W. Va. Code R. § 85-20-41 - Treatment Guidelines: Carpal Tunnel Syndrome

41.1. The purpose of the Carpal Tunnel Syndrome ("CTS") Rule is to provide the treating physician with treatment guidance and treatment parameters so that the treating team can:

a. Determine if the illness is work-related; that is, determine causality.

b. Properly diagnose the illness through a careful history, physical examination and appropriate diagnostic tests and examinations.

c. Initiate timely and proper treatment; and

d. Keep the injured worker in the workplace, through modified or restricted duty if necessary, as much as possible during the treatment plan.

41.2. Background. CTS is one of several nerve compression/entrapment syndromes of the upper extremity. This condition occurs when pressure increases in the canal and disrupts the normal flow of nerve impulses to the hand. The exact cause of this condition is unclear. It is often bilateral. The prevalence of CTS in the general population is approximately 3.1%. Half of CTS cases are idiopathic. Providers considering the diagnosis and compensability of CTS are advised to assess several factors, diagnostic accuracy, confounding conditions, work setting and duration of symptoms in assigning causality.

41.3. Diagnostic Accuracy. Hand symptoms may be produced by tendonitis, arthritis, tumor, interrupted blood flow, trauma or nerve entrapment at levels from the neck to the hand. Symptoms suggesting CTS include numbness and paresthesia (especially at night), weakness, uselessness and pain in a median nerve distribution. Clinical examination findings are frequently difficult to interpret. Tinel's and Phalen's tests have limited sensitivity and specificity. Thenar atrophy is a late sign.

41.4. Confounding Conditions. Medical conditions frequently produce or contribute to CTS. Recognition of these conditions is important for good outcomes. Diabetes mellitus, hypothyroidism, obesity, alcohol abuse, rheumatoid arthritis, postural abnormalities and other conditions can precipitate CTS symptoms. Pregnancy is a well-established risk factor for reversible CTS. Sleep disorders significantly aggravate CTS for some patients. Hobbies and sports activities may contribute to CTS symptoms. A careful look for contributing noncompensable factors may impact causality and response to treatment.

41.5. Work Setting. Occupational groups at high risk for CTS have included grinders, butchers, grocery store workers, frozen food factory workers, manufacturing workers, dental hygienists, platers and workers with high force, high repetitive manual movement. The literature notes a high prevalence of concurrent medical conditions capable of causing CTS in persons with the syndrome, without regard to any particular occupation. Studies have failed to show a relationship between normal clerical activities and CTS. When evaluating CTS in this work setting, a careful search for other contributing factors is essential. Awkward wrist positioning, vibratory tools, significant grip force, and high force of repetitive manual movements have all been shown to contribute to CTS. The Moore-Garg Strain Index is a valuable tool for assessing risk for work-related CTS.

41.6. Duration. Work-related CTS is associated with years of repetitive activity. To find CTS in workers with weeks to months of exposure suggests a pre-existing condition.

41.7. Diagnosis Criteria.

a. Pertinent Historical and Physical Findings

1. Patients usually complain of painful, burning paresthesia or numbness involving the thumb, index, long and occasionally radial aspect of the ring digit or the entire hand.

2. These symptoms are usually worse while lying down or sitting quietly.

3. Activities such as driving, holding a telephone or fixing one's hair often precipitate the paresthesia.

4. The most common complaints usually include nocturnal paresthesia, clumsiness with loss of fine dexterity and dropping things.

5. The patient often feels as if there is a loss of circulation. The paresthesia is often relieved by actively working the fingers, shaking the hand or holding it in a dependent position.

6. Pain is usually present over the palmar wrist area and may radiate proximally as far as the shoulder or neck.

7. Findings are consistent with those of a nerve irritation.

A. Tinel's test may be positive over the medial nerve in the proximal palm or wrist.

B. Numbness in the fingers may be elicited with the wrist in extreme extension or flexion (Phalen's test).

C. There may be decreased sensation distal to the wrist, particularly over the thumb, index and middle fingers, inability to flex or oppose the thumb or abduct it in its own plane and thenar muscle atrophy.

