Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 22 - Neurological and Neuromuscular Disorder Medical Treatment Guidelines
Subchapter A - Carpal Tunnel Syndrome (CTS) Medical Treatment Guidelines
Section I-2211 - Therapeutic Procedures-Non-Operative
Universal Citation: LA Admin Code I-2211
Current through Register Vol. 50, No. 9, September 20, 2024
A. 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.
B. 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 "Return-to-Work" in this section for detailed information.
C. 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.
D. Third, providers should provide and document education to the patient. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of facilitating self-management of symptoms.
E. Lastly, formal psychological or psychosocial screening 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.
F. In cases where a patient is unable to attend an outpatient center, home therapy may be necessary. Home therapy may include active and passive therapeutic procedures as well as other modalities to assist in alleviating pain, swelling, and abnormal muscle tone. Home therapy is usually of short duration and continues until the patient is able to tolerate coming to an outpatient center.
G. Non-operative treatment procedures for CTS can be divided into two groups: conservative care and rehabilitation. Conservative care is treatment applied to a problem in which spontaneous improvement is expected in 90 percent of the cases within three months. It is usually provided during the tissue-healing phase and lasts no more than six months, and often considerably less. Rehabilitation is treatment applied to a more chronic and complex problem in a patient with de-conditioning and disability. It is provided during the period after tissue healing to obtain maximal medical recovery. Treatment modalities may be utilized sequentially or concomitantly depending on chronicity and complexity of the problem, and treatment plans should always be based on a diagnosis utilizing appropriate diagnostic procedures.
H. The following procedures are listed in alphabetical order.
1. Acupunctur e is an accepted and widely
used procedure for the relief of pain and inflammation and there is some
scientific evidence to support its use. 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. While it is commonly used when pain medication is reduced or
not tolerated, it may be used as an adjunct to physical rehabilitation and/or
surgical intervention to hasten thereturn of functional activity. Acupuncture
should be performed by licensed practitioners.
a. Definition : Acupuncture is the insertion
and removal of filiform needles to stimulate acupoints (acupuncture points).
Needles may be inserted, manipulated, and retained for a period of time.
Acupuncture can be used to reduce pain, reduce inflammation, increase blood
flow, increase range of motion, decrease the side effect of medication-induced
nausea, promote relaxation in an anxious patient, and reduce muscle spasm.
Indications include joint pain, joint stiffness, soft tissue pain and
inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar
tissue pain.
i. Time to produce effect: three
to six treatments
ii. Frequency:
one to three times per week
iii.
Optimum duration: one to two months
iv. Maximum duration: 14 treatments
b. Acupuncture with Electrical
Stimulation is the use of electrical current (micro- amperage or
milli-amperage) on the needles at the acupuncture site. It is used to increase
effectiveness of the needles by continuous stimulation of the acupoint.
Physiological effects (depending on location and settings) can include
endorphin release for pain relief, reduction of inflammation, increased blood
circulation, analgesia through interruption of pain stimulus, and muscle
relaxation. 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.
i. Time to produce
effect: three to six treatments
ii.
Frequency: one to three times per week
iii. Optimum duration: one to two
months
iv. Maximum duration: 14
treatments
c. Other
Acupuncture Modalities . Acupuncture treatment is based on individual patient
needs and therefore treatment may include a combination of procedures to
enhance treatment effect. Other procedures may include the use of heat, soft
tissue manipulation/massage, and exercise. Refer to Active Therapy and Passive
Therapy for a description of these adjunctive acupuncture modalities.
i. Time to produce effect: three to six
treatments
ii. Frequency: one to
three times per week
iii. Optimum
duration: one to two months
iv.
Maximum duration: 14 treatments
(a). Any of
the above acupuncture treatments may extend longer if objective functional
gains can be documented or when 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.
