Current through Register Vol. 50, No. 9, September 20, 2024
A. Cervical computed axial tomography or
magnetic resonance imaging (ct/mri) are generally accepted, well-established
procedures indicated to rule out cervical disc or other cervical spine
disorders when clinical findings suggest these diagnoses. It should not be
routinely performed for TOS. MRI is the preferred test over a CT unless a
fracture is suspected, and then CT may be superior to MRI. CT/MRI is not
indicated early unless there is a neurological deficit and/or the need to rule
out a space- occupying lesion, such as a tumor. Repeat cervical MRI is not
indicated for TOS. If cervical spine injury is confirmed, refer to the OWCA's
Cervical Spine Injury Medical Treatment Guidelines. If a
cervical spine disorder is not suspected, conservative therapy as indicated in
Section F, Non-operative Procedures should be done for at least 8 to 12 weeks,
prior to ordering an MRI for persistent symptoms.
B. Electrodiagnostic Studies
1. Electromyography/Nerve Conduction
Velocities (EMG/NCV) is a generally accepted, well-established procedure.
EMG/NCV is primarily indicated to rule out other nerve entrapment syndromes
such as carpal tunnel or cubital tunnel syndrome when indicated by clinical
examination, or to establish true neurogenic TOS. Most cases of non-specific
TOS have normal electrodiagnostic studies, but EMG/NCV should be considered
when symptoms have been present for approximately three months or if the
patient has failed eight weeks of conservative therapy. EMG/NCV may also be
performed to rule out other disorders. Somato-sensory evoked potentials
(SSEPs), F waves and NCV across the thoracic outlet have no diagnostic value
and should not be performed. The diagnosis is usually made by comparison to the
normal extremity. For bilateral disease, each EMG lab must establish its own
absolute limits of latency and amplitude from volunteer controls so that
measurements exceeding these limits can be noted.
2. Criteria for True Neurogenic TOS
a. reduction of the ulnar sensory nerve
action potential to digits (usually less than 60 percent of unaffected side);
or
b. medial antebrachial sensory
action potential which is low or absent compared to the unaffected side;
or
c. reduction of the median
M-wave amplitude (usually less than 50 percent of unaffected side);
or
d. needle EMG examination
reveals neurogenic changes in intrinsic hand muscles and the abductor pollicus
brevis muscle.
3.
Portable automated electrodiagnostic device: (also known as surface EMG) is not
a substitute for conventional EMG/NCS testing in clinical decision-making, and
therefore, is not recommended.
4.
Quantitative Sensory Testing (QST). Research is not currently available on the
use of QST in the evaluation of TOS. QST tests the entire spectrum of the
neurological system including the brain. It is not able to reliably distinguish
between organic and psychogenic pathology and therefore, is not
recommended.
C. Vascular
Studies. Noninvasive vascular testing, such as pulse-volume recording in
different positions, is not indicated in cases of neurogenic TOS. Since the
presence or absence of a pulse cutoff on physical examination is not helpful in
establishing a diagnosis of TOS, the recording of finer degrees of positional
pulse alteration will not add to the diagnosis. Vascular laboratory studies,
including duplex scanning, Doppler studies, standard and MR arteriography and
venography, are not cost-effective in cases of neurogenic TOS. These studies
are only indicated in patients who have arterial or venous occlusive signs.
Dynamic venography with the arm in 180 degrees of abduction may be used in
cases with continued swelling and/or periodic cyanosis who have not improved
with conservative therapy. Approximately 20 percent of asymptomatic individuals
will have an abnormal dynamic venogram. Some individuals may have a pectoralis
minor syndrome which occludes the axillary vein rather than the subclavian
vein. In these cases, less invasive surgery than the TOS operative procedures
may be indicated.
D. Thermography
is not generally accepted or widely used for TOS. It may be used if
differential diagnosis includes CRPS; in such cases refer to the OWCA's Complex
Regional Pain Syndrome/Reflex Sympathetic Dystrophy Medical Treatment
Guidelines.
E. Anterior scalene or
pectoralis muscle blocks may be performed to provide additional information
prior to expected surgical intervention. It is recommended that EMG or
sonography guidance be used to assure localization.
F.
Personality/psychological/psychiatric/psychosocial evaluations are generally
accepted and well-established diagnostic procedures with selective use in the
acute TOS population and more widespread use in the sub-acute and chronic TOS
population.
1. 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 as well as 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.
2.
Formal psychological or psychosocial evaluation should be performed on patients
not making expected progress within 6-12 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:
a. employment history;
b. interpersonal relationships-both social
and work;
c. leisure
activities;
d. current perception
of the medical system;
e. results
of current treatment;
f. perceived
locus of control; and
g. childhood
history, including abuse and family history of disability.
3. This information should provide clinicians
with a better understanding of the patient, and enable a more effective
rehabilitation.
4. The evaluation
will determine the need for further psychosocial interventions, and in those
cases, a Diagnostic Statistical Manual (DSM) of Mental Disorders 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 one to two hours. A professional fluent in the
primary language of the patient is strongly preferred. When such a provider is
not available, services of a professional language interpreter must be
provided. When issues of chronic pain are identified, the evaluation should be
more extensive and follow testing procedures as outlined in the OWCA's Chronic
Pain Disorder Medical Treatment Guidelines.
a. Frequency-one time visit for evaluation.
If psychometric testing is indicated as a portion of the initial evaluation,
time for such testing shall be allotted at least, six hours of professional
time or whatever is deemed appropriate by the health care
professional.
G. Special tests are generally well-accepted
tests and are performed as part of a skilled assessment of the patients'
capacity to return to work, his/her strength capacities, and physical work
demand classifications and tolerance. The procedures in this subsection are
listed in alphabetical order, not by importance.
1. Computer-enhanced evaluations may include
isotonic, isometric, isokinetic and/or isoinertial measurement 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. The added value of computer enhanced evaluations is unclear.
Targeted work tolerance screening or gradual return to work is preferred.
a. Frequency-one time for evaluation. Can
monitor improvements in strength every three to four weeks up to a total of six
evaluations.
2.
Functional capacity evaluation (FCE) 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, cognitive, and sensory perceptual
aspects of competitive employment may be evaluated. Components of this
evaluation may include: musculoskeletal screen; cardiovascular profile/aerobic
capacity; coordination; lift/carrying analysis; job-specific activity
tolerance; maximum voluntary effort; pain assessment/psychological screening;
and non-material and material handling activities.
a. When an FCE is being used to determine
return to a specific jobsite, the provider is responsible for fully
understanding the job duties. A jobsite evaluation is frequently necessary.
FCEs cannot be used in isolation to determine work restrictions. The authorized
treating physician must interpret the FCE in light of the individual patient's
presentation and medical and personal perceptions. FCEs should not be used as
the sole criteria to diagnose malingering.
b. Full FCEs are sometimes necessary. In many
cases, a work tolerance screening will identify the ability to perform the
necessary job tasks. If partial FCEs are performed, it is recognized that all
parts of the FCE that are not performed are considered normal.
i. Frequency-can be used initially to
determine baseline status and for case closure when patient is unlikely to
return to pre-injury position and further information is desired to determine
permanent work restrictions. Prior authorization is required for FCEs performed
during treatment.
3. Jobsite evaluation is a comprehensive
analysis of the physical, mental and sensory components of a specific job.
These components may include, but are not limited to: postural tolerance
(static and dynamic); aerobic requirements; range of motion; torque/force;
lifting/carrying; cognitive demands; social interactions; visual perceptual;
sensation; coordination; environmental requirements; repetitiveness; and
essential job functions. Job descriptions provided by the employer are helpful
but should not be used as a substitute for direct observation.
a. A jobsite evaluation may include
observation and instruction of how work is done, what material changes (desk,
chair) should be made, and determination of readiness to return to work.
Postural risk factors should be identified and awkward postures of overhead
reach, hyperextension or rotation of the neck, shoulder drooped or
forward-flexed and head-chin forward postures should be eliminated. Unless
combined with one of the above postures, repetitiveness is not by itself a risk
factor. Refer to Cumulative Trauma Disorder and Shoulder Guidelines for further
suggestions.
i. Requests for a jobsite
evaluation should describe the expected goals for the evaluation. Goals may
include, but are not limited to the following:
(a). to determine if there are potential
contributing factors to the person's condition and/or for the physician to
assess causality;
(b). to make
recommendations for, and to assess the potential for ergonomic
changes;
(c). to provide a detailed
description of the physical and cognitive job requirements;
(d). to assist the patient in their return to
work by educating them on how they may be able to do their job more safely in a
bio-mechanically appropriate manner;
(e). to give detailed work/activity
restrictions.
(i). Frequency-one time with
additional visits as needed for follow-up per jobsite.
4.
Vocational Assessment. 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. If prognosis for return to former
occupation is determined to be poor, except in the most extenuating
circumstances, vocational assessment should be implemented within 3 to 12
months post-injury. Declaration of MMI should not be delayed solely due to lack
of attainment of a vocational assessment.
a.
Frequency-one time with additional visits as needed for follow-up.
5. Work tolerance screening is a
determination of an individual's tolerance for performing a specific job based
on a job activity or task and may be used when a full functional capacity
evaluation is not indicated. The screening is monitored by a therapist and may
include a test or procedure to specifically identify and quantify work-relevant
cardiovascular, physical fitness and postural tolerance. It may also address
ergonomic issues affecting the patient's return-to-work potential.
a. Frequency-one time for initial screen. May
monitor improvements in strength every three to four weeks up to a total of six
visits.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
23:1203.1.