D. There can be significant variations in location of pain and sensory changes.

E. The examiner also needs to evaluate additional or alternate sites of compression that can produce similar symptoms.

b. Appropriate Diagnostic Tests and Examinations

1. Radiographs of the hand and wrist if indicated by history and examination, mainly in patients with history of previous trauma or painful range of motion of the wrist.

2. Nerve conduction studies and electromyograms. (Mild cases wait 6 weeks).

3. Response to conservative measures; splinting of wrist and carpal tunnel steroid injections.

4. Laboratory studies if symptoms suggest an underlying disease such as diabetes mellitus, thyroid dysfunction or rheumatoid arthritis.

5. Radiograph of cervical spine, upper extremity and/or chest if symptoms suggest a more proximal disease process.

c. Specialist Directed Tests and Examinations

1. CT scan and MRI only if indicated by previous plain films and history pace-occupying deformity or mass.

2. Wrist arthrogram if findings suggestive of carpal instability.

d. Supporting Evidence.

1. Since double crush syndrome (entrapment of a nerve at more than one level) and systemic diseases causing carpal tunnel syndrome are not unusual, a thorough evaluation is essential.

2. EMG/NCS is the standard diagnostic modality and has high sensitivity and specificity. Regarding EMG and NCS, there is variability in the skill of the testing physician and diagnostic reference criteria do vary. This should be carefully monitored by the referring physician and by a Quality Assurance mechanism.

41.8. Treatment.

a. Non-operative Treatment

1. Indications

A. Symptoms mild or moderate (but without thenar atrophy).

B. Pregnancy or other systemic problems that may be treated medically.

C. Onset of symptoms associated with work exposure, and plausibly subjective and/or objective findings.

D. Associated with other physical conditions, i.e. cervical radiculopathy.

2. Treatment.

A. Initial Four Weeks -- Options

1. Splint wrist in neutral.

2. Nonsteroidal anti-inflammatory drugs.

3. Steroid injections, optional.

4. Eliminate or modify aggravating activities with the cooperation of the employer.

5. Physical medicine.

6. Concurrent treatment of systemic disease until the injury has returned to pre-injury status.

7. Self care: ice, elevation, range of motion, stretching, exercises, postural correction, etc.

3. Referral

A. If there is no substantial improvement by four (4) weeks, the injured worker should be referred for evaluation and possible treatment.

B. Treatment should be by either a physical medicine practitioner or a surgeon (orthopedic, hand, plastic, or neurosurgeon).

1. Physical Medicine.

(a) A physical medicine practitioner shall evaluate for functional anatomical lesions in the neck, shoulder, thorax, elbow and wrist. Physical medicine examiners: Chiropractor (DC), Osteopathic Physician (DO who specializes in manipulation), Physical Medicine and Rehabilitation Specialist (MD/DO, formerly known as "physiatrist"), Physical Therapist (PT), and Occupational Therapist (OT).

(b) If functional anatomical lesions are identified, two to eight (2-8) weeks of treatment with a physical medicine practitioner (DC, DO who specializes in manipulation, MD/DO who is a physical medicine and rehabilitation specialist, PT, OT) should be performed on a decreasing frequency. The referring physician shall be provided progress reports at 2-week intervals. Treatment should cease if two weeks pass without significant documented functional improvement. It is important that the injured worker continue to work and perform his or her activities of daily living during this therapy. Modified duty or work reassignment is appropriate during treatment.

b. Ambulatory Surgery.

1. Indications

A. Unresponsive or progression of symptoms in the face of non-operative treatment; objective signs.

B. Thenar atrophy or objective impairment of sensibility (widened two-point discrimination or diminished light touch).

C. Intolerable numbness and pain.

D. Mass or deformity in carpal tunnel.

2. Treatment Options

A. The operative treatment usually includes minimal invasive type of surgery vs. open type of surgery, and is indicated according to the condition of the patient.

B. In some of the severe CTS cases, the surgeon may wish to seek an examination by another physician in order to determine if the injured worker is an appropriate candidate for recovery and return to work.

3. Home Health Care. When self-care is compromised during the early post-operative period, homemaker services may be required in some instances. Examples: opposite hand amputation or limiting injury.