2. Biofeedback
a. A form of behavioral medicine that helps
patients learn self-awareness and self-regulation skills for the purpose of
gaining greater control of their physiology, such as muscle activity, brain
waves, and measures of autonomic nervous system activity. Electronic
instrumentation is used to monitor the targeted physiology and then displayed
or fed back to the patient visually, auditorially or tactilely, with coaching
by a biofeedback specialist. Biofeedback is provided by clinicians certified in
biofeedback and/or who have documented specialized education, advanced
training, or direct or supervised experience qualifying them to provide the
specialized treatment needed (e.g., surface EMG, EEG, or other).
b. Treatment is individualized to the
patient's work-related diagnosis and needs. Home practice of skills is required
for mastery and may be facilitated by the use of home training tapes. The
ultimate goal in biofeedback treatment is normalizing the physiology to the
pre-injury status to the extent possible and involves transfer of learned
skills to the workplace and daily life. Candidates for biofeedback therapy or
training must be motivated to learn and practice biofeedback and
self-regulation techniques.
c.
Indications for biofeedback include individuals who are suffering from
musculoskeletal injury where 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
emotional stress/pain responses such as anxiety, depression, anger, sleep
disturbance, and other central and autonomic nervous system imbalances.
Biofeedback is often utilized along with other treatment modalities.
i. Time to produce effect: three to four
sessions
ii. Frequency: one to two
times per week
iii. Optimum
duration: five to six sessions
iv.
Maximum duration: 10 to 12 sessions. Treatment beyond 12 sessions must be
documented with respect to need, expectation, and ability to facilitate
positive symptomatic or functional gains.
3. Injections-Therapeutic .
a. Steroids Injections. Beneficial effects of
injections are well-established, but generally considered to be temporary.
Recurrence of symptoms is frequent. It is not clear whether or not injections
slow progression of electrodiagnostic changes. Therefore, although symptoms may
be temporarily improved, nerve damage may be progressing. When motor changes
are present, surgery is preferred over injections. Injections may be given for
confirmation of Carpal Tunnel Syndrome Diagnosis.
i. Time to produce effect: two to five
days
ii. Frequency: every six to
eight weeks
iii. Optimum number:
two injections
iv. Maximum number:
three injections in 6 months
b. If following the first injection,
symptomatic relief is followed by recurrent symptoms, the decision to perform a
second injection must be weighed against alternative treatments such as
surgery. Surgery may give more definitive relief of symptoms.
4. Job Site Alteration. Early
evaluation and training of body mechanics and other ergonomic factors are
essential for every injured worker and should be done by a qualified
individual. In some cases, this requires a job site evaluation. Some evidence
supports alteration of the job site in the early treatment of Carpal Tunnel
Syndrome (CTS). There is no single factor or combination of factors that is
proven to prevent or ameliorate CTS, but a combination of ergonomic and
psychosocial factors is generally considered to be important. Physical factors
that may be considered include use of force, repetition, awkward positions,
upper extremity vibration, cold environment, and contact pressure on the carpal
tunnel. Psychosocial factors to be considered include pacing, degree of control
over job duties, perception of job stress, and supervisory support. The job
analysis and modification should include input from the employee, employer, and
ergonomist or other professional familiar with work place evaluation. The
employee must be observed performing all job functions in order for the job
site analysis to be valid. Periodic follow-up is recommended to evaluate
effectiveness of the intervention and need for additional ergonomic changes.
a. Ergonomic changes should be made to modify
the hazards identified. In addition workers should be counseled to vary tasks
throughout the day whenever possible. Occupational Safety and Health
Administration (OSHA) suggests that workers who perform repetitive tasks,
including keyboarding, take 15-30 second breaks every 10 to 20 minutes, or
5-minute breaks every hour. Mini breaks should include stretching
exercises.
b. Interventions should
consider engineering controls, e.g., mechanizing the task, changing the tool
used, or adjusting the work site, or administrative controls, e.g., adjusting
the time an individual performs the task.
c. Seating Description . The following
description may aid in evaluating seated work positions: The head should
incline only slightly forward, and if a monitor is used, there should be 18-24
inches of viewing distance with no glare. Arms should rest naturally, with
forearms parallel to the floor, elbows at the sides, and wrists straight or
minimally extended. The back must be properly supported by a chair, which
allows change in position and backrest adjustment. There must be good knee and
legroom, with the feet resting comfortably on the floor or footrest. Tools
should be within easy reach, and twisting or bending should be
avoided.
d. Job Hazard Checklist .
The following Table 3 is adopted from Washington State's job hazard checklist,
and may be used as a generally accepted guide for identifying job duties which
may pose ergonomic hazards. The fact that an ergonomic hazard exists at a
specific job, or is suggested in the table, does not establish a causal
relationship between the job and the individual with a musculoskeletal injury.
However, when an individual has a work-related injury and ergonomic hazards
exist that affect the injury, appropriate job modifications should be made.
Proper correction of hazards may prevent future injuries to others, as well as
aid in the recovery of the injured worker.
Table 3: Identifying Job Duties Which May Pose Ergonomic Hazards
|
Type of Job Duty |
Hours per Day |
|
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 a ream of paper): Highly repetitive motion Palmar flexion greater than 30 degrees, dorsiflexion greater than 45 degrees, or radial deviation greater than 30 degrees ----------------------------------------------------------- No other risk factors |
More than 3 hours total/day -------------------- More than 4 hours total/day |
|
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 battery): *Handles should be rounded and soft, with at least 1-2.5" in diameter grips at least 5" long. Highly repetitive motion Palmar flexion greater than 30 degrees, dorsiflexion greater than 45 degrees, or radial deviation greater than 30 degrees ----------------------------------------------------------- No other risk factors |
More than 3 hours total/day ------------------- More than 4 hours total/day |
|
Repetitive Motion (using the same motion with little or no variation every few seconds), excluding keying activities: High, forceful exertions with the hands, with palmar flexion greater than 30 degrees, dorsiflexion greater than 45 degrees, or radial deviation greater than 30 degrees ----------------------------------------------------------- No other risk factors |
More than 2 hours total/day -------------------More than 6 hours total/day |
|
Intensive Keying: Palmar flexion greater than 30 degrees, dorsiflexion greater than 45 degrees, or radial deviation greater than 30 degrees ----------------------------------------------------------- No other risk factors |
More than 4 hours total/day ------------------- More than 7 hours total/day |
|
Repeated Impact: Using the hand (heel/base of palm) as a hammer more than once/minute |
More than 2 hours total/day |
|
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 (10m/sec/sec). Frequency range 8-15 Hz and acceleration 6 g Frequency range 80 Hz and acceleration 40 g Frequency range 250 Hz and acceleration 250 g ---------------------------------------------------------- Frequency range 8-15 Hz and acceleration 1.5 g Frequency range 80 Hz and acceleration 6 g Frequency range 250 Hz and acceleration 20 g |
More than 30 minutes at a time -------------------- More than 4 hours at a time |
5. M edications including nonsteroidal
anti-inflammatory medications (NSAIDS), oral steroids, diuretics, and
pyridoxine (Vitamin B6) have not been shown to have significant long-term
beneficial effect in treating Carpal Tunnel Syndrome. Although NSAIDS are not
curative, they and other analgesics may provide symptomatic relief. All
narcotics and habituating medications should be prescribed with strict time,
quantity, and duration guidelines with a definite cessation parameter.
Prescribing these drugs on an as needed basis (PRN) should almost always be
avoided.
a. Vitamin B6 : Randomized trials
have demonstrated conflicting results. Higher doses may result in development
of a toxic peripheral neuropathy. In the absence of definitive literature
showing a beneficial effect, use of Vitamin B6 cannot be recommended.
b. Oral Steroids : have been shown to have
short-term symptomatic benefit but no long-term functional benefit and are not
recommended due to possible side effects.
6. Occupational Rehabilitation Programs
a. Non-Interdisciplinary . These programs are
work-related, outcome-focused, individualized treatment programs. Objectives of
the program 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.
i. Work Conditioning. These programs are
usually initiated once reconditioning has been completed but may be offered at
any time throughout the recovery phase. It should be initiated when imminent
return of a patient to modified or full duty is not an option, but the
prognosis for returning the patient to work at completion of the program is at
least fair to good.
(a). Length of visit: one
to two hours per day
(b).
Frequency: two to five visits per week
(c). Optimum duration: two to four
weeks
(d). Maximum duration: six
weeks. Participation in a program beyond six weeks must be documented with
respect to need and the ability to facilitate positive symptomatic or
functional gains.
ii.
Work Simulation is a program where an individual completes specific
work-related tasks for a particular job and return to work. Use of this program
is appropriate when modified duty can only be partially accommodated in the
work place, when modified duty in the work place is unavailable, or when the
patient requires more structured supervision. The need for work place
simulation should be based upon the results of a Functional Capacity Evaluation
and or Job site Analysis.
(a). Length of
visit: two to six hours per day
(b). Frequency: two to five visits per
week
(c). Optimum duration: two to
four weeks
(d). Maximum duration:
six weeks. Participation in a program beyond six weeks must be documented with
respect to need and the ability to facilitate positive symptomatic or
functional gains.
b. Interdisciplinary programs are
characterized by a variety of disciplines that participate in the assessment,
planning, and/or implementation of an injured workers program with the goal for
patients to gain full or optimal function and return to work. There should be
close interaction and integration among the disciplines to ensure that all
members of the team interact to achieve team goals. These programs are for
patients with greater levels of perceived disability, dysfunction,
de-conditioning and psychological involvement. For patients with chronic pain,
refer to the Chronic Pain Disorder Medical Treatment Guideline.
i. Work Hardening is an interdisciplinary
program addressing a patient's employability and return to work. It includes a
progressive increase in the number of hours per day that a patient completes
work simulation tasks until the patient can tolerate a full workday. This is
accomplished by addressing the medical, psychological, behavioral, physical,
functional, and vocational components of employability and
return-to-work.
ii. This can
include a highly structured program involving a team approach or can involve
any of the components thereof. The 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, occupational therapy, physical
therapy, case manager, and psychologist. As appropriate, the team may also
include: chiropractor, RN, or vocational specialist.
(a). Length of visit: Up to eight
hours/day
(b). Frequency: two to
five visits per week
(c). Optimum
duration: two to four weeks
(d).
Maximum duration: six weeks. Participation in a program beyond six weeks must
be documented with respect to need and the ability to facilitate positive
symptomatic or functional gains.
7. Orthotics/Immobilization with Splinting is
a generally accepted, well-established and widely used therapeutic procedure.
There is some evidence that splinting leads to more improvement in symptoms and
hand function than watchful waiting alone. Because of limited patient
compliance with day and night splinting in published studies, evidence of
effectiveness is limited to nocturnal splinting alone. Splints should be loose
and soft enough to maintain comfort while supporting the wrist in a relatively
neutral position. This can be accomplished using a soft or rigid splint with a
metal or plastic support. 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.
a. Splints may be effective when worn at
night or during portions of the day, depending on activities. Most studies show
that full time night splinting for a total of four to six weeks is the most
effective protocol. 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.
b. Splinting
is generally effective for milder cases of CTS. Long-term benefit has not been
established. An effect should be seen in two-sour weeks.
i. Time to produce effect: one-four weeks.
If, after four weeks, the patient has partial improvement, continue to follow
since neuropathy may worsen, even in the face of diminished symptoms.
ii. Frequency: Nightly. Daytime intermittent,
depending on symptoms and activities
iii. Optimum duration: four to eight
weeks
iv. Maximum duration: two to
four months. If symptoms persist, consideration should be given to either
repeating electrodiagnostic studies or to more aggressive treatment.
8. Patient Education
a. No treatment plan is complete without
addressing issues of individual and/or group patient education as a means of
prolonging the beneficial effects of treatment, as well as facilitating
self-management of symptoms and injury prevention. The patient should be
encouraged to take an active role in the establishment of functional outcome
goals. They should be educated on their specific injury, assessment findings,
and plan of treatment. Instruction on proper body mechanics and posture,
positions to avoid, self-care for exacerbation of symptoms, and home exercise
should also be addressed.
i. Time to produce
effect: Varies with individual patient
ii. Frequency: Should occur at every
visit
9.
Personality/Psychological/Psychiatric/ Psychosocial Intervention is generally
accepted, widely used and well established. This group of therapeutic and
diagnostic modalities includes, but is not limited to, individual counseling,
group therapy, stress management, psychosocial crises intervention, hypnosis
and meditation. Any screening or diagnostic workup should clarify and
distinguish between preexisting versus aggravated versus purely causative
psychological conditions. Psychosocial intervention is recommended as an
important component in the total management program that should be implemented
as soon as the problem is identified. This can be used alone or in conjunction
with other treatment modalities. Providers treating patients with chronic pain
should refer to the Chronic Pain Disorder Medical Treatment Guidelines.
a. Time to produce effect: two to four
weeks
b. Frequency: one to three
times weekly for the first 4 weeks (excluding hospitalization, if required),
decreasing to one to two times per week for the second month. Thereafter, two
to four times monthly.
c. Optimum
duration: six weeks to three months
d. Maximum duration: 3 to 12 months.
Counseling is not intended to delay but to enhance functional recovery. For
select patients, longer supervised treatment may required and if further
counseling beyond 3 months is indicated, documentation addressing which
pertinent issues are pre-existing versus aggravated versus causative, as well
as projecting a realistic functional prognosis, should be provided by the
authorized treating provider every 4 to 6 weeks during treatment.
10. Restriction of Activities .
Continuation of normal daily activities is the recommendation for acute and
chronic pain without neurologic symptoms. There is good evidence against the
use of bed rest in cases without neurologic symptoms. Bed rest may lead to
de-conditioning and impair rehabilitation. Complete work cessation should be
avoided, if possible, since it often further aggravates the pain presentation.
Modified return-to-work is almost always more efficacious and rarely
contraindicated in the vast majority of injured workers with Carpal Tunnel
Syndrome
a. Medication use in the treatment
of Carpal Tunnel Syndrome is appropriate for controlling acute and chronic pain
and inflammation. Use of medications will vary widely due to the spectrum of
injuries from simple strains to post-surgical healing. All drugs should be used
according to patient needs. A thorough medication history, including use of
alternative and over the counter medications, should be performed at the time
of the initial visit and updated periodically.
11. Return to Work. Early return-to-work
should be a prime goal in treating Carpal Tunnel Syndrome given the poor
prognosis for the injured employee who is out of work for more than six months.
The employee and employer should be educated in the benefits of early
return-to-work. When attempting to return an employee with CTS to the
workplace, clear, objective physical restrictions that apply to both work and
non-work related activities should be specified by the provider. Good
communication between the provider, employee, and employer is essential.
Return-to-work is any work or duty that the employee can safely perform, which
may not be the worker's regular job activities. Due to the large variety of
jobs and the spectrum of severity of CTS, it is not possible for the OWCA to
make specific return-to-work guidelines, but the following general approach is
recommended:
a. Establishment of
Return-To-Work . Ascertainment of return-to-work status is part of the medical
treatment and rehabilitation plan, and should be addressed at every visit.
Limitations in ADLs should also be reviewed at every encounter, and help to
provide the basis for work restrictions provided they are consistent with
objective findings. The OWCA recognizes that employers vary in their ability to
accommodate restricted duty, but encourages employers to be active participants
and advocates for early return-to-work. In most cases, the patient can be
returned to work in some capacity, either at a modified job or alternate
position, immediately unless there are extenuating circumstances, which should
be thoroughly documented and communicated to the employer. Return-to-work
status should be periodically reevaluated, at intervals generally not to exceed
three weeks, and should show steady progression towards full activities and
full duty.
b. Establishment of
Activity Level Restrictions : It is the responsibility of the
physician/provider to provide both the employee and employer clear, concise,
and specific restrictions that apply to both work and non-work related
activities. The employer is responsible to determine whether modified duty can
be provided within the medically determined restrictions. Refer to the "Job
Site Alteration" section for specific activity and ergonomic factors to be
considered when establishing work restrictions for an employee with
CTS.
c. Compliance with Activity
Level Restrictions : The employee's compliance with the activity level
restrictions is an important part of the treatment plan and should be reviewed
at each visit. In some cases, a job site analysis, a functional capacity
evaluation, or other special testing may be required to facilitate
return-to-work and document compliance. Refer to the "Job Site Alteration" and
"Work Tolerance Screening" sections.
12. Therapy - Active.
a. Active therapies are based on the
philosophy that therapeutic exercises and/or activities 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 to allow self-care to continue after
discharge. This form of therapy requires supervision from a therapist or
medical provider such as verbal, visual, and/or tactile instructions(s). At
times a provider may help stabilize the patient or guide the movement pattern,
but the energy required to complete the task is predominately executed by the
patient.
b. Patients should be
instructed to continue active therapies at home as an extension of the
treatment process in order to maintain improvement levels. Home exercise can
include exercise with or without mechanical assistance or resistance and
functional activities with assistance devices.
c. Interventions are selected based on the
complexity of the presenting dysfunction with ongoing examination, evaluation
and modification of the plan of care as improvement or lack thereof occurs.
Change and/or discontinuation of an intervention should occur if there is
attainment of expected goals/outcome, lack of progress, lack of tolerance
and/or lack of motivation. Passive interventions/ modalities may only be used
as adjuncts to the active program.
i. Nerve
Gliding exercises consist of a series of flexion and extension movements of the
hand and wrist that produce tension and longitudinal movement along the length
of the median and other nerves of the upper extremity. 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. Biomechanical principles have been more thoroughly studied
than clinical outcomes. Randomized trials have been lacking or have suffered
from design flaws that preclude sound conclusions of the effectiveness of these
exercises, but these flaws have tended to underestimate rather than
overestimate the usefulness of nerve gliding. The exercises are simple to
perform and can be done by the patient after brief instruction. It is
considered accepted therapy for CTS.
(a).
Time to Produce Effect: two-four weeks
(b). Frequency: Up to five times per day by
patient (patient-initiated)
(c).
Optimum Duration: two sessions
(d).
Maximum Duration: three sessions
ii. Instruction in Therapeutic Exercise .
Instruction should focus on alleviating associated myofascial symptoms. Please
refer to the Cumulative Trauma Disorder (CTD) guideline for information on
therapeutic exercise techniques.
iii. Proper Work Techniques . Please refer to
the "Job Site Evaluation" and "Job Site Alteration" sections of this
guideline.
13. Therapy-Passive . Therapy 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 and
swelling and to improve the rate of healing soft tissue injuries. They should
be used in adjunct with active therapies. They may be used intermittently as a
therapist deems appropriate or regularly if there are specific goals with
objectively measured functional improvements during treatment. Diathermies have
not been shown to be beneficial to patients with CTS and may interfere with
nerve conduction.
a. Manual Therapy
Techniques are passive interventions in which the providers use his or her
hands to administer skilled movements designed to modulate pain; increase joint
range of motion; reduce/eliminate soft tissue swelling, inflammation, or
restriction; induce relaxation; and improve contractile and non-contractile
tissue extensibility. These techniques are applied only after a thorough
examination is performed to identify those for whom manual therapy would be
contraindicated or for whom manual therapy must be applied with caution. Soft
tissue mobilization/manipulation techniques are generally accepted and widely
used adjunctive treatment modalities in the treatment of myofascial symptoms
related to carpal tunnel syndrome. Mobilization and manipulation can include
myofascial release therapy, muscle energy techniques, neural gliding, high
velocity, low amplitude (HVLA) technique, osteopathic manipulation, joint
mobilization and non-force techniques.
i.
Time to produce effect: two to six treatments
ii. Frequency: one to three times/week,
decreasing over time
iii. Optimum
duration: four to six weeks
iv.
Maximum duration: eight to ten weeks
b. Ultrasound : There is some evidence that
ultrasound may be effective in symptom relief and in improving nerve conduction
in mild to moderate cases of CTS. No studies have demonstrated long-term
functional benefit. It may be used in conjunction with an active therapy
program for non-surgical patients who do not improve with splinting and
activity modification. It is not known if there are any long-term deleterious
neurological effects from ultrasound.
c. Microcurrent TENS : There is some evidence
that concurrent application of microamperage TENS applied to distinct
acupuncture points and low-level laser treatment may be useful in treatment of
mild to moderate CTS. This treatment may be useful for patients not responding
to initial conservative treatment or who wish to avoid surgery. Patient
selection criteria should include absence of denervation on EMG and motor
latencies not exceeding 7 ms. The effects of microamperage TENS and low-level
laser have not been differentiated; there is no evidence to suggest whether
only one component is effective or the combination of both is required.
i. Time to produce effect: one week
ii. Frequency: three sessions per
week
iii. Optimum duration: three
weeks
iv. Maximum duration: four
weeks
v. Other Passive Therapy :
For associated myofascial symptoms, please refer to the Cumulative Trauma
Disorder guideline.
14. Vocational Rehabilitation is a generally
accepted intervention. Initiation of vocational rehabilitation requires
adequate evaluation of patients for quantification highest functional level,
motivation, and achievement of maximum medical improvement. Vocational
rehabilitation may be as simple as returning to the original job or as
complicated as being retrained for a new occupation. 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.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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