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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsSeptember 2013

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19 DE Admin. Code 1342
A public meeting was held on July 29, 2013, by the Department of Labor to receive public comments relating to revised sections of the Fee Schedule Instructions and Guidelines ("Fee Schedule Instructions"), Forms, Provider Certification, and Utilization Review, as well as revise the Health Care Practice Guidelines to reduce the frequency of some treatment, services, or procedures and clean up language inadvertently left in the original guidelines. Pursuant to 29 Del.C. §10118(a), August 13, 2013, marks the deadline (15 days after the public meeting) to receive written public comments on the above revisions. This addendum lists the additional public comments received. The members of the Health Care Advisory Panel (HCAP) members present at the July 29, 2013, and whose electronic signatures appear below, reaffirm their recommendation that the Secretary of Labor adopt this proposal as it was published in the Register of Regulations, Volume 17, Issue 1 (July 2013), with the properly noted subsequent technical revisions to the anesthesia methodology and revenue neutral language.
The proposed Fee Schedule Instructions and Guidelines; Forms; Provider Certification, Utilization Review; and Health Care Practice Guidelines notice appeared in the Register of Regulations, Volume 17, Issue 1 (July 1, 2013). The Fee Schedule Instructions and Guidelines ("Fee Schedule Instructions"), Forms, Provider Certification, Utilization Review, and Health Care Practice Guidelines are available from the Department of Labor, Division of lndustrial Affairs, Office of Workers' Compensation or on the department's website:
Pursuant to 19 Del.C. §2322C, health care practice guidelines have been adopted and recommended by the Health Care Advisory Panel to guide utilization of health care treatments in workers' compensation including, but not limited to, care provided for the treatment of employees by or under the supervision of a licensed health care provider, prescription drug utilization, inpatient hospitalization and length of stay, diagnostic testing, physical therapy, chiropractic care and palliative care. The health care practice guidelines apply to all treatments provided after the effective date of the regulation adopted by the Department of Labor, May 23, 2008, and regardless of the date of injury.
Services rendered by any health care provider certified pursuant to 19 Del.C. §2322D(a) to provide treatment or services for injured employees shall be presumed, in the absence of contrary evidence, to be reasonable and necessary if such treatment and/or services conform to the most current version of the Delaware health care practice guidelines.
Services provided by any health care provider that is not certified pursuant to 19 Del.C. §2322D(a) shall not be presumed reasonable and necessary unless such services are pre-authorized by the employer or insurance carrier, subject to the exception set forth in 19 Del.C. §2322D(b).
2.1 EDUCATION of the patient and family, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of CTS and disability. Currently, practitioners often think of education last, after medications, manual therapy and surgery. 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 inexpensive communication providing reassuring information to the patient. More in-depth education currently exists within a treatment regime employing functional restorative and innovative programs of prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of facilitating self-management of symptoms and prevention.
2.2 TREATMENT PARAMETER time frames for specific interventions commence once treatments have been initiated, not on the date of injury. Obviously, duration will be impacted by patient compliance, as well as comorbitities and availability of services. Clinical judgment may substantiate the need to accelerate or decelerate modify the time frames total number of visits discussed in this document. The majority of injured workers with Carpal Tunnel Syndrome often will achieve resolution of their condition within 12 to 56 visits (Guide To Physical Therapy Practice – Second Edition). It is anticipated that most injured workers will not require the maximum number of visits described in these guidelines. They are designed to be a ceiling and care extending beyond the maximum allowed visits may warrant utilization review.
2.3 ACTIVE INTERVENTIONS emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment, are generally emphasized over passive modalities, especially as treatment progresses. Generally, passive interventions are viewed as a means to facilitate progress in an active rehabilitation program with concomitant attainment of objective functional gains. All rehabilitation programs must incorporate “Active Interventions” no later than three weeks after the onset of treatment. Reimbursement for passive modalities only after the first three weeks of treatment without clear evidence of Active Interventions will require supportive documentation.
2.4 ACTIVE THERAPEUTIC EXERCISE PROGRAM Exercise program goals should incorporate patient strength, endurance, flexibility, coordination, and education. This includes functional application in vocational or community settings.
2.5 POSITIVE PATIENT RESPONSE Positive results are defined primarily as functional gains that can be objectively measured. Objective functional gains include, but are not limited to, positional tolerances, range-of-motion, strength, endurance, activities of daily living, cognition, behavior, and efficiency/velocity measures that can be quantified. Subjective reports of pain and function should be considered and given relative weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on objective findings.
2.6 RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS If a given treatment or modality is not producing positive results within 3 to 4 weeks, the treatment should be either modified or discontinued. Reconsideration of diagnosis should also occur in the event of poor response to a seemingly rational intervention.
