19 Del. Admin. Code § 1342-A-4.0

Current through Register Vol. 27, No. 12, June 1, 2024

Section 1342-A-4.0 - Initial Diagnostic Procedures

4.1INTRODUCTION The two standard procedures that are to be utilized when initially evaluating a work-related carpal tunnel complaint are History Taking, and Physical Examination.

History-taking and Physical Examination are generally accepted, well-established, and widely used procedures which establish the foundation/basis for and dictate all ensuing stages of diagnostic and therapeutic procedures. When findings of clinical evaluation and those of other diagnostic procedures do not complement each other, the objective clinical findings should have preference.

4.2HISTORY

4.2.1Description of symptoms - should address at least the following:

4.2.1.1 Numbness, tingling, and/or burning of the hand involving the distal median nerve distribution; however, distribution of the sensory symptoms may vary considerably between individuals. Although the classic median nerve distribution is to the palmar aspect of the thumb, the index finger, the middle finger and radial half of the ring finger, patients may report symptoms in any or all of the fingers. The Katz Hand diagram (see Fig. 1) may be useful in documenting the distribution of symptoms; the classic pattern of carpal tunnel affects at least two of the first three digits and does not involve dorsal and palmar aspects of the hand. A probable pattern involves the palmar but not dorsal aspect of the hand (excluding digits).

4.2.1.2 Nocturnal symptoms frequently disrupt sleep and consist of paresthesias and/or pain in the hand and/or arm.

4.2.1.3 Pain in the wrist occurs frequently and may even occur in the forearm, elbow or shoulder. While proximal pain is not uncommon, its presence warrants evaluation for other pathology in the cervical spine, shoulder and upper extremity.

4.2.1.4 Shaking the symptomatic hand to relieve symptoms may be reported.

4.2.1.5 Clumsiness of the hand or dropping objects is often reported, but may not be present early in the course.

Click here to view Image

Figure 1 - Katz Hand Diagram Used with permission. JAMA 2000; 283 (23): 3110-17. Copyrighted 2000, American Medical Association.

4.2.2Identification 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.

4.2.3Demographics: Age, hand dominance, gender, etc.

4.2.4Past 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:

4.2.4.1 Pregnancy

4.2.4.2 Arthropathies including connective tissue disorders, rheumatoid arthritis, systemic lupus erythematosus, gout, osteoarthritis and spondyloarthropathy

4.2.4.3 Colles' fracture or other acute trauma

4.2.4.4 Amyloidosis

4.2.4.5 Hypothyroidism, especially in older females

4.2.4.6 Diabetes mellitus, