second injection should be performed by a specialist with expertise in the anatomy of the upper extremity.
* Optimum Frequency: 3 injections in 1 year spaced at least 2 to 8 weeks apart injection.
* Maximum Frequency: 4 per year if injections result in functional benefit without local reactions or complications.
Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections. Refer to Section H.4.c Steroid Injections for further details.
First extensor compartment release is rarely necessary. Most cases resolve spontaneously over a number of months. Surgery may be performed to achieve functional gains for those with the required diagnostic exam findings who continue to have significant ongoing impaired activities of daily living after 8 weeks of treatment which include job modifications, injections, and other therapy.
There is some evidence that endoscopic and open release result in equally satisfactory 24 week outcomes and approximately equal return to work times for de Quervain's tenosynovitis. However, with endoscopic release there is a lower risk of transient injury to the superficial radial nerve, better scar satisfaction, and a slightly more rapid resolution of pain and functional limitations.
Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work, as well as possible complications. The patient should agree to comply with the pre- and post-operative treatment plan including home exercise. The provider should be especially careful to make sure the patient understands the amount of post-operative therapy required and the length of partial- and full-disability expected post-operatively.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since many patients with the most common conditions will improve significantly over time without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Typically the patient should show some progress toward cessation at about six weeks. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery. Patients with demonstrated success may continue the program up to 3 months or longer if needed based on the operative procedure. Refer to Section H.7.f Smoking Cessation Medications and Treatment for further details.
* Active or resisted wrist extension;
* Active or resisted middle finger extension;
* Active or resisted supination.
* Active or resisted wrist flexion;
* Active or resisted long finger flexion;
* Active or resisted pronation.
Electro diagnostic studies can be considered to rule out neurological sources of pain, such as radial tunnel syndrome or posterior interosseous nerve entrapment.
Literature indicates that over 80% of patients with greater than 4 weeks of pain recovered by 1 year. The natural history of epicondylitis supports an expectation of improvement within 3 months of using patient education and modified activities.
Brace types include proximal forearm band/sleeve, cock-up wrist splint, forearm/hand splint, and dynamic extensor brace.
Braces may be used in patients who are able to tolerate wearing the brace during activity and do not experience worsening pain and/or additional symptoms due to brace, but should be discontinued in the event of adverse effects.
There is no evidence that one brace type is superior to other types. However, some brace types may be impractical for use in most workers. For example, surgical technicians and food handlers would be unable to use most braces involving the wrist due to incompatibility with occupational function. The forearm band brace type appears to be the least cumbersome brace option and may be the best tolerated. However, this brace has the disadvantage of sometimes putting pressure on the radial nerve or occasional incorrect use by the patient.
Selecting the appropriate brace type is a decision that should be made by both patient and treating physician or therapist and should include appropriate patient education and follow-up. Braces which restrict range of motion should not be used continuously as this may result in permanent loss of motion. Compression straps should not be positioned in a manner which would irritate branches of the radial nerve. Braces should achieve maximum function and patient comfort.
Whenever a case is identified as a work-related cumulative trauma condition, job alterations are an expected treatment. These may be in the form of:
Steroid injections under significant pressure should be avoided as the needle may be penetrating the tendon and injection into the tendon can cause possible tendon breakdown, tendon degeneration, or rupture.
There is strong evidence that in the setting of lateral epicondylitis, the effects of corticosteroid injections on pain and function are more favorable than placebo in the first four weeks, but these benefits are reversed by six months and are detrimental compared to placebo injections in the intermediate and long term. Thus, injections for epicondylitis must include a discussion with the patient regarding lack of long-term benefits compared to no injection, as well as the need to combine other therapy, including a slow increase of activities that aggravate the condition. Steroid injections do provide short term benefit and may be considered an adjunctive therapy for some patients.
* Time to Produce Effect: 1 to 2 injections. If the first injection is unsuccessful and symptoms continue, the second injection should be performed by a specialist with expertise in the anatomy of the upper extremity.
* Optimum Frequency: 3 injections in 1 year spaced at least 2 to 8 weeks apart.
* Maximum Frequency: 3 to 4 per year if injections result in functional benefit without local reactions or complications.
Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections. Refer to Section H.4.c Steroid Injections for further details.
Botulinum toxin injection is known to cause short-term third (middle) finger strength deficits and possible digit paresis, which may persist for up to 3 to 4 months. Botulinum toxin injection should only be used in patients whose occupational performance will be unaffected by this side effect, and should not be used in patients with physically demanding job descriptions.
It should not be considered a first line of treatment. Other conservative measures should be tried first. A single botulinum toxin type A injection may provide pain reduction for up to 3 to 4 months in patients with chronic lateral epicondylitis which has persisted after 3 months of treatment.
Botulinum toxins are manufactured at different potencies, and units of the different manufacturers are not equivalent. Careful botulinum toxin dosing should be used to avoid complete paresis and allow maintained functionality and return to work.
The decision to use botulinum toxin for pain relief from chronic lateral epicondylitis symptoms should be made carefully by both patient and treating physician, with knowledge of the known side effects and consideration of the individual occupational demands of the patient.
Botulinum injection should only be performed by a physician or surgeon who has expertise in the anatomy of the upper extremity and who is experienced in the use of this agent. Ultrasound guidance may be helpful. Prior authorization is required.
* Maximum: One injection episode.
There is some evidence that, for patients with symptoms lasting 6 months or more, autologous blood injections result in better pain and functional outcomes after 1 year than steroid injections.
* Optimum Frequency: 2 injections may be required.
There is good evidence that in the setting of lateral epicondylitis, platelet-rich plasma injections may lead to a small to moderate functional benefit in comparison to autologous whole blood or saline at two to three months, but effects on pain are uncertain.
There is good evidence that platelet-rich plasma injections produces more favorable symptomatic and functional improvement than triamcinolone injection in patients with chronic lateral epicondylitis, with this advantage persisting for 24 months after treatment.
In summary, there is strong evidence for the use of platelet-rich plasma injections in patients who have not improved with conservative therapy.
* Optimum Frequency: 2 injections may be required.
A systematic review of low quality studies found a lack of evidence for the effectiveness of ultrasound, laser, pulsed electromagnetic field therapy, TENS, and extracorporeal shock wave for the treatment of lateral epicondylitis. Therefore, they are not recommended. However, high volt or interferential may be useful in some patients.
This subsection reviews the evidence base for using physical therapy, including mobilization and manipulation, in the treatment of epicondylitis.
There is good evidence that there are early benefits from an 8 week program of weekly, individualized physical therapy for patients who do not receive a corticosteroid injection. However, the natural history of the condition tends to obscure these early benefits at one year from the time therapy begins.
There is some evidence that for subjects with long-term lateral epicondylalgia, a daily 6-week eccentric home exercise regimen is effective in increasing pain-free hand-grip, increasing wrist-extensor strength, and reducing the number of cases that meet the diagnostic criteria for lateral epicondylalgia.
There is some evidence that the addition of Mulligan mobilization to a regimen comprising of ultrasound therapy and progressive exercises is more effective in decreasing pain and increasing pain-free grip strength than ultrasound therapy and progressive exercises alone in the treatment of lateral epicondylitis.
Although one Cochrane found inadequate evidence to support deep transverse friction massage alone, another study is supportive of deep tissue massage combined with manipulation. There is some evidence that both Cyriax physiotherapy (deep transverse friction massage combined with Mills manipulation) and phonophoresis with supervised exercise and static stretching are effective over a period of 4 weeks of treatment for lateral epicondylalgia in decreasing pain, increasing pain-free grip strength, and improving functional status. However, Cyriax physiotherapy provides a superior benefit compared to phonophoresis with supervised exercise and static stretching.
The muscle energy technique is a manual therapy technique in which the patient performs voluntary contraction against a counter force from the provider to stretch muscles and improve range of motion. There is some evidence that the muscle energy technique is superior to corticosteroid injection in improving grip strength in lateral epicondylitis. However, it is not clear that the technique is better than no treatment.
There is good evidence that manual and manipulative therapy combined with exercise and/or multimodal therapy shows small, clinically important reductions in pain and improved physical function in the short-term care (<= 3-6 months) of patients with lateral epicondylitis and carpal tunnel syndrome.
There is good evidence that physical therapy using manipulation, home exercise and supervised exercise reduced pain at 6 weeks but not at 52 weeks. This may be appropriate therapy to hasten return to work.
In summary, physical therapy including manual and manipulative therapy is encouraged based on good evidence.
* Time to Produce Effect: 4 treatments.
* Optimum Frequency: 12 treatments over 6 weeks.
Lateral epicondyle release/debridement is generally accepted; however, over 80% of cases improve with conservative therapy only. Intermittent discomfort may recur over 6 months to 1 year after initial conservative treatment.
The patient may be a good surgical candidate when the diagnosis is confirmed on physical exam (Refer to Section D.1.d Physical Examination) and functional deficits interfere with activities of daily living and/or job duties after at least 3 months of active patient participation in non-operative therapy including worksite changes, medication, splints, and injections or other therapy noted above.
Prior to surgical intervention, the patient and treating physician should identify functional operative goals, the likelihood of achieving improved ability to perform activities of daily living or work, and possible complications. The patient should agree to comply with the pre- and post-operative treatment plan including home exercise. The provider should be especially careful to make sure the patient understands the amount of post-operative therapy required and the length of partial- and full-disability expected post-operatively.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since many patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Typically the patient should show some progress toward cessation at about six weeks. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery. Patients with demonstrated success may continue the program up to 3 months or longer if needed based on the operative procedure. Refer to Section H.7.f Smoking Cessation Medications and Treatment for further details.
Whenever a case is identified as a work-related cumulative trauma condition, job alterations are an expected treatment. These may be in the form of:
* Time to Produce Effect: 1 to 2 injections. If the first injection is unsuccessful and symptoms continue, the second injection should be performed by a specialist with expertise in the anatomy of the upper extremity.
* Optimum Frequency: 3 injections in 1 year spaced at least 2 to 8 weeks apart.
* Maximum Frequency: 3 to 4 per year if injections result in functional benefit without local reactions or complications.
Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections. Refer to Section H.4.c Steroid Injections for further details.
Prior to surgical intervention, the patient and treating physician should identify functional operative goals, the likelihood of achieving improved ability to perform activities of daily living or work, and possible complications. The patient should agree to comply with the pre- and post-operative treatment plan including home exercise. The provider should be especially careful to make sure the patient understands the amount of post-operative therapy required and the length of partial- and full-disability expected post-operatively.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since many patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Typically the patient should show some progress toward cessation at about six weeks. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery. Patients with demonstrated success may continue the program up to 3 months or longer if needed based on the operative procedure. Refer to Section H.7.f Smoking Cessation Medications and Treatment for further details.
Whenever a case is identified as a work-related cumulative trauma condition, job alterations are an expected treatment. These may be in the form of:
* Time to Produce Effect: 1 to 2 injections. If the first injection is unsuccessful and symptoms continue, the second injection should be performed by a specialist with expertise in the anatomy of the upper extremity.
* Optimum Frequency: 3 injections in 1 year spaced at least 2 to 8 weeks apart.
* Maximum Frequency: 3 to 4 per year if injections result in functional benefit without local reactions or complications.
Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections. Refer to Section H.4.c Steroid Injections for further details.
Surgery is rarely necessary but may be indicated when a tendon is ruptured, chronically enlarged or entrapped, or on rare occasions when conservative measures have failed and tendonitis is clearly present.
Any decision for surgical intervention should be based on a hand surgeon's evaluation of need and the existence of a clear functional deficit that can be corrected by surgical intervention.
Prior to surgical intervention, the patient and treating physician should identify functional operative goals, the likelihood of achieving improved ability to perform activities of daily living or work, and possible complications. The patient should agree to comply with the pre- and post-operative treatment plan including home exercise. The provider should be especially careful to make sure the patient understands the amount of post-operative therapy required and the length of partial- and full-disability expected post-operatively.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since many patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Typically the patient should show some progress toward cessation at about six weeks. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery. Patients with demonstrated success may continue the program up to 3 months or longer if needed based on the operative procedure. Refer to Section H.7.f Smoking Cessation Medications and Treatment for further details.
* Forced supination and pronation with axial pressure on an ulnar deviated wrist;
* The patient pushes up from a seating position using the hand; and/or
* Ballottement of the distal ulna with the wrist supinated causes abnormal motion as compared to the asymptomatic side.
Whenever a case is identified as a work-related cumulative trauma condition, job alterations are an expected treatment. These may be in the form of:
* Time to Produce Effect: 1 to 2 injections. If the first injection is unsuccessful and symptoms continue, the second injection should be performed by a specialist with expertise in the anatomy of the upper extremity.
* Optimum Frequency: 3 injections in 1 year spaced at least 2 to 8 weeks apart.
* Maximum Frequency: 3 to 4 per year if injections result in functional benefit without local reactions or complications.
Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections.
A patient may be a surgical candidate if there are concomitant fractures, instability, or if symptoms continue to interfere with ADLs or job duties after non-surgical interventions for 2 to 3 months.
Those with a corresponding abnormality in the opposite wrist should have an especially rigorous diagnostic review before proceeding to a surgical intervention.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since many patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Typically the patient should show some progress toward cessation at about six weeks. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery. Patients with demonstrated success may continue the program up to 3 months or longer if needed based on the operative procedure. Refer to Section H.7.f Smoking Cessation Medications and Treatment for further details.
For both non-union and soft-tissue: Smokers have a higher risk of nonunion and post-operative costs. Therefore, if a treating physician recommends a specific smoking cessation program peri-operatively, it should be covered by the insurer. Typically the patient should show some progress toward cessation at about six weeks. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels.
The surgeon will make the final determination as to whether smoking cessation is required prior to surgery. Patients with demonstrated success may continue the program up to 3 months or longer if needed based on the operative procedure. Refer to Section H.7 Medications for further details.
Active range of motion may be affected, usually only in severe cases.
Whenever a case is identified as a work-related cumulative trauma condition, job alterations are an expected treatment. These may be in the form of:
There is some evidence that in the intermediate term (up to three months), injections with triamcinolone and with diclofenac are equally effective in patients with trigger digit.
The patient should rest the digit partially or completely for 0 - 7 days after the injection.
Steroid Injections: may decrease inflammation and pain and allow the therapist to progress with rehabilitation therapy. Steroid injections under significant pressure should be avoided as the needle may be penetrating the tendon and injection into the tendon can cause possible tendon breakdown, tendon degeneration, or rupture.
* Time to Produce Effect: 1 to 2 injections. If the first injection is unsuccessful and symptoms continue, the second injection should be performed by a specialist with expertise in the anatomy of the upper extremity.
* Optimum Frequency: 3 injections in 1 year spaced at least 2 to 8 weeks apart.
* Maximum Frequency: If additional injections are being considered, referral to a specialist should be considered.
Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections. Refer to Section H.4.c Steroid Injections for further details.
Surgery is often not necessary. Any decision for surgical intervention should be based on a hand surgeon's evaluation of need and the existence of a clear functional deficit that can be corrected by surgical intervention. Trigger digit release, open or percutaneous, may be indicated when:
Prior to surgical intervention, the patient and treating physician should identify functional operative goals, the likelihood of achieving improved ability to perform activities of daily living or work, and possible complications. The patient should agree to comply with the pre- and post-operative treatment plan including home exercise. The provider should be especially careful to make sure the patient understands the amount of post-operative therapy required and the length of partial- and full-disability expected post-operatively.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since many patients with the most common conditions will improve significantly over time without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Typically the patient should show some progress toward cessation at about six weeks. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery. Patients with demonstrated success may continue the program up to 3 months or longer if needed based on the operative procedure. Refer to Section H.7.f Smoking Cessation Medications and Treatment for further details.
G. SPECIFIC PERIPHERAL NERVE DIAGNOSIS, TESTING &TREATMENT PROCEDURES
The following elements are commonly associated with carpal tunnel syndrome:
EDX studies are imperfect indicators of the outcome of treatment of carpal tunnel syndrome, since they may be only weakly correlated with functional scores. However, they may provide useful information when symptomatic and functional recovery after treatment has not occurred.
EDX findings in carpal tunnel syndrome reflect slowing of median motor and sensory conduction across the carpal tunnel region due to demyelination. Axonal loss, when present, is demonstrated by needle electromyography in median nerve supplied thenar muscles.
Laboratory testing for cumulative trauma conditions may be required periodically to monitor patients on chronic medications.
There is strong evidence that, in patients with carpal tunnel syndrome which has not become chronic, carpal tunnel release leads to a moderate treatment advantage with respect to functional improvement 6 months after surgery. While there is considerable benefit from conservative treatment such as splinting and individualized hand therapy, there is insufficient evidence to identify which patients are likely not to benefit from conservative treatment sufficiently to avoid surgery.
There is insufficient evidence to support ergonomic positioning or keyboards as clearly beneficial for carpal tunnel syndrome.
One study of a variety of vertical and gel mouse pads did not support the use of any particular pad to decrease carpal tunnel pressure.
Whenever a case is identified as a work related cumulative trauma condition, job alterations are an expected treatment. These may be in the form of:
Ergonomic job site evaluation and change are a required treatment for all cumulative trauma conditions as this may eliminate the need for invasive treatment.
Suggested ergonomic changes usually also apply to uninjured workers in the same job position. Refer to Section E.6.c Job Site Evaluations and Section H.6 Job Site Alteration.
There is good evidence that NSAIDS and diuretics add no benefits for symptom improvement compared to placebo at 4 weeks, and some evidence that Vitamin B6 adds no benefit on symptom improvement compared to placebo at 10-12 weeks. The American Academy of Orthopaedic Surgeons (AAOS) says there is moderate evidence against non-steroid oral medications. Although NSAIDs are not curative, they and other analgesics may provide symptomatic relief.
Oral Steroids: There is good evidence that oral steroids are more effective than placebo in improving symptoms in the short term, and there is some evidence that they are not effective in the long term (12 months). There is some evidence that 6 weeks of oral steroids are more effective than splinting in improving function but not symptoms in the short term. Given the lack of long term effects and the problematic side effects, steroids are not recommended.
There is no evidence in favor of full-time use of a wrist splint compared with night-only use. There is no evidence in favor of a wrist splint in the neutral position compared to an extended wrist position of 20° in the short term (2 weeks). There is insufficient evidence to support a specific type of splint for splinting over other treatment.
There is some evidence in the short term (4 weeks) and absence of evidence in the midterm (4-6 months) that a nocturnal hand brace is more effective for reducing pain and improving function compared to no treatment. There is some evidence in the short term that a 3-month night treatment with either the soft hand brace or the wrist splint is effective in reducing symptoms and improving function, but there is no significant difference between the 2 interventions.
Splints may be effective when worn at night or during portions of the day, depending on activities. Depending on job activities, intermittent daytime splinting can also be helpful. Splint use is rarely mandatory. Providers should be aware that over-usage is counterproductive and should counsel patients to minimize daytime splint use in order avoid detrimental effects such as stiffness and dependency over time.
* Time to Produce Effect: 2 to 4 weeks. If after 4 weeks, the patient has partial improvement, continue to follow since neuropathy may worsen, even in the face of diminished symptoms.
There is good evidence that in patients with carpal tunnel syndrome who have not improved after 2 months of splinting, an injection of 80 mg of methylprednisolone and of 40 mg of methylprednisolone are equally likely to lead to short-term 5-week improvements in carpal tunnel symptoms compared to placebo. However, the success of methylprednisolone in avoiding surgery in carpal tunnel syndrome patients is modest. Although approximately 92% of placebo-injected patients are likely to require carpal tunnel release within one year, about three quarters of patients who have a methylprednisolone injection are also likely to have surgery. However, this modest difference in rates of surgery may prevent a large number of carpal tunnel release operations if steroid injections are offered to a large population of carpal tunnel syndrome patients who continue to have symptoms after a 2 month trial of splinting.
There is some evidence that 60mg methylprednisone injection is more effective than 20 or 40mg methylprednisone at 6 months but not at one year. There is some evidence that there is no significant difference between a single corticosteroid injection of 15mg methylprednisolone compared with 2 local corticosteroid injections regarding symptom improvement at 8, 24, and 40 weeks after injection.
When approaching the decision to consider steroid injection in a patient with mild to moderate carpal tunnel syndrome, it is important to consider the trend of a good initial therapeutic response followed by a diminishing response after 3 months and high rates of relapse by 1 year. Underlying medical conditions and potential ergonomic risk factors for carpal tunnel syndrome should be considered and addressed, if possible. In the case of an identified modifiable condition, a steroid injection may provide a less invasive short-term response to manage symptoms. Shared decision making with the patient should be had regarding the high risk of relapse and the potential lack of response after steroid injection. If a steroid injection is performed and symptoms recur following the first injection symptomatic relief, the decision to perform a second injection must be weighed against alternative treatments such as surgery.
Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections. Refer to Section H.4.c Steroid Injections for further details.
* Time to Produce Effect: 1 to 2 injections. If the first injection is unsuccessful and symptoms continue, the second injection should be performed by a specialist with expertise in the anatomy of the upper extremity.
* Maximum Frequency: 3 injections.
These exercises are based on the principle that the tissues of the peripheral nervous system are designed for movement and that tension and glide (excursion) of nerves may have an effect on neurophysiology through alterations in vascular and axoplasmic flow. The exercises are simple to perform and can be done by the patient after brief instruction. Biomechanical principles have been more thoroughly studied than clinical outcomes.
There is no evidence in favor of the addition of tendon and nerve gliding exercises to 4 weeks of night splinting compared to splinting alone.
There is good evidence that neuro-dynamic technique plus splinting add no benefit to reduce pain or improve function compared to splinting alone after 3 weeks.
Due to lack of quality evidence, use of mobilization and exercise should be based on patient preference and provider expertise.
* Time to Produce Effect: 2 to 4 weeks.
* Frequency: Up to 5 times per day by patient (patient-initiated).
* Optimum Duration: 2 provider-directed sessions.
* Maximum Duration: 3 provider-directed sessions.
There is some evidence from a high quality randomized controlled trial that an initial treatment approach for carpal tunnel syndrome involving physical manual therapy directed at the entire course of the median nerve from the scalene muscles to the wrist, in combination with nerve and tendon gliding exercises, is as successful as carpal tunnel release at 6 months and at 1 year. The physical manual therapy combined with nerve and tendon gliding exercises may show advantages over surgery at 1 and 3 months. However, there was incomplete analysis of patient data.
There is good evidence that soft tissue mobilization plus home exercises is effective in reducing pain and improving function at 6 months.
Use of mobilization and exercise should be based on patient preference and provider expertise.
* Time to Produce Effect: 4 to 6 weeks.
* Frequency: 1 to 3 times per week.
* Optimum Duration: 4 to 6 weeks.
* Maximum Duration: 8 weeks.
Another systematic review found insufficient evidence to support ultrasound therapy.
There is some evidence that ultrasound therapy plus splinting is no more effective than placebo ultrasound plus splinting in reducing pain and symptoms and improving functionality in the conservative treatment of patients with carpal tunnel syndrome.
Therefore, ultrasound without phonophoresis is not recommended.
* Time to Produce Effect: 2 to 6 treatments.
* Frequency: 2 times per week.
* Optimum and Maximum Duration: 4 to 8 weeks.
* Optimum and Maximum Frequency: 6 to 9 sessions over 5 weeks.
There is some evidence that laser acupuncture adds no benefits to night pain improvement compared to placebo at 3 weeks. There is some evidence that there are no differences between needle acupuncture combined with a wrist brace and placebo needle acupuncture combined with a wrist brace. Neither treatment is clinically effective in improving function in patients with mild or moderate carpal tunnel syndrome. Therefore, it is not recommended.
There is strong evidence that in patients with carpal tunnel syndrome which has not become chronic, carpal tunnel release leads to a moderate treatment advantage with respect to functional improvement 6 months after surgery. However, there is considerable benefit to conservative treatment such as worksite ergonomic changes, splinting, and individualized hand therapy, which are appropriate for first-line treatment. There is insufficient evidence to identify which patients are likely not to benefit from conservative treatment sufficiently to avoid surgery.
For patients with clinically typical carpal tunnel symptoms of median nerve distribution numbness, with or without pain, which awakens the patient at night and is alleviated by shaking the hand: there is some evidence that the symptom and function outcomes of mini-open carpal tunnel release are similar at 6 months for patients who do and do not undergo preoperative nerve conduction studies. However, the study excluded patients with atypical symptoms or unusual courses of disease, recurrent syndrome, diabetic neuropathy, and cervical radiculopathy.
Overall, it is probably reasonable to expect that 40 to 50% of patients with mild exam findings may improve or remain stable overtime.
There is strong evidence that surgery is more effective than splinting or injections in producing long-term symptom relief and normalization of median nerve conduction velocity for those patients with clinically significant carpal tunnel syndrome with positive nerve conduction velocity findings. There is also a positive cost utility for surgery over conservative care for patients with positive nerve conduction studies. There is good evidence that surgery improves symptoms more effectively than steroid injection for up to five months.
In one prospective study, duration of symptoms prior to surgery, up to 5 years, did not affect the ability to achieve symptom or functional outcome success with surgery. Patients with more severe symptoms and longer duration of symptoms showed significant improvement with surgery. Patients with thenar atrophy, weakness of the abductor pollicis brevis, and fixed sensory deficits may still improve with surgery. Patients with mild symptoms and functional deficits demonstrated the smallest changes from pre- to post-operative scores. However, their post-operative scores were higher than the post-operative scores of those with more severe symptoms.
AND
There is insufficient evidence to formulate a post-operative care plan.
The rehabilitation program should be based upon communication between the surgeon and the therapist and using therapies as outlined in Section H Therapeutic Procedures - Non-Operative. In all cases, communication between the physician and therapist is important to the timing of exercise progressions.
Suggested parameters for return-to-work are:
|
Time Frame |
Activity Level |
|
2 days |
Return to work with restrictions on utilizing the affected extremity |
|
2 to 3 weeks |
Sedentary and non-repetitive work |
|
4 to 6 weeks |
Case-by-case basis |
|
6 to 12 weeks |
Heavy labor, forceful and repetitive |
Note: All return-to-work decisions are based upon clinical outcome.
Relief from steroid injections may provide additional confirmation. If median nerve symptoms do not improve following initial surgery or the symptoms improve initially and then recur but are unresponsive to non-operative therapy (Section H Therapeutic Procedures - Non-Operative), consider the following:
A second opinion by a hand surgeon and repeat nerve conduction studies are required if repeat surgery is contemplated. The decision to undertake repeat surgery must factor in all of the above possibilities. Results of surgery for recurrent carpal tunnel syndrome vary widely depending on the etiology of recurrent symptoms.
MRI: Imaging is generally not indicated but may be useful when space occupying lesions are suspected.
EDX: Electrodiagnostic (EDX) studies are well-established and widely accepted for evaluation of patients suspected of having peripheral nerve pathology. Studies may confirm the diagnosis or direct the examiner to alternative disorders. When polyneuropathy is suspected, it may be worthwhile to perform electrodiagnostic testing in the lower extremities. Studies require clinical correlation due to the occurrence of false positive and false negative results. Symptoms of peripheral nerve pathology may occur with normal EDX studies, especially early in the clinical course.
To assure accurate testing, temperature should be maintained at 32 to 34 degrees C, preferably recorded from the hand/digits. For temperature below 32 degrees C, the hand should be warmed.
All studies must include normative values for their laboratories. Studies of both upper extremities may be done for comparison.
During the study, the elbow should be maintained in moderate flexion, usually 70-90 degrees. Two positive findings in this position constitute a positive test. The following criteria are used:
Surgery may be considered when 1) findings on history and objective evidence correlate specifically with the diagnosis; 2) job site alteration and other conservative measures have not alleviated the symptoms; and 3) functional deficits persist after 6 to 8 weeks.
Subjective complaints should be localized and appropriate to the diagnosis, neurologic complaints should be consistent with the nerve distribution in question, and physical exam findings should correlate with the history. Objective evidence should be present and include: positive physical exam findings as described in Section G.2.c or a motor deficit commensurate with the suspected neurologic lesion. In general, patients with minimal symptoms or without objective findings of weakness tend to respond better to conservative treatment.
Surgery may be considered as an initial therapy in situations where there is clinical and electrodiagnostic evidence of severe or progressive neuropathy.
Prior to surgical intervention, the patient and treating physician should identify functional operative goals, the likelihood of achieving improved ability to perform activities of daily living or work, and possible complications. The patient should agree to comply with the pre- and post-operative treatment plan including home exercise. The provider should be especially careful to make sure the patient understands the amount of post-operative therapy required and the length of partial- and full-disability expected post-operatively.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since many patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Typically the patient should show some progress toward cessation at about six weeks. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery. Patients with demonstrated success may continue the program up to 3 months or longer if needed based on the operative procedure. Refer to Section H.7.f Smoking Cessation Medications and Treatment for further details.
A second opinion by a hand surgeon and repeat nerve conduction studies are required if repeat surgery is contemplated.
medial epicondylectomy, anterior subcutaneous transfer, and submuscular or intramuscular transfer. There is good evidence that simple decompression and anterior transposition lead to equally good functional outcomes. There is good evidence that the complication rate in terms of post-operative infection is considerably higher with anterior transposition than with simple decompression, for which the infection rate is approximately two thirds lower. Transposition is a more complicated procedure requiring greater operative experience. Simple decompression appears to be cost effective and may be a preferable procedure.
Simple decompression appears to be effective even in patients with more severe disease, and it has fewer complications. There may be a subset of patients not yet identified by the current literature who would benefit more from a transposition. The complications and complexity of these procedures varies. Patients should understand the risks of each procedure, expected recovery, and need for follow-up therapy before consenting to the procedure.
Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.
There are five types of the Guyon Canal Syndrome based on the anatomic area of compression and neurological signs. Testing should include strength of the adductor pollicis, abductor digiti minimi, and lumbricals. Testing the ability of the long finger to cross the index finger is useful.
MRI or ultrasound may be used to rule out space occupying lesions.
Diagnostic injections may be done to confirm the diagnosis.
Whenever a case is identified as a work-related cumulative trauma condition, job alterations are an expected treatment. These may be in the form of:
* Time to Produce Effect: 1 injection.
* Maximum Frequency: 3 injections in 1 year spaced at least 4 to 8 weeks apart.
Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections. Refer to Section H.4 Injections for further details.
Surgery may be considered when:
Surgery may be considered as an initial therapy in situations where there is clinical and electrodiagnostic evidence of severe or progressive neuropathy.
Prior to surgical intervention, the patient and treating physician should identify functional operative goals, the likelihood of achieving improved ability to perform activities of daily living or work, and possible complications. The patient should agree to comply with the pre- and post-operative treatment plan including home exercise. The provider should be especially careful to make sure the patient understands the amount of post-operative therapy required and the length of partial- and full-disability expected post-operatively.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since many patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Typically the patient should show some progress toward cessation at about six weeks. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery. Patients with demonstrated success may continue the program up to 3 months or longer if needed based on the operative procedure. Refer to Section H.7.f Smoking Cessation Medications and Treatment for further details.
Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.
MRI can be done if space occupying lesions are suspected.
* Time to Produce Effect: 1 injection.
* Maximum Frequency: 3 injections in 1 year spaced at least 4 to 8 weeks apart
Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections. Refer to Section H.4.c Steroid Injections for further details.
Surgery may be considered when 1) findings on history and objective evidence correlate specifically with the diagnosis; 2) job site alteration and other conservative measures have not alleviated the symptoms; and 3) functional deficits persist after 8 to 10 weeks. Subjective complaints should be localized and appropriate to the diagnosis, neurologic complaints should be consistent with the nerve distribution in question, and physical exam findings of weakness should correlate with the history. Objective evidence should be present and may include: positive physical exam findings as described in section 6.c; positive electrodiagnostic (EDX) studies; or a motor deficit commensurate with the suspected neurologic lesion.
Surgery may be considered as an initial therapy in situations where there is clinical and electrodiagnostic evidence of severe or progressive neuropathy.
Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work, as well as possible complications. The patient should agree to comply with the pre- and post-operative treatment plan including home exercise. The provider should be especially careful to make sure the patient understands the amount of post-operative therapy required and the length of partial- and full-disability expected post-operatively.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since many patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Typically the patient should show some progress toward cessation at about six weeks. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery. Patients with demonstrated success may continue the program up to 3 months or longer if needed based on the operative procedure. Refer to Section H.7.f Smoking Cessation Medications and Treatment for further details.
Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.
There may be sensation loss over the palm and over the thenar eminence which is not present with carpal tunnel syndrome.
* Time to Produce Effect: 1 injection.
* Maximum Frequency: 3 injections in 1 year spaced at least 4 to 8 weeks apart.
Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections. Refer to Section H.4.c Steroid Injections for further details.
Most patients with this condition recover with conservative therapy. Surgery may be considered when:
When no objective evidence is present and the patient continues to have signs and symptoms consistent with the diagnosis after 6 months of conservative treatment including a psychological evaluation, a second opinion should be obtained before operative treatment is considered.
Electrodiagnostic (EDX) studies may show delayed median nerve conduction in the forearm. If nerve conduction velocity is normal with suggestive clinical findings, the study may be repeated after a 3 to 6 month period of continued conservative treatment. If the study is still normal, the decision on treatment is made based on the consistency of clinical findings and the factors noted above.
Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work, as well as possible complications. The patient should agree to comply with the pre- and post-operative treatment plan including home exercise. The provider should be especially careful to make sure the patient understands the amount of post-operative therapy required and the length of partial- and full-disability expected post-operatively.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since many patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Typically the patient should show some progress toward cessation at about six weeks. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery. Patients with demonstrated success may continue the program up to 3 months or longer if needed based on the operative procedure. Refer to Section H.7.f Smoking Cessation Medications and Treatment for further details.
Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.
MRI or ultrasound may be done if space occupying lesions are suspected.
X-rays may be normal or demonstrate spur formation over the involved epicondyle.
Diagnostic lidocaine injections may be used to confirm the diagnosis if surgery is being considered, as EMGs are frequently normal in this condition.
Whenever a case is identified as a work-related cumulative trauma condition, job alterations are an expected treatment. These may be in the form of:
* Time to Produce Effect: 1 injection.
* Maximum Frequency: 3 injections in 1 year spaced at least 4 to 8 weeks apart.
Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections. Refer to Section H.4.c Steroid Injections for further details.
Surgery may be considered when:
When no objective evidence is present and the patient continues to have signs and symptoms consistent with the diagnosis after 6 months of conservative treatment and a psychological evaluation, a second opinion should be obtained before operative treatment is considered.
Most cases improve with conservative treatment. Surgery should only be performed to achieve functional gains on those with significant ongoing impaired activities of daily living.
Complications: Radial nerve decompression is reported to have good success. However, complications can occur and include infection, damage to the posterior interosseous nerve, or damage to the extensor carpi radialis brevis or extensor digitorum communis.
Prior to surgical intervention, the patient and treating physician should identify functional operative goals, the likelihood of achieving improved ability to perform activities of daily living or work, and possible complications. The patient should agree to comply with the pre- and post-operative treatment plan including home exercise. The provider should be especially careful to make sure the patient understands the amount of post-operative therapy required and the length of partial-and full-disability expected post-operatively.
Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since many patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician. If a treating physician recommends a specific smoking cessation program peri-operatively, this should be covered by the insurer. Typically the patient should show some progress toward cessation at about six weeks. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels. The surgeon will make the final determination as to whether smoking cessation is required prior to surgery. Patients with demonstrated success may continue the program up to 3 months or longer if needed based on the operative procedure. Refer to Section H.7.f Smoking Cessation Medications and Treatment for further details.
H. THERAPEUTIC PROCEDURES - NON-OPERATIVE
Treating providers, employers, and insurers are highly encouraged to reference Section B General Guidelines Principles before initiating any therapeutic procedure. All treatment plans should specify frequency, duration, and expected treatment milestones. Before initiation of any therapeutic procedure, the authorized treating provider, employer, and insurer must consider these important issues in the care of the injured worker.
First, patients undergoing therapeutic procedure(s) should be released or returned to modified- or restricted-duty during their rehabilitation at the earliest appropriate time. Refer to Section H.11 Return-to-Work for detailed information.
Second, cessation and/or review of treatment modalities should be undertaken when no further significant subjective or objective improvement in the patient's condition is noted. If patients are not responding within the recommended duration periods, alternative treatment interventions, further diagnostic studies, or consultations should be pursued.
Third, providers should provide and document patient education. Functional progression is expected through prescribed activity such as neuromuscular and postural re-education/re-patterning exercises. Before diagnostic tests or referrals for invasive treatment take place, the patient should be able to clearly articulate the goals of the intervention, the general side effects, and associated risks, as well as agree with the expected treatment plan.
Lastly, formal psychological or psychosocial evaluation should be performed on patients not making expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests.
Home therapy is an important component of therapy and may include active and passive therapeutic procedures as well as other modalities to assist in alleviating pain, swelling, and abnormal muscle tone.
ACUPUNCTURE: When acupuncture has been studied in randomized clinical trials, it is often compared with sham acupuncture and/or no acupuncture (usual care). The differences between true acupuncture and usual care have been moderate but clinically important. These differences can be partitioned into two components: non-specific effects and specific effects. Non-specific effects include patient beliefs and expectations, attention from the acupuncturist, administration of acupuncture in a relaxing setting, and other components of what is often called the placebo effect. Specific effects refer to any additional effects which occur in the same setting of expectations and attention, but they are attributable to the penetration of the skin in the specific, classic acupuncture points on the surface of the body by the needles themselves.
A sham procedure is a non-therapeutic procedure that appears similar to the patient as the purported therapeutic procedure being tested. In most controlled studies, sham and classic acupuncture have produced similar effects. However, the sham controlled studies have shown consistent advantages of both true and sham acupuncture over no acupuncture when the studies have included a third comparison group that was randomized to usual medical care. Having this third comparison group has helped to interpret the non-specific effects of acupuncture, since the third comparison group controls for some influences on study outcome. These influences include more frequent contact with providers, the natural history of the condition, regression to the mean, the effect of being observed in a clinical trial, and--if the follow-up observations are done consistently in all three treatment groups--biased reporting of outcomes. Controlling for these factors enables researchers to more closely estimate the contextual and personal interactive effects of acupuncture as it is generally practiced.
Clinical trials of acupuncture typically enroll participants who are interested in acupuncture, and who may respond to some of the non-specific aspects of the intervention more than patients who have no interest in or desire for acupuncture. The non-specific effects of acupuncture may not be produced in patients who have no wish to be referred for it.
Another study provides good evidence that true acupuncture at traditional meridians is marginally better than sham acupuncture with blunt needles in reducing pain, but effects on disability are unclear. In these studies, 5-15 treatments were provided. Comparisons of acupuncture and sham acupuncture have been inconsistent, and the advantage of true over sham acupuncture has been small in relation to the advantage of sham over no acupuncture.
Acupuncture is recommended for subacute or chronic pain patients who are trying to increase function and/or decrease medication usage and have an expressed interest in this modality. It is also recommended for subacute or acute pain for patients who cannot tolerate NSAIDs or other medications.
Acupuncture is not the same procedure as dry needling for coding purposes. However, some acupuncturists may use acupuncture treatment for myofascial trigger points. Dry needling is performed specifically on myofascial trigger points. Refer to Section H.4.d Trigger Point Injections.
Acupuncture should generally be used in conjunction with manipulative and physical therapy/rehabilitation.
Credentialed practitioners with experience in evaluation and treatment of chronic pain patients must evaluate prior to acupuncture treatments. The exact mode of action is only partially understood. Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the brain, promotes deep relaxation, and affects the release of neurotransmitters. Acupuncture is commonly used as an alternative or in addition to traditional Western pharmaceuticals. It may be used when pain medication is reduced or not tolerated; as an adjunct to physical rehabilitation and surgical intervention; and/or as part of multidisciplinary treatment to hasten the return of functional activity. Acupuncture must be performed by practitioners with the appropriate credentials in accordance with state and other applicable regulations. Therefore, if not otherwise within their professional scope of practice and licensure, those performing acupuncture must have the appropriate credentials, such as L.A.c. R.A.c, or Dipl. Ac.
There is some evidence that acupuncture has a very short term 2 week effect on pain compared to sham acupuncture for lateral epicondylitis.
Indications: All patients being considered for acupuncture treatment should have subacute or chronic pain (lasting approximately 3-4 weeks depending on the condition) and meet the following criteria:
* they should have participated in an initial active therapy program; and
* they should show a clear preference for this type of care or previously have benefited from acupuncture; and
* they must continue to be actively engaged in physical rehabilitation therapy and return to work.
Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain.
It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.
* Time to Produce Effect: 3 to 6 treatments.
* Frequency: 1 to 3 times per week.
* Optimum Duration: 1 to 2 months.
* Maximum Duration: 14 treatments.
Any of the above acupuncture treatments may extend longer if objective functional gains can be documented and symptomatic benefits facilitate progression in the patient's treatment program. Treatment beyond 14 treatments must be documented with respect to need and ability to facilitate positive symptomatic or functional gains. Such care should be re-evaluated and documented with each series of treatments.
BIOFEEDBACK: Biofeedback is a form of behavioral medicine that helps patients learn self-awareness and self-regulation skills to increase control of their physiology, such as muscle activity, brain waves, and measures of autonomic nervous system activity. Stress-related psycho-physiological reactions may arise as a reaction to organic pain and in some cases may cause pain. Electronic instrumentation is used to monitor the targeted physiology and then displayed or fed back to the patient visually, auditorily, or tactilely, with coaching by a biofeedback specialist. There is good evidence that biofeedback or relaxation therapy is equal in effect to cognitive behavioral therapy for chronic low back pain.
Indications for biofeedback include cases of musculoskeletal injury, in which muscle dysfunction or other physiological indicators of excessive or prolonged stress response affects and/or delays recovery. Other applications include training to improve self-management of pain, anxiety, panic, anger or emotional distress, opioid withdrawal, insomnia/sleep disturbance, and other central and autonomic nervous system imbalances. Biofeedback is often utilized for relaxation training. Mental health professionals may also utilize it as a component of psychotherapy, where biofeedback and other behavioral techniques are integrated with psychotherapeutic interventions. Biofeedback is often used in conjunction with physical therapy or medical treatment.
* Time to Produce Effect: 3 to 4 sessions.
* Frequency: 1 to 2 times per week.
* Optimum Duration: 5 to 6 sessions.
* Maximum Duration: 10 to 12 sessions. Treatment beyond 12 sessions must be documented with respect to need, expectation, and ability to facilitate functional gains.
EDUCATION/INFORMED DECISION MAKING: of patients, families, employers, insurers, policy makers, and the community should be the primary emphasis in the treatment of shoulder pain and disability. Unfortunately, practitioners often think of education and informed decision making last, after medications, manual therapy, and surgery.
Informed decision making is the hallmark of a successful treatment plan. In most cases, the continuum of treatment from the least invasive to the most invasive (e.g., surgery) should be discussed. The intention is to find the treatment along this continuum which most completely addresses the condition. Patients should identify their personal functional goals of treatment at the first visit. It is recommended that specific individual goals are articulated at the beginning of treatment as this is likely to lead to increased patient satisfaction above that achieved from improvement in pain or other physical function. Progress toward the individual functional goals identified should be addressed at follow up visits and throughout treatment by other members of the health care team as well as the authorized physicians.
Documentation of this process should occur whenever diagnostic tests or referrals from the authorized treating physician are contemplated. The informed decision making process asks the patients to set their personal functional goals of treatment, describe their current health status and any concerns they have regarding adhering to the diagnostic or treatment plan proposed. The provider should clearly describe the following:
Before diagnostic tests or referrals for invasive treatment take place, the patient should be able to clearly articulate the goals of the intervention, the general side effects and risks associated with it, and their decision regarding compliance with the suggested plan. There is some evidence that information provided only by video is not sufficient education.
Practitioners must develop and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers, and the community as a whole. An education-based paradigm should always start with reassuring information to the patient and informed decision making. More in-depth education currently exists within a treatment regimen employing functional restoration, prevention, and cognitive behavioral techniques. Patient education and informed decision making should facilitate self-management of symptoms and prevention.
* Time to produce effect: Varies with individual patient
* Frequency: Should occur at every visit.
INJECTIONS - THERAPEUTIC: are generally accepted, well-established procedures that may play a significant role in the treatment of patients with upper extremity pain or pathology. Therapeutic injections involve the delivery of anesthetic and/or antiinflammatory medications to the painful structure. Therapeutic injections have many potential benefits. Ideally, a therapeutic injection will:
Special Considerations: The use of injections has become progressively sophisticated. Each procedure considered has an inherent risk. Risk versus benefit should be evaluated when considering injection therapy. In addition, all injections must include sterile technique.
Contraindications: General contraindications include local or systemic infection, bleeding disorders, allergy to medications used, and patient refusal. Specific contraindications may apply to individual injections.
There is some evidence in literature on lateral epicondylitis that, for patients with symptoms lasting 6 months or more, autologous blood injections result in better pain and functional outcomes after 1 year than steroid injections.
There is good evidence that, in the setting of lateral epicondylitis, PRP may lead to a small to moderate functional benefit in comparison to autologous whole blood or saline at two to three months, but effects on pain are uncertain.
There is good evidence that PRP produces more favorable symptomatic and functional improvement than triamcinolone injection in patients with chronic lateral epicondylitis, with this advantage persisting for 24 months after treatment.
In summary, there is strong evidence for the use of PRP in patients who have not improved with conservative therapy. Ultrasound guided may be useful.
* Optimum frequency: 2 injections may be required
Botulinum toxin injections should not be considered a first line of treatment. Other conservative measures should be tried first. Careful botulinum toxin dosing should be used to avoid complete paresis and maintain function and return to work.
Botulinum toxin injections are listed in this guideline as a treatment option for lateral and medial epicondylitis. Prior authorization is required. For more specific details, the reader must refer to Section F.3.g Non-operative Treatment Procedures (Epicondylitis) and Section F.4.e Non-operative Treatment Procedures (Extensor Tendon Disorders).
* Maximum: 1 injection per episode of symptomatic treatment (for some conditions there may be re-occurrences).
There is strong evidence that, in the setting of lateral epicondylitis, the effects of corticosteroid injections on pain and function are more favorable than placebo in the first four weeks, but these benefits are reversed by six months. In addition, corticosteroid injections are detrimental compared to placebo injections in the intermediate and long term.
There is some evidence for steroid injections as a short term treatment in carpal tunnel syndrome. Refer to Section G.1 Carpal Tunnel Syndrome for more details.
General complications of injections may include transient neurapraxia, nerve injury, infection, hematoma, glucose elevation, and endocrine changes.
The majority of diabetic patients will experience an increase in glucose following steroid injections. Average increases in one study were 125mg/dL and returned to normal in 48 hours. In other studies, the increased glucose levels remained elevated up to 7 days, especially after multiple injections. All diabetic patients should be told to follow their glucose levels carefully over the 7 days after a steroid injection. For patients who have not been diagnosed with diabetes, one can expect some increase in glucose due to insulin resistance for a few days after a steroid injection. Clinicians should consider diabetic screening tests for those who appear to be at risk for type 2 diabetes and checking hemoglobin A1c and/or glucose for diabetics. Caution should be used when considering steroid injections for patients with an A1c level of 8% or greater.
Intra-articular or epidural injections cause rapid drops in plasma cortisol levels which usually resolve in one to 4 weeks. There is some evidence that an intraarticular injection of 80 mg of methylprednisolone acetate into the knee has about a 25% probability of suppressing the adrenal gland response to exogenous adrenocortocotrophic hormone ACTH for four or more weeks after injection, but complete recovery of the adrenal response is seen by week 8 after injection. This adrenal suppression could require treatment if surgery or other physiologically stressful events occur.
Case reports of Cushing's syndrome, hypopituitarism and growth hormone deficiency have been reported uncommonly and have been tied to systemic absorption of intra-articular and epidural steroid injections. Cushing's syndrome has also been reported from serial occipital nerve injections and paraspinal injections.
Morning cortisol measurements may be ordered prior to repeating steroid injections or prior to the initial steroid injection when the patient has received multiple previous steroid injections.
Given this information regarding increase in blood glucose levels, effects on the endocrine system, and possible osteoporotic influence, it is suggested that intraarticular and epidural injections be limited to a total of 3 to 4 per year (all joints combined). For further specific recommendations, refer to diagnostic sections of this guideline.
* Time to Produce Effect: Immediate with local anesthesia, or within 3 days if no anesthesia.
* Optimum Duration: Usually 1 to 2 injections is adequate.
* Maximum Frequency: Not more than 3 to 4 times annually.
Description: Trigger point injections and dry needling are both generally accepted treatments. Trigger point treatments can consist of dry needling or the injection of local anesthetic, with or without corticosteroid, into highly localized, extremely sensitive bands of skeletal muscle fibers. These muscle fibers produce local and referred pain when activated. Medication is injected in a four-quadrant manner in the area of maximum tenderness. Injection and dry needling efficacy can be enhanced if treatments are immediately followed by myofascial therapeutic interventions, such as vapo-coolant spray and stretch, ischemic pressure massage (myotherapy), specific soft tissue mobilization and physical modalities. There is conflicting evidence regarding the benefit of trigger point injections. A truly blinded study comparing dry needle treatment of trigger points is not feasible. There is no evidence that injection of medications improves the results of trigger-point injections. Needling alone may account for some of the therapeutic response of injections. Needling must be performed by practitioners with the appropriate credentials in accordance with state and other applicable regulations.
There is no indication for conscious sedation for patients receiving trigger point injections or dry needling. The patient must be alert to help identify the site of the injection.
Indications: Trigger point injections and dry needling may be used to relieve myofascial pain and facilitate active therapy and stretching of the affected areas. They are to be used as an adjunctive treatment in combination with other treatment modalities such as active therapy programs. Trigger point injections should be utilized primarily to facilitate functional progress. Patients should continue in an aggressive aerobic and stretching therapeutic exercise program, as tolerated, while undergoing intensive myofascial interventions. Myofascial pain is often associated with other underlying structural problems. Any abnormalities need to be ruled out prior to injection.
Trigger point injections and dry needling are indicated in patients with consistently observed, well-circumscribed trigger points. Trigger point injections and dry needling may demonstrate a local twitch response, characteristic radiation of pain pattern, and local autonomic reaction such as persistent hyperemia following palpation. Generally, neither trigger point injections nor dry needling are necessary unless consistently observed trigger points are not responding to specific, noninvasive, myofascial interventions within approximately a 6-week time frame. However, both trigger point injections and dry needling may be occasionally effective when utilized in the patient with immediate, acute onset of pain or in a post-operative patient with persistent muscle spasm or myofascial pain.
Complications: Potential but rare complications of trigger point injections and dry needling include infection, pneumothorax, anaphylaxis, penetration of viscera, neurapraxia, and neuropathy. If corticosteroids are injected in addition to local anesthetic, there is a risk of local myopathy. Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be immediately repositioned. The following treatment parameters apply to both interventions combined.
* Time to produce effect: Local anesthetic 30 minutes; 24 to 48 hours for no anesthesia.
* Frequency: Weekly. Suggest no more than 4 injection sites per session per week to avoid significant post-injection or post-needling soreness.
* Optimum duration: 4 weeks total for all sites.
* Maximum duration: 8 weeks total for all sites. Occasional patients may require 2 to 4 repetitions of trigger point injection or dry needling series over a 1 to 2 year period.
Laboratory studies may lend some biological plausibility to claims of connective tissue growth, but high quality published clinical studies are lacking. The dependence of the therapeutic effect on the inflammatory response is poorly defined, raising concerns about the use of conventional anti-inflammatory drugs when proliferate injections are given. There is no evidence that prolotherapy compared to a steroid injection for aggravated carpometacarpal arthritis provides a clinically meaningful advantage. Therefore, it is not recommended.
There is no evidence that hyaluronate injections are superior to steroid injections for carpometacarpal thumb arthritis. There is some evidence that intra-articular hyaluronan is not superior to placebo for improving pain in the setting of carpometacarpal osteoarthritis and that it does not improve function in a clinically important way in the first six months after injection. Therefore, they are not recommended.
INTERDISCIPLINARY REHABILITATION PROGRAMS: This is the gold standard of treatment for individuals who have not responded to less intensive modes of treatment. There is good evidence that interdisciplinary programs that include screening for psychological issues, identification of fear-avoidance beliefs and treatment barriers, and establishment of individual functional and work goals will improve function and decrease disability. These programs should assess the impact of pain and suffering on the patient's medical, physical, psychological, social, and/or vocational functioning. In general, interdisciplinary programs evaluate and treat multiple and sometimes irreversible conditions. These conditions include, but are not limited to, painful musculoskeletal, neurological, and other chronic pain conditions and psychological issues; drug dependence, abuse, or addiction; high levels of stress and anxiety; failed surgery; and pre-existing or latent psychopathology. The number of professionals on the team in a chronic pain program may vary due to the complexity of the needs of the person served. The Division recommends consideration of referral to an interdisciplinary program within six months post-injury in patients with delayed recovery, unless successful surgical interventions or other medical and/or psychological treatment complications are at issue.
Chronic pain patients need to be treated as outpatients within a continuum of treatment intensity. Outpatient chronic pain programs are available with services provided by a coordinated interdisciplinary team within the same facility (formal) or as coordinated among practices by the authorized treating physician (informal). Formal programs are able to provide a coordinated, high-intensity level of services and are recommended for most chronic pain patients who have received multiple therapies during acute management.
Patients with addiction problems, high-dose opioid use, or abuse of other drugs may require inpatient and/or outpatient chemical dependency treatment programs before or in conjunction with other interdisciplinary rehabilitation. Guidelines from the American Society of Addiction Medicine are available and may be consulted relating to the intensity of services required for different classes of patients in order to achieve successful treatment.
Informal interdisciplinary pain programs may be considered for patients who are currently employed, those who cannot attend all-day programs, those with language barriers, or those living in areas not offering formal programs. Before treatment has been initiated, the patient, physician, and insurer should agree on treatment approach, methods, and goals. Generally, the type of outpatient program needed will depend on the degree of impact the pain has had on the patient's medical, physical, psychological, social, and/or vocational functioning.
When referring a patient for formal outpatient interdisciplinary pain rehabilitation, an occupational rehabilitation program, or an opioid treatment program, the Division recommends the program meets the criteria of the Commission on Accreditation of Rehabilitation Facilities (CARF).
Inpatient pain rehabilitation programs are rarely needed but may be necessary for patients with any of the following conditions:
* Communication: To ensure positive functional outcomes, communication between the patient, insurer, and all professionals involved must be coordinated and consistent. Any exchange of information must be provided to all parties, including the patient. Care decisions should be communicated to all parties and should include the family and/or support system.
* Documentation: Through documentation by all professionals involved and/or discussions with the patient, it should be clear that functional goals are being actively pursued and measured on a regular basis to determine their achievement or need for modification. It is advisable to have the patient undergo objective functional measures.
* Treatment Modalities: Use of modalities may be necessary early in the process to facilitate compliance with and tolerance to therapeutic exercise, physical conditioning, and increasing functional activities. Active treatments should be emphasized over passive treatments. Active and self-monitored passive treatments should encourage self-coping skills and management of pain, which can be continued independently at home or at work. Treatments that can foster a sense of dependency by the patient on the caregiver should be avoided. Treatment length should be decided based upon observed functional improvement. For a complete list of active and passive therapies, refer to Section H.13 Therapy - Active and H.14 Therapy - Passive. All treatment timeframes may be extended based on the patient's positive functional improvement.
* Therapeutic Exercise Programs: A therapeutic exercise program should be initiated at the start of any treatment rehabilitation. Such programs should emphasize education, independence, and the importance of an on-going exercise regimen. There is good evidence that exercise, alone or as part of a multi-disciplinary program, results in decreased disability for workers with non-acute low back pain. There is not sufficient evidence to support the recommendation of any particular exercise regimen over any other exercise regimen.
* Return-to-Work: The authorized treating physician should continually evaluate the patients for their potential to return to work. For patients who are currently employed, efforts should be aimed at keeping them employed. Formal rehabilitation programs should provide assistance in creating work profiles. For more specific information regarding return to work, refer to H.11 Return-to-Work.
* Patient Education: Patients with pain need to re-establish a healthy balance in lifestyle. All providers should educate patients on how to overcome barriers to resuming daily activity, including pain management, decreased energy levels, financial constraints, decreased physical ability, and change in family dynamics.
* Psychosocial Evaluation and Treatment: Psychosocial evaluation should be initiated, if not previously done. Providers should have a thorough understanding of the patient's personality profile, especially if dependency issues are involved. Psychosocial treatment may enhance the patient's ability to participate in pain treatment rehabilitation, manage stress, and increase their problem-solving and self-management skills.
* Vocational Assistance: Vocational assistance can define future employment opportunities or assist patients in obtaining future employment. Refer to H.11 Return-to-Work for detailed information.
* Interdisciplinary programs are characterized by a variety of disciplines that participate in the assessment, planning, and/or implementation of the treatment program. These programs are for patients with greater levels of perceived disability, dysfunction, de-conditioning, and psychological involvement. Programs should have sufficient personnel to work with the individual in the following areas: behavioral, functional, medical, cognitive, pain management, psychological, social, and vocational.
The interdisciplinary team maintains consistent integration and communication to ensure that all team members are aware of the plan of care for the patient, are exchanging information, and implement the plan of care. The team members make interdisciplinary team decisions with the patient and then ensure that decisions are communicated to the entire care team.
The Medical Director of the pain program should ideally be board certified in pain management. Alternatively, he/she should be board certified in his/her specialty area and have completed a one-year fellowship in interdisciplinary pain medicine or palliative care recognized by a national board. As a final alternative, he or she should have two years of experience in an interdisciplinary pain rehabilitation program. Teams that assist in the accomplishment of functional, physical, psychological, social, and vocational goals must include: a medical director, pain team physician(s), who should preferably be board certified in an appropriate specialty, and a pain team psychologist. Professionals from other disciplines on the team may include, but are not limited to: a biofeedback therapist, an occupational therapist, a physical therapist, a registered nurse (RN), a case manager, an exercise physiologist, a psychologist, a psychiatrist, and/or a nutritionist.
* Time to Produce Effect: 3 to 4 weeks.
* Frequency: Full time programs - No less than 5 hours per day, 5 days per week; part-time programs - 4 hours per day, 2-3 days per week.
* Optimum Duration: 3 to 12 weeks at least 2-3 times a week. Follow-up visits weekly or every other week during the first 1 to 2 months after the initial program is completed.
* Maximum Duration: 4 months for full-time programs and up to 6 months for part-time programs. Periodic review and monitoring thereafter for 1 year, and additional follow-up based on the documented maintenance of functional gains.
There is some evidence that an integrated care program, consisting of workplace interventions and graded activity teaching that pain need not limit activity, is effective in returning patients with chronic low back pain to work, even with minimal reported reduction of pain. The occupational medicine rehabilitation interdisciplinary team should, at a minimum, be comprised of a qualified medical director who is board certified with documented training in occupational rehabilitation; team physicians having experience in occupational rehabilitation; an occupational therapist; and a physical therapist.
As appropriate, the team may also include any of the following: chiropractor, an RN, a case manager, a psychologist, a vocational specialist, or a certified biofeedback therapist.
* Time to Produce Effect: 2 weeks.
* Frequency: 2 to 5 visits per week, up to 8 hours per day.
* Optimum Duration: 2 to 4 weeks.
* Maximum Duration: 6 weeks. Participation in a program beyond 6 weeks must be documented with respect to need and the ability to facilitate positive symptomatic and functional gains.
This program is different from a formal program in that it involves lower frequency and intensity of services/treatment. Informal rehabilitation is geared toward those patients who do not need the intensity of service offered in a formal program or who cannot attend an all-day program due to employment, daycare, language, or other barriers.
Patients should be referred to professionals experienced in outpatient treatment of chronic pain. The Division recommends the authorized treating physician consult with physicians experienced in the treatment of chronic pain to develop the plan of care. Communication among care providers regarding clear objective goals and progress toward the goals is essential. Employers should be involved in return to work and work restrictions. The family and/or social support system should be included in the treatment plan. Professionals from other disciplines likely to be involved include: a biofeedback therapist, an occupational therapist, a physical therapist, an RN, a psychologist, a case manager, an exercise physiologist, a psychiatrist, and/or a nutritionist.
* Time to Produce Effect: 3 to 4 weeks.
* Frequency: Full-time programs - No less than 5 hours per day, 5 days per week; Part-time programs - 4 hours per day for 2-3 days per week.
* Optimum Duration: 3 to 12 weeks at least 2-3 times a week. Follow-up visits weekly or every other week during the first 1 to 2 months after the initial program is completed.
* Maximum Duration: 4 months for full-time programs and up to 6 months for part-time programs. Periodic review and monitoring thereafter for 1 year, and additional follow-up based upon the documented maintenance of functional gains.
General Principles of Job Site Alteration
There is no single factor or combination of factors that is proven to prevent or ameliorate cumulative trauma conditions, but a combination of ergonomic and psychosocial factors are generally considered to be important. Ergonomic factors that may be considered include use of force, repetition, awkward positions, upper extremity vibration, cold environment, and contact pressure on the nerve. Psychosocial factors to be considered include pacing, degree of control over job duties, perception of job stress, and supervisory support.
All job site evaluations should include suggested ergonomic changes as applicable. It is inappropriate to limit a job site evaluation to a strict isolated evaluation of causation risk factors only.
Job evaluation and modification should include input from a licensed health care professional with training in ergonomics or a certified ergonomist; the employee; and the employer. The employee must be observed performing relevant job functions in order for the job site evaluation to be a valid representation of a typical workday. If the employee is unable to perform the job function for observation, a co-worker in an identical job position may be observed instead. Periodic follow-up is recommended to assess the effectiveness of the intervention and need for additional ergonomic changes.
Because ergonomic changes are a required medical treatment for cumulative trauma conditions and the person performing the evaluations is a health care professional, it is assumed the insurer will pay for the job site evaluation.
SEE NEXT PAGE FOR ERGONOMIC CONSIDERATIONS TABLE
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Type of Job Duty |
Hours per Day |
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Pinching an unsupported object(s) weighing 2 lbs or more per hand, or pinching with a force of 4 lbs or more per hand (comparable to pinching a half-ream of paper): |
More than 3 hours total/day |
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1. Highly repetitive motion. |
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2. Wrist palmar flexion greater than 45 degrees, wrist extension greater than 30 degrees, ulnar deviation greater than 20 degrees, or radial deviation greater than 20 degrees. |
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3. Most of the work cycle performed with the elbow flexed equal to or greater than 90 degrees. |
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4. No other risk factors. |
More than 4 hours total/day |
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Gripping (an) unsupported object(s) weighing 10 lbs or more/hand, or gripping with a force of 10 lbs or more/hand (comparable to clamping light duty automotive jumper cables onto a batter): *Handles should be rounded and soft, with at least 1.25''-2.0" in diameter grips at least 5" long. Preferably, a power grip should be used. |
More than 3 hours total/day |
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1. Highly repetitive motion. |
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2. Wrist palmar flexion greater than 45 degrees, wrist extension greater than 30 degrees, ulnar deviation greater than 20 degrees, or radial deviation greater than 20 degrees. |
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3. Most of the work cycle performed with the elbow flexed equal to or greater than 90 degrees. |
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No other risk factors. |
More than 4 hours total/day |
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Repetitive Motion (using the same motion with little or no variation) with a cycle time 30 seconds or less or greater than 50% of cycle time performing the same task: |
More than 2 hours total/day |
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1. High, forceful exertions with the hands, with wrist palmar flexion greater than 45 degrees, wrist extension greater than 30 degrees, ulnar deviation greater than 20 degrees, or radial deviation greater than 20 degrees. |
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2. Most of the work cycle performed with the elbow flexed equal to or greater than 90 degrees. |
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3. No other risk factors. |
More than 4 hours total/day |
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Intensive Keying: |
More than 4 hours total/day |
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1. Wrist palmar flexion greater than 45 degrees, wrist extension greater than 30 degrees, ulnar deviation greater than 20 degrees, or radial deviation greater than 20 degrees. |
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2. Most of the work cycle performed with the elbow flexed equal to or greater than 90 degrees. |
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3. No other risk factors. |
More than 7 hours total/day |
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Repeated Impact: |
More than 2 hours total/day |
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1. Using the hand (heel/base of palm) as a hammer more than once per minute. |
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Vibration: Two determinants of the tolerability of segmental vibration of the hand are the frequency and the acceleration of the motion of the vibrating tool, with lower frequencies being more poorly tolerated at a given level of imposed acceleration, expressed below in multiples of the acceleration due to gravity. |
More than 30 minutes at a time |
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1. Frequency range 8-15 Hz and acceleration 6 g |
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2. Frequency range 80 Hz and acceleration 40 g |
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3. Frequency range 250 Hz and acceleration 250 g |
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Vibration, continued: |
More than 4 hours at a time |
|
4. Frequency range 8-15 Hz and acceleration 1.5 g |
|
|
5. Frequency range 80 Hz and acceleration 6 g |
|
|
6. Frequency range 250 Hz and acceleration 20 g |
* This table may not be used to establish causation. Refer to Section D.3 Medical Causation for Cumulative Trauma Conditions. Recommendations for ergonomic changes to make the workplace more comfortable and efficient for the worker are not identical to risk factors which may cause an identified cumulative trauma condition.
Oral non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are useful in treating conditions associated with degenerative joint disease and/or inflammation. Topical medications may also be useful in controlling pain.
There is good evidence that acetaminophen is not more effective than placebo for the treatment of knee osteoarthritis. Thus, it may not be useful for upper extremity osteoarthritis. It may be used on patients with contraindications to other medications.
* Optimum Duration: 7 to 10 days.
* Maximum Duration: Long-term use as indicated on a case-by-case basis. Use of this substance long-term (for 3 days per week or greater) may be associated with rebound pain upon cessation.
Topical NSAIDs may be more appropriate for some patients as there is some evidence they are associated with fewer systemic adverse events than oral NSAIDs.
NSAIDs may be associated with non-unions; thus, their use with fractures is questionable.
Certain NSAIDs may have interactions with various other medications. Individuals may have adverse events not listed above. Intervals for metabolic screening are dependent on the patient's age and general health status and should be within parameters listed for each specific medication. Complete Blood Count (CBC) and liver and renal function should be monitored at least every six months in patients on chronic NSAIDs and initially when indicated.
* Optimal Duration: 1 week.
* Maximum duration: 1 year. Use of these substances long-term (3 days per week or greater) is associated with rebound pain upon cessation.
COX-2 inhibitors should not be first-line for low risk patients who will be using an NSAID short-term. COX-2 inhibitors are indicated in select patients who do not tolerate traditional NSAIDs. Serious upper GI adverse events can occur even in asymptomatic patients. Patients at high risk for GI bleeding include those who use alcohol, smoke, are older than 65, take corticosteroids or anti-coagulants, or have a longer duration of therapy. Celecoxib is contraindicated in sulfonamide allergic patients.
* Optimal Duration: 7 to 10 days.
* Maximum Duration: Chronic use is appropriate in individual cases. Use of these substances long-term (3 days per week or greater) is associated with rebound pain upon cessation.
Opioids medications should be prescribed with strict time, quantity, and duration guidelines, and with definitive cessation parameters. Pain is subjective in nature and should be evaluated using a pain scale and assessment of function to rate effectiveness of the opioid prescribed. It is recommended that the provider access the Colorado Prescription Drug Monitoring Program (PDMP) before prescribing opioids. The PDMP allows the prescribing physician to see most of the controlled substances prescribed by other physicians for an individual patient. Any use beyond the maximum should be documented and justified based on the diagnosis and/or invasive procedures.
* Optimum Duration: Usually 3-5 days post-operatively
* Maximum Duration: 2 weeks. Use beyond 2 weeks is acceptable in appropriate cases when functional improvement is documented. Refer to the Division's Chronic Pain Disorder Medical Treatment Guidelines, which give a detailed discussion regarding medication use in chronic pain management. Use beyond 30 days after non-traumatic injuries, or 6 weeks post-operatively is not recommended. If longer treatment is justified, the physician should access the Colorado Prescription Drug Monitoring Program (PDMP) and follow recommendations in the Chronic Pain Guideline.
Anti-anxiety medications are best used for short-term treatment (i.e., less than 6 months). Accompanying sleep disorders are best treated with sedating antidepressants prior to bedtime. Frequently, combinations of the above agents are useful. As a general rule, physicians should assess the patient's prior history of substance abuse or depression prior to prescribing any of these agents.
Due to the habit-forming potential of the benzodiazepines and other drugs found in this class, they are not generally recommended.Refer to the Chronic Pain Guidelines which give a detailed discussion regarding medication use in chronic pain management.
* Optimal Duration: 1 to 6 months.
* Maximum Duration: 6 to 12 months, with monitoring.
There is some evidence that among adults motivated to quit smoking, 12 weeks of open-label treatment including counseling and one of the following: nicotine patch, varenicline, or combination nicotine replacement therapy (nicotine patch and nicotine lozenge) are equally effective in assisting motivated smokers to quit smoking over a period of one year.