2.7 SURGICAL INTERVENTIONS Surgery should be contemplated within the context of expected functional outcome and not purely for the purpose of pain relief. The concept of “cure” with respect to surgical treatment by itself is generally a misnomer. All operative interventions must be based upon positive correlation of clinical findings, clinical course and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with positive identification of pathologic conditions.
2.8 SIX-MONTH TIME-FRAME The prognosis drops precipitously for returning an injured worker to work once he/she has been temporarily totally disabled for more than six months. The emphasis within these guidelines is to move patients along a continuum of care and return-to-work within a six-month time frame, whenever possible. It is important to note that time frames may not be pertinent to injuries that do not involve work-time loss or are not occupationally related.
2.9 RETURN-TO-WORK is therapeutic, assuming the work is not likely to aggravate the basic problem or increase long-term pain. The practitioner must provide specific physical limitations per the Physician’s Form. The following physical limitations should be considered and modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, bending at the waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors. Even if there is residual chronic pain, return-to-work is not necessarily contraindicated.
2.10 DELAYED RECOVERY Strongly consider a psychological evaluation, if not previously provided, as well as initiating interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to make expected progress 6 to 12 weeks after an injury. The Division recognizes that 3 to 10% of all industrially injured patients will not recover within the timelines outlined in this document despite optimal care. Such individuals may require treatments beyond the limits discussed within this document, but such treatment will require clear documentation by the authorized treating practitioner focusing on objective functional gains afforded by further treatment and impact upon prognosis.
2.11 GUIDELINE RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE Guidelines are recommendations based on available evidence and/or consensus recommendations.
2.12 CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI) MMI should be declared when a patient’s condition has plateaued to the point where the authorized treating physician no longer believes further medical intervention is likely to result in improved function. However, some patients may require treatment after MMI has been declared in order to maintain their functional state. The recommendations in this guideline are for pre-MMI care and are not intended to limit post-MMI treatment.
4.1 INTRODUCTION The two standard procedures that are to be utilized when initially evaluating a work-related carpal tunnel complaint are History Taking, and Physical Examination.
4.2.1 Description of symptoms - should address at least the following:
4.2.2 Identification of Occupational Risk Factors: Job title alone is not sufficient information. The clinician is responsible for documenting specific information regarding repetition, force and other risk factors, as listed in the table entitled, ‘Risk Factors Associated with CTS’- Table 2. A job site evaluation may be required.
4.2.3 Demographics: Age, hand dominance, gender, etc.
4.2.4 Past Medical History and Review of Systems: A study of CTS patients showed a 33% prevalence of related disease. Risk factors for CTS include female gender; obesity; Native American, Hispanic, or Black heritage, and certain medical conditions:
4.2.5 Activities of Daily Living (ADLs): include such activities as self care and personal hygiene, communication, ambulation, attaining all normal living postures, travel, non-specialized hand activities, sexual function, sleep, and social and recreational activities. Specific movements in this category include pinching or grasping keys/pens/other small objects, grasping telephone receivers or cups or other similar-sized objects, and opening jars. The quality of these activities is judged by their independence, appropriateness, and effectiveness. Assess not simply the number of restricted activities but the overall degree of restriction or combination of restrictions.
4.2.6 Avocational Activities: Information must be obtained regarding sports, recreational, and other avocational activities that might contribute to or be impacted by CTD development. Activities such as hand-operated video games, crocheting/needlepoint, home computer operation, golf, racquet sports, bowling, and gardening are included in this category.
4.2.7 Social History: Exercise habits, alcohol consumption, and psychosocial factors.
4.3 PHYSICAL EXAMINATION Please refer to Table 1 for respective sensitivities and specificities for findings used to diagnose CTS (a-f).
4.4 RISK FACTORS A critical review of epidemiologic literature identified a number of physical exposures associated with CTS. For example, trauma and fractures of the hand and wrist may result in CTS. Other physical exposures considered risk factors include: repetition, force, vibration, pinching and gripping, and cold environment. When workers are exposed to several risk factors simultaneously, there is an increased likelihood of CTS. Not all risk factors have been extensively studied. Exposure to cold environment, for example, was not examined independently; however, there is good evidence that combined with other risk factors cold environment increases the likelihood of a CTS. Table 2 at the end of this section entitled, "Risk Factors Associated CTS," summarizes the results of currently available literature.
4.5 LABORATORY TESTS 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 negate work-relatedness of any specific case. When a patient's history and physical examination suggest infection, metabolic or endocrinologic disorders, tumorous conditions, systemic musculoskeletal disorders (e.g., rheumatoid arthritis), or potential problems related to prescription of medication (e.g., renal disease and nonsteroidal anti-inflammatory medications), then laboratory tests, including, but not limited to, the following can provide useful diagnostic information:
5.1 ELECTRODIAGNOSTIC (EDX) STUDIES are well established and widely accepted for evaluation of patients suspected of having CTS. The results are highly sensitive and specific for the diagnosis. Studies may confirm the diagnosis or direct the examiner to alternative disorders. Studies require clinical correlation due to the occurrence of false positive and false negative results. Symptoms of CTS may occur with normal EDX studies, especially early in the clinical course.
5.2.1 Radiographic Imaging: Not generally required for most CTS diagnoses. However, it may be necessary to rule out other pathology in the cervical spine, shoulder, elbow, wrist or hand. Wrist and elbow radiographs would detect degenerative joint disease, particularly scapholunate dissociation and thumb carpometacarpal abnormalities which occasionally occur with CTS.
5.2.2 Magnetic Resonance Imaging (MRI): Considered experimental and not recommended for diagnosis of Carpal Tunnel Syndrome. Trained neuroradiologists have not identified a single MRI parameter that is highly sensitive and specific. MRI is less accurate than standard electrodiagnostic testing, and its use as a diagnostic tool is not recommended.
5.2.3 Sonography: This tool has not been sufficiently studied to define its diagnostic performance relative to electrodiagnostic studies. It is not a widely applied test. Sonography may detect synovial thickening in CTS caused by rheumatoid arthritis. It may be useful if space-occupying lesions, such as, lipomas, hemangiomas, fibromas, and ganglion cysts, are suspected. Its routine use in CTS is not recommended.
5.3 ADJUNCTIVE TESTING Clinical indications for the use of tests and measurements are predicated on the history and systems review findings, signs observed on physical examination, and information derived from other sources and records. They are not designed to be the definitive indicator of dysfunction.
5.3.1 Electromyography: is a generally accepted, well-established procedure. It is indicated when acute and/or chronic neurogenic changes in the thenar eminence are associated with the conduction abnormalities discussed above.
5.3.2 Electroneurometer: May serve as a diagnostic tool as it helps to detect early distal sensorineural impairment.
5.3.3 Portable Automated Electrodiagnostic Device: Measures distal median nerve motor latency and F-wave latency at the wrist and has been tested in one research setting. It performed well in this setting following extensive calibration of the device. Motor nerve latency compared favorably with conventional electrodiagnostic testing, but F-wave latency added little to diagnostic accuracy. It remains an investigational instrument whose performance in a primary care setting is as yet not established, and is not recommended as a substitute for conventional electrodiagnostic testing in clinical decision-making.
5.3.4 Quantitative Sensory Testing (QST): May be used as a screening tool in clinical settings pre- and post-operatively. Results of tests and measurements of sensory integrity are integrated with the history and systems review findings and the results of other tests and measures. QST has been divided into two types of testing:
5.3.5 Pinch and Grip Strength Measurements: May be accepted as a diagnostic tool for CTS. 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. When all five handle settings of the dynamometer are used, a bell-shaped curve, reflecting maximum strength at the most comfortable handle setting, should be 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.
5.3.6 Laboratory Tests In one study of carpal tunnel patients seen by specialists, 9% of patients were diagnosed with diabetes, 7% with hypothyroidism, and 15% with chronic inflammatory disease including spondyloarthropathy, arthritis, and systemic lupus erythematosis. Up to two thirds of the patients were not aware of their concurrent disease. Estimates of the prevalence of hypothyroidism in the general population vary widely, but data collected from the Colorado Thyroid Disease Prevalence Study revealed subclinical hypothyroidism in 8.5% of participants not taking thyroid medication. The prevalence of chronic joint symptoms in the Behavioral Risk Factor Surveillance System (BRFSS) from the Centers for Disease Control (CDC) was 12.3%. If after 2-3 weeks, the patient is not improving the physician should strongly consider the following laboratory studies: thyroid function studies, rheumatoid screens, chemical panels, and others, if clinically indicated.
6.1 ACUPUNCTURE is an accepted and widely used procedure for the relief of pain and inflammation. 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 the return of functional activity. Acupuncture should be performed by MD, DO[, or] DC with appropriate training[; or a licensed acupuncturist].
6.1.1 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.
6.1.2 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.
6.1.3 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 sections F 12 and 13 Active Therapy and Passive Therapy for a description of these adjunctive acupuncture modalities.
6.2 BIOFEEDBACK is 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).
6.3 INJECTIONS-THERAPEUTIC 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.
6.4 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.
6.4.1 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.
6.4.2 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.
6.4.3 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.
6.4.4 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.
6.5 MEDICATIONS 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.
6.5.1 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.
6.5.2 Oral Steroids: have been shown to have short-term symptomatic benefit but no long-term functional benefit and are only rarely recommended due to possible side effects.
6.6.1 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.
6.7 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.
6.8 PATIENT EDUCATION 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.
6.9 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
6.10 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.
6.10.1 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 Division 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.
6.10.2 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.
6.10.3 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.
6.11 THERAPY-PASSIVE 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.
6.11.1 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.
Nerve Gliding: consist of a series of flexion and extension movements of the hand, wrist, elbow, shoulder, and neck 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. Nerve gliding performed on a patient by the clinician should be reinforced by patient performance of similar techniques as part of a home exercise program at least twice per day. Massage: Manual or Mechanical - Massage is manipulation of soft tissue with broad ranging relaxation and circulatory benefits. This may include stimulation of acupuncture points and acupuncture channels (acupressure), application of suction cups and techniques that include pressing, lifting, rubbing, pinching of soft tissues by or with the practitioner’s hands. Indications include edema, muscle spasm, adhesions, the need to improve peripheral circulation and range of motion, or to increase muscle relaxation and flexibility prior to exercise.
6.11.2 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.
6.11.3 Microcurrent TENS and LASER: 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.
6.11.4 Other Passive Therapy: For associated myofascial symptoms, please refer to the Cumulative Trauma Disorder guideline.
6.12 THERAPY-ACTIVE 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.
6.12.1 Activities of Daily Living: Supervised instruction, active-assisted training, and/or adaptation of activities or equipment to improve a person’s capacity in normal daily living activities such as self-care, work re-integration training, homemaking, and driving.
6.12.2 Functional Activities: are the use of therapeutic activity to enhance mobility, body mechanics, employability, coordination, and sensory motor integration.
6.12.3 Neuromuscular Re-education: is the skilled application of exercise with manual, mechanical, or electrical facilitation to enhance strength, movement patterns, neuromuscular response, proprioception, kinesthetic sense, coordination education of movement, balance, and posture. Indications include the need to promote neuromuscular responses through carefully timed proprioceptive stimuli, to elicit and improve motor activity in patterns similar to normal neurologically developed sequences, and improve neuromotor response with independent control.
6.12.4 Proper Work Techniques: Please refer to the “Job Site Evaluation” and “Job Site Alteration” sections of these guidelines.
6.12.5 Therapeutic Exercise: with or without mechanical assistance or resistance may include isoinertial, isotonic, isometric and isokinetic types of exercises. Indications include the need for cardiovascular fitness, reduced edema, improved muscle strength, improved connective tissue strength and integrity, increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle recruitment, increased range of motion, and are used to promote normal movement patterns. Can also include complementary/alternative exercise movement therapy.
7.1 SURGICAL DECOMPRESSION is well-established, generally accepted, and widely used and includes open and endoscopic techniques. There is good evidence that surgery is more effective than splinting in producing long-term symptom relief and normalization of median nerve conduction velocity.
7.1.1 Endoscopic Techniques: have had a higher incidence of serious complications (up to 5%) compared to open techniques (less than 1%). The most commonly seen serious complications are incomplete transection of the transverse carpal ligament and inadvertent nerve or vessel injuries. The incidence of complications may be lower for surgeons who have extensive experience and familiarity with certain endoscopic techniques. Choice of technique should be left to the discretion of the surgeon.
7.1.2 Indications for Surgery: include positive history, abnormal electrodiagnostic studies, and/or failure of conservative management. Job modification should be considered prior to surgery. Please refer to the “Job Site Alteration” section for additional information on job modification.
7.1.3 Surgery as an Initial Therapy: Surgery should be considered as an initial therapy in situations where:
7.1.4 Surgery When Electrodiagnostic Testing is Normal: Surgery may be considered in cases where electrodiagnostic testing is normal. An opinion from a hand surgeon may be considered. The following criteria should be considered in deciding whether to proceed with surgery:
7.1.5 Suggested parameters for return-to-work are:
7.2 NEUROLYSIS has not been proven advantageous for carpal tunnel syndrome. Internal neurolysis should never be done. Very few indications exist for external neurolysis.
7.3 TENOSYNOVECTOMY has not proven to be of benefit in primary carpal tunnel syndrome but occasionally can be beneficial in certain patients with co-existing or systemic disorders.
7.4 CONSIDERATIONS FOR REPEAT SURGERY The single most important factor in predicting symptomatic improvement following carpal tunnel release is the severity of preoperative neuropathy. Patients with moderate electrodiagnostic abnormalities have better results than those with either very severe or no abnormalities. Incomplete cutting of the transverse carpal ligament or iatrogenic injury to the median nerve are rare.
7.5 POST-OPERATIVE TREATMENT Considerations for post-operative therapy are:
Last Updated: December 31 1969 19:00:00.
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