4. Physical Rehabilitation.

A. Brief post-operative splinting, optional.

B. Finger and wrist range of motion.

C. Scar massage after sutures removed.

D. Grip and pinch strengthening.

E. Range of motion exercises of affected extremity.

F. Progressive activity reintroduction.

G. Physical medicine, if indicated, should be limited to six weeks.

5. Supporting Evidence.

A. Carpal tunnel release relieved pain and paresthesia in up to 90% of patients with correct diagnosis.

B. Significant pre-operative median nerve involvement, concurrent medical conditions and/or inability to modify aggravating exposures may affect post-operative functional recovery.

c. In-Patient Treatment.

1. Inpatient Treatment.

A. Rare.

B. Associated with other trauma or condition, i.e. crush injury, burns, etc.

2. Indications for Admission.

A. Compartment syndrome of forearm.

B. Other serious medical conditions which increase surgical anesthetic risks.

C. Complication at time of operative procedure.

D. Treatment options: same as for ambulatory patient.

E. Indications for discharge: medical condition stabilized.

F. Home health care: same as for ambulatory patient.

G. Rehabilitation: same as for ambulatory patient.

d. Estimated Duration of Care

1. Non-operative Treatment

A. Activity modification may be indicated.

B. Depending on objective findings and past duration of symptoms and as outlined in the Presley Reed Guide referenced in this Rule.

2. Operative Treatment

A. Consistent with global guidelines and as outlined in the Presley Reed Guide referenced in this Rule.

B. Three month follow-up unless there are complicating factors.

e. Anticipated Outcome.

1. Improved sensory and/or motor and/or autonomic function.

2. Elimination of paresthesia.

3. Lessening of pain.

4. In severe carpal tunnel syndrome cases, complete relief of the symptoms is usually not obtained. The surgery is performed to stop progression of the nerve damage or to delay progression of damage already present in the form of nerve fibrosis and vascular changes.

f. Modifiers

1. Pregnant and nursing women usually have decreased or resolved symptoms shortly after delivery or cessation of lactation, but persistent symptoms may require surgical release.

2. Age and gender are not modifiers.

3. Co-existent neurological or systemic disorder, i.e. diabetes, thyroid dysfunction, amyloidosis, etc., may make symptoms more severe and less likely to fully resolve following treatment.

g. Cold laser is an experimental and unproven therapy. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will not pay for such treatment.

41.9. Rehabilitation

a. Keeping Workers on the Job.

1. Workers generally are in a more positive psychosocial, motivational and financial mode when they continue to work. These factors impact significantly on the rehabilitation outcome.

2. Barring a clear medical contraindication, if the employer can provide suitable reasonable accommodations based upon restrictions recommended by the physician due to the compensable medical condition, the injured worker should continue to work during the recovery process and be released to return to such work as soon as possible when temporary disability is unavoidable.

b. The Work Release

1. Return to work may be initiated via two paths, starting with the physician's work release or with a proposal from the employer or a qualified rehabilitation professional.

2. In either case, the release must be as specific as possible so the employer and patient clearly understand what is expected. The physician should address:

A. Physical restrictions, time restrictions (hours per day and/or week and duration of the restriction).

B. Pacing restrictions.

C. Break requirements (frequency and purpose, such as for rest from certain activities, icing, warm-up exercise, self-massage, etc.).

D. Recommended job site accommodations (such as workstation height or set-up) or ergonomic devices (such as anti-vibration tool wraps).

3. When the employer or a qualified rehabilitation professional offers a return to work proposal, the attending physician should expect to be provided:

A. A functional job analysis with which to make an informed decision regarding the work release. The job analysis must thoroughly describe job duties, physical demands (strength and production/work pace), tools used and environment.

B. Assurance that the employer (line supervisors and co-workers, not just human resources personnel) will support the worker in the restricted or alternate duty return to work.

C. A rehabilitation plan signed by the employer, injured worker and a qualified rehabilitation professional when restricted or alternate duty (part-time or full-time) is to be approved. This plan should describe the accommodations being offered and the time frame for which they will be available.

c. Career Changes. Injured workers with significant permanent upper extremity residual impairment will frequently need a permanent change of vocations.

d. The provisions of Section 41.9 may be used to govern the rehabilitation processes of injuries other than carpal tunnel syndrome as appropriate.

Notes

W. Va. Code R. § 85-20-41