There is some evidence that among adults motivated to quit smoking, abrupt smoking cessation is more effective than gradual cessation for abstinence lasting over a period of 4 weeks to 6 months, even for smokers who initially prefer to quit by gradual reduction.
It is necessary that all topical agents be used with strict instructions for application as well as the maximum number of applications per day to obtain the desired benefit and avoid potential toxicity. As with all medications, patient selection must be rigorous to select those patients with the highest probability of compliance. Refer to Section H.14.c Iontophoresis in Therapy-Passive for information regarding topical iontophoretic agents.
* Optimal Duration: 1 week.
* Maximal Duration: 2 weeks per episode.
* Optimal Duration: 1 week.
* Maximal Duration: 2 weeks per episode.
* Time to effect: 3 weeks vii. Topical Lidocaine: There is no evidence that lidocaine patches have a functional benefit over other well-accepted treatment for carpal tunnel. At the time of this writing, post-herpetic neuralgia is the only medical condition for which topical lidocaine patch is FDA approved (Food and Drug Administration). The patches are not generally recommended, although may be used when the primary complaint of the patient is pain and the patient refuses a steroid injection.
These generally-accepted programs are work-related, outcome focused, individualized treatment programs. Objectives of the programs include, but are not limited to, improvement of cardiopulmonary and neuromusculoskeletal functions (strength, endurance, movement, flexibility, stability, and motor control functions), patient education, and symptom relief. The goal is for patients to gain full- or optimal-function and return to work. The service may include the time limited use of passive modalities with progression to achieve treatment and/or simulated/real work.
* Length of Visit: 1 to 2 hours per day.
* Frequency: 2 to 5 visits per week.
* Optimum Duration: 2 to 4 weeks.
* Maximum Duration: 6 weeks. Participation in a program beyond 6 weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.
* Length of Visit: 2 to 6 hours per day.
* Frequency: 2 to 5 visits per week.
* Optimum Duration: 2 to 4 weeks.
* Maximum Duration: 6 weeks. Participation in a program beyond 6 weeks must be documented with respect to need and the ability to facilitate positive symptomatic or functional gains.
Psychosocial treatment is a well-established therapeutic and diagnostic intervention with selected use in acute pain patients and more widespread use in sub-acute and chronic pain populations. Psychosocial treatment is recommended as an important component in the total management of a patient with chronic pain and should be implemented as soon as the problem is identified.
Several studies have noted lack of a direct connection between impairment and disability. It appears that the lack of connection is due to differences among individuals in level of depression, coping strategies, or other psychological distress.
If a diagnosis consistent with the standards of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) has been determined, the patient should be evaluated for the potential need for psychiatric medications. The authorized treating physician or the consulting psychiatrist may order the use of any medication to treat a diagnosed condition. Visits for management of psychiatric medications are medical in nature and are not a component of psychosocial treatment. Therefore, separate visits for medication management may be necessary, depending on the patient and medications selected.
Psychosocial interventions include psychotherapeutic treatments for mental health conditions as well as behavioral medicine treatments. These interventions may similarly be beneficial for patients without psychiatric conditions but who may need to make major life changes to cope with pain or adjust to disability. Examples of these treatments include cognitive behavioral therapy (CBT), relaxation training, mindfulness training, and sleep hygiene training.
The screening or diagnostic workup should clarify and distinguish between pre-existing, aggravated, and/or purely causative psychological conditions. Therapeutic and diagnostic modalities include, but are not limited to, individual counseling and group therapy. Treatment can occur within an individualized model, a multi-disciplinary model, or a structured pain management program.
A psychologist with a PhD, PsyD, or EdD credentials or a psychiatric MD/DO may perform psychosocial treatments. The following professionals may also treat in consultation with a psychologist with a PhD, PsyD, or EdD or a psychiatric MD/DO: other licensed mental health providers; licensed health care providers with training in CBT; or licensed and certified CBT therapists who have experience in treating chronic pain disorders in injured workers.
CBT is a group of psychological therapies that are sometimes referred to by more specific names such as Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy. Variations of CBT methods can be used to treat a variety of conditions, including chronic pain, depression, anxiety, phobias, and post-traumatic stress disorder (PTSD). For patients with multiple diagnoses, more than one type of CBT might be needed. The CBT used in research studies is often "manualized CBT," meaning that the treatment follows a specific protocol in a manual. In clinical settings, CBT may involve the use of standardized materials, but it is also commonly adapted by a psychologist or psychiatrist to the patient's unique circumstances. If the CBT is being performed by a non-mental health professional, a manual approach would be strongly recommended. CBT must be distinguished from neuropsychological therapies used to teach compensatory strategies to brain injured patients, which are also called "cognitive therapy."
It should be noted that most clinical trials on CBT exclude subjects who have significant psychiatric diagnoses. Consequently, the selection of patients for CBT should include the following considerations. CBT is instructive and structured, using an educational model with homework to teach inductive rational thinking. Because of this educational model, a certain level of literacy is assumed for most CBT protocols. Patients who lack the cognitive and educational abilities required by a CBT protocol are unlikely to be successful. Further, given the highly structured nature of CBT, it is more effective when a patient's circumstances are relatively stable. For example, if a patient is about to be evicted, is actively suicidal, or is coming to sessions intoxicated, these matters will generally preempt CBT treatment for pain, and require other types of psychotherapeutic response. Conversely, literate patients whose circumstances are relatively stable, but who catastrophize or cope poorly with pain or disability are often good candidates for CBT for pain. Similarly, literate patients whose circumstances are relatively stable, but who exhibit unfounded medical phobias, are often good candidates for CBT for anxiety.
There is good evidence that cognitive intervention reduces low back disability in the short-term and in the long-term. In one of the studies, the therapy consisted of 6, 2-hour sessions given weekly to workers who had been sick-listed for 8-12 weeks. Comparison groups include those who received routine care. There is good evidence that psychological interventions, especially CBT, are superior to no psychological intervention for chronic low back pain. There is also good evidence that self-regulatory interventions, such as biofeedback and relaxation training, may be equally effective. There is good evidence that six group therapy sessions lasting one and a half hours each focused on CBT skills improved function and alleviated pain in uncomplicated sub-acute and chronic low back pain patients. There is some evidence that CBT provided in 7, 2-hour small group sessions can reduce the severity of insomnia in chronic pain patients. A Cochrane meta-analysis grouped very heterogeneous behavioral interventions and concluded that there was good evidence that CBT may reduce pain and disability, but the effect size was uncertain. In total, the evidence clearly supports CBT, and it should be offered to all chronic pain patients who do not have other serious issues, as discussed above.
CBT is often combined with active therapy in an interdisciplinary program, whether formal or informal. It must be coordinated with a psychologist or psychiatrist. CBT can be done in a small group or individually, and the usual number of treatments varies between 8 and 16 sessions.
Before CBT is done, the patient must have a full psychological evaluation. The CBT program must be done under the supervision of a psychologist with a PhD, PsyD, EdD, or psychiatric MD/DO.
Psychological Diagnostic and Statistical Manual of Mental Disorders (DSM) disorders are common in chronic pain. One study demonstrated that the majority of patients who had failed other therapy and participated in an active therapy program also suffered from major depression. However, in a program that included CBT and other psychological counseling, the success rate for return to work was similar for those with and without a DSM diagnosis. This study further strengthens the argument for having some psychological intervention included in all chronic pain treatment plans.
For all psychological/psychiatric interventions, an assessment and treatment plan with measurable behavioral goals, time frames, and specific interventions must be provided to the treating physician prior to initiating treatment. A status report must be provided to the authorized treating physician every two weeks during initial more frequent treatment and monthly thereafter. The report should provide documentation of progress toward functional recovery and a discussion of the psychosocial issues affecting the patient's ability to participate in treatment. The report should also address pertinent issues such as pre-existing, aggravated, and/or causative issues, as well as realistic functional prognosis.
* Time to Produce Effect: 6 to 8 1-2 hour sessions, group or individual (1-hour individual or 2-hour group).
* Maximum Duration: 16 sessions.
NOTE: Before CBT is done, the patient must have a full psychological evaluation. The CBT program must be done under the supervision of a psychologist with a PhD, PsyD, or EdD or a Psychiatric MD/DO.
* Time to Produce Effect: 6 to 8 weeks.
* Frequency: 1 to 2 times weekly for the first 2 weeks (excluding hospitalization, if required), decreasing to 1 time per week for the second month. Thereafter, 2 to 4 times monthly with the exception of exacerbations, which may require increased frequency of visits. Not to include visits for medication management
* Optimum Duration: 2 to 6 months.
* Maximum Duration: 6 months. Not to include visits for medication management. For select patients, longer supervised psychological/psychiatric treatment may be required, especially if there are ongoing medical procedures or complications. If counseling beyond 6 months is indicated, the management of psychosocial risks or functional progress must be documented. Treatment plan/progress must show severity.
Continuation of normal daily activities is the recommendation for most patients, since immobility will negatively affect rehabilitation. Prolonged immobility results in a wide range of deleterious effects, such as a reduction in aerobic capacity and conditioning, loss of muscle strength and flexibility, increased segmental stiffness, promotion of bone demineralization, impaired disc nutrition, and the facilitation of the illness role.
Some level of immobility may occasionally be appropriate, including splinting/casting. While these interventions may be occasionally ordered in the acute phase, the provider should be aware of their impact on the patient's ability to adequately comply with and successfully complete rehabilitation. Activity should be increased based on the improvement of core strengthening.
Patients should be educated regarding the detrimental effects of immobility versus the efficacious use of limited rest periods. Adequate rest allows the patient to comply with active treatment and benefit from the rehabilitation program. In addition, complete work cessation should be avoided, if possible, since it often further aggravates the pain presentation and promotes disability. Modified return to work is almost always more efficacious and rarely contraindicated in the vast majority of injured workers.
Return to work and/or work-related activities, whenever possible, is one of the major components in treatment and rehabilitation. Return to work should be addressed by each workers' compensation provider at the first meeting with the injured employee and updated at each additional visit. A return-to-work format should be part of a company's health plan, knowing that return to work can decrease anxiety, reduce the possibility of depression, and reconnect the worker with society.
Because a prolonged period of time off work will decrease the likelihood of return to work, the first weeks of treatment are crucial in preventing and/or reversing chronicity and disability mindset. In complex cases, experienced nurse case managers may be required to assist in return to work. Other services, including psychological evaluation and/or treatment, job site analysis, and vocational assistance, may be employed.
Two counseling sessions with an occupational physician, and work site visit if necessary, may be helpful for workers who are concerned about returning to work.
At least one study suggests that health status is worse for those patients who do not return to work than those who do. Self-employment and injury severity predict return to work. Difficulty with pain control, ADLs, and anxiety and depression were common.
The following should be considered when attempting to return an injured worker with chronic pain to work.
Recommendations to Employers and Employees of Small Businesses: employees of small businesses who are diagnosed with chronic pain may not be able to perform any jobs for which openings exist. Temporary employees may fill those slots while the employee functionally improves. Some small businesses hire other workers, and if the injured employee returns to the job, the supervisor/owner may have an extra employee. Case managers may assist with resolution of these problems and with finding modified job tasks or jobs with reduced hours, etc., depending on company philosophy and employee needs.
Recommendations to Employers and Employees of Mid-sized and Large Businesses: Employers are encouraged by the Division to identify modified work within the company that may be available to injured workers with chronic pain who are returning to work with temporary or permanent restrictions. To assist with temporary or permanent placement of the injured worker, it is suggested that a program be implemented that allows the case manager to access descriptions of all jobs within the organization.
Sleep disturbances are a common secondary symptom of cumulative trauma conditions. Although primary insomnia may accompany pain as an independent co-morbid condition, it more commonly occurs secondary to the pain condition itself. Exacerbations of pain often are accompanied by exacerbations of insomnia; the reverse can also occur. Sleep laboratory studies have shown disturbances of sleep architecture in pain patients. Loss of deep slow-wave sleep and increase in light sleep occur and sleep efficiency, the proportion of time in bed spent asleep, is decreased. These changes are associated with patient reports of non-restorative sleep. Many affected patients develop behavioral habits that exacerbate and maintain sleep disturbances. Excessive time in bed, irregular sleep routine, napping, low activity, and worrying in bed are all maladaptive responses that can arise in the absence of any psychopathology. Behavioral modifications are accepted interventions, easily implemented, and can include:
These modifications should be undertaken before sleeping medication is prescribed for long-term use.
The following active therapies are widely used and accepted methods of care for a variety of work-related injuries. They are based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion, and alleviating discomfort. Active therapy requires an internal effort by the individual to complete a specific exercise or task, and thus assists in developing skills promoting independence and self-care after discharge. This form of therapy requires supervision from a therapist or medical provider such as verbal, visual, and/or tactile instructions. At times a provider may help stabilize the patient or guide the movement pattern, but the energy required to complete the task is predominantly executed by the patient.
Patients should be instructed to continue active therapies at home as an extension of the treatment process in order to maintain improvement levels. Follow-up visits to reinforce and monitor progress and proper technique are recommended. Home exercise can include exercise with or without mechanical assistance or resistance and functional activities with assistive devices. Frequency times and duration of treatment apply only to diagnoses not previously covered in Sections F and G.
On occasion, specific diagnoses and post-surgical conditions may warrant durations of treatment beyond those listed as "maximum." Factors such as exacerbation of symptoms, re-injury, interrupted continuity of care, need for post-operative therapy, and comorbidities may also extend durations of care. Specific goals with objectively measured functional improvement during treatment must be cited to justify extended durations of care. If no functional gain is observed after the number of treatments under "time to produce effect" has been completed, then the treatment should be discontinued and alternative treatment interventions, further diagnostic studies, or further consultations should be pursued.
* Time to Produce Effect: 4 to 5 treatments.
* Frequency: 3 to 5 times per week.
* Optimum Duration: 4 to 6 weeks.
* Maximum Duration: 6 weeks.
* Time to Produce Effect: 4 to 5 treatments.
* Frequency: 3 to 5 times per week.
* Optimum Duration: 4 to 6 weeks.
* Maximum Duration: 6 weeks.
* Time to Produce Effect: 2 to 4 weeks.
* Frequency: Up to 5 times per day by patient (patient-initiated).
* Optimum Duration: 2 provider-directed sessions.
* Maximum Duration: 3 provider-directed sessions.
* Time to Produce Effect: 2 to 6 treatments.
* Frequency: 3 times per week.
* Optimum Duration: 4 to 8 weeks.
* Maximum Duration: 8 weeks.
* Time to Produce Effect: 2 to 6 treatments.
* Frequency: 3 to 5 times per week.
* Optimum Duration: 4 to 8 weeks.
* Maximum Duration: 8 weeks.
Most of the following passive therapies and modalities are generally well-accepted methods of care for a variety of work-related injuries. This includes those treatment modalities that do not require energy expenditure on the part of the patient. They are principally effective during the early phases of treatment and are directed at controlling symptoms such as pain, inflammation, swelling, and at improving the rate of healing soft tissue injuries. They should be used in adjunct with active therapies to help control swelling, pain and inflammation during the rehabilitation process. They may be used intermittently as a therapist deems appropriate or regularly if there are specific goals with objectively measured functional improvements during treatment.
On occasion, specific diagnoses and post-surgical conditions may warrant durations of treatment beyond those listed as "maximum." Factors such as exacerbation of symptoms, re-injury, interrupted continuity of care, need for post-operative therapy, and comorbidities may also extend durations of care. Specific goals with objectively measured functional improvement during treatment must be cited to justify extended durations of care. If no functional gain is observed after the number of treatments under "time to produce effect" has been completed, then the treatment should be discontinued and alternative treatment interventions, further diagnostic studies, or further consultations should be pursued.
The following passive therapies and modalities are listed in alphabetical order.
Electrical stimulation is rarely used in cumulative trauma conditions. However, high voltage, galvanic, and/or interferential stimulators may assist in edema control to decrease pain and improve therapy compliance. It may be appropriate in rare situations when nerve damage or other work related issues have resulted in muscle atrophy and the patient is unable to engage in sufficient active therapy to increase muscle mass. TENS therapy or PENS are not indicated for diagnoses in these Guidelines. Refer to Exhibit 9 Chronic Pain Medical Treatment Guidelines for usage.
* Time to Produce Effect: 2 to 4 treatments.
* Frequency: Varies, depending upon indication, between 2 to 3 times/day to 1 time/week. Provide home unit if frequent use.
* Optimum Duration: 2 to 4 weeks.
* Maximum Duration: Home unit as needed.
There is some evidence that highly motivated tennis players may show up to a 35% additional improvement over no other treatment when administered low energy shock wave treatment without local anesthesia. Two other studies are not of sufficient quality to qualify for evidence. There is some evidence that three weekly sessions of radial ESWT and sham ESWT lead to statistically similar symptomatic and functional outcomes at three months, but a benefit of radial ESWT cannot be ruled out due to uncertainties in the data.
The preponderance of evidence does not support the efficacy of ESWT in the working population; therefore, it is not recommended.
* Time to Produce Effect: 1 to 4 treatments.
* Frequency: 2 to 3 times per week with at least 48 hours between treatments.
* Optimum Duration: 6 to 9 treatments.
* Maximum Duration: 9 treatments.
High velocity, low amplitude (HVLA) technique, chiropractic manipulation, osteopathic manipulation, muscle energy techniques, counter strain, and non-force techniques are all types of manipulative treatment. This may be applied by osteopathic physicians (D.O.), chiropractors (D.C.), properly trained physical therapists (P.T.), properly trained occupational therapists (O.T.), or properly trained physicians. Under these different types of manipulation exist many subsets of different techniques that can be described as a) "direct," or a forceful engagement of a restrictive/pathologic barrier; b) "indirect," or a gentle/non-forceful disengagement of a restrictive/pathologic barrier; c) the patient actively assisting in the treatment; and d) the patient relaxing, allowing the practitioner to move the body tissues. When the proper diagnosis is made and coupled with the appropriate technique, manipulation has no contraindications and can be applied to all tissues of the body. Pre-treatment assessment should be performed as part of each manipulative treatment visit to ensure that the correct diagnosis and correct treatment is employed. Refer to the specific diagnosis for use with cumulative trauma conditions.
There is good evidence that manual and manipulative therapy combined with exercise and/or multimodal therapy shows small, clinically important reductions in pain and improved physical function in the short-term care (<=3-6 months) of patients with lateral epicondylitis and carpal tunnel syndrome.
There is some evidence that both Cyriax physiotherapy (deep transverse friction massage combined with mills manipulation) and phonophoresis with supervised exercise and static stretching are effective over 4 weeks. Both treatments decrease pain, increase pain-free grip strength, and improve functional status in people with lateral epicondylalgia. However, Cyriax physiotherapy provides a superior benefit compared to phonophoresis with supervised exercise and static stretching.
* Time to Produce Effect (for all types of manipulative treatment): 1 to 6 treatments.
* Frequency: Up to 3 times per week for the first 3 weeks as indicated by the severity of involvement and the desired effect.
* Optimum Duration: 10 treatments.
* Maximum Duration: 12 treatments. Additional visits may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with co-morbidities. Functional gains including increased range of motion must be demonstrated to justify continuing treatment.
There is some evidence that the muscle energy technique is superior to corticosteroid injection in improving grip strength in lateral epicondylitis. The muscle energy technique is a manual therapy technique in which the patient performs voluntary contraction against a counter force from the provider to stretch muscles and improve range of motion. However, it is not clear that the technique is better than no treatment.
There is good evidence that manual and manipulative therapy combined with exercise and/or multimodal therapy shows small, clinically important reductions in pain and improved physical function in the short-term care (<=3-6 months) of patients with lateral epicondylitis and carpal tunnel syndrome.
There is some evidence that both Cyriax physiotherapy (deep transverse friction massage combined with mills manipulation) and phonophoresis with supervised exercise and static stretching are effective over 4 weeks. Both treatments decrease pain, increase pain-free grip strength, and improve functional status in people with lateral epicondylalgia. However, Cyriax physiotherapy provides a superior benefit compared to phonophoresis with supervised exercise and static stretching.
* Time to Produce Effect: 4 to 6 treatments.
* Frequency: 2 to 3 times per week.
* Optimum Duration: 4 to 6 weeks.
* Maximum Duration: 6 weeks.
* Time to Produce Effect: 4 to 6 treatments.
* Frequency: 2 to 3 times per week.
* Optimum Duration: 4 to 6 weeks.
* Maximum Duration: 6 weeks.
* Time to Produce Effect: Immediate.
* Frequency: 1 to 2 times per week.
* Optimum Duration: 6 weeks.
* Maximum Duration: 2 months.
Splint comfort is critical and may affect compliance. Although off-the-shelf splints are usually sufficient, custom thermoplastic splints may provide better fit for certain patients. Splint use is rarely mandatory. Providers should be aware that over usage is counterproductive, and counsel patients to minimize daytime splint use in order avoid detrimental effects, such as, stiffness and dependency over time.
* Time to Produce Effect: 1 to 4 weeks.
* Frequency: Daytime intermittent or night use, depending on symptoms and activities.
* Optimum Duration: 4 to 8 weeks.
* Maximum Duration: 2 to 4 months. If symptoms persist, consideration should be given to further diagnostic studies or to other treatment options.
* Time to Produce Effect: 1 to 4 treatments.
* Frequency: 1 to 3 times per week.
* Optimum Duration: 4 weeks.
* Maximum Duration: 1 month. If beneficial, provide with home unit or purchase if effective.
* Time to Produce Effect: Immediate.
* Frequency: 2 to 5 times per week (clinic). Home treatment as needed.
* Optimum Duration: 3 weeks as primary or intermittently as an adjunct to other therapeutic procedures up to 2 months.
* Maximum Duration: 2 months. If symptoms persist, provider should consider further diagnostic studies or other treatment options.
* Time to Produce Effect: 4 to 8 treatments.
* Frequency: 2 to 3 times per week.
* Optimum Duration: 4 to 6 weeks.
* Maximum Duration: 2 months.
VOCATIONAL REHABILITATION: is a generally accepted intervention. However, Senate Bill 87-79 limits the use of vocational rehabilitation in Colorado. This treatment requires adequate evaluation of patients for quantification of highest functional level, motivation, and achievement of maximum medical improvement (MMI). Vocational rehabilitation may be as simple as returning to the original job or as complicated as being retrained for a new occupation. The effectiveness of vocational rehabilitation may be enhanced when performed in combination with work hardening and work conditioning.
It may also be beneficial for full vocational rehabilitation to be started before MMI if it is evident that the injured worker will be unable to return to his/her previous occupation. A positive goal and direction may aid the patient in decreasing stress and depression, and promote optimum rehabilitation.
For history of this section, see Editor's Notes in the first section, 7 CCR 1101-3
7 CCR 1101-3 has been divided into smaller sections for ease of use. Versions prior to 01/01/2011, and rule history, are located in the first section, 7 CCR 1101-3. Prior versions can be accessed from the History link that appears above the text in 7 CCR 1101-3. To view versions effective after 01/01/2011, select the desired part of the rule, for example 7 CCR 1101-3 Rules 1-17, or 7 CCR 1101-3 Rule 18: Exhibit 1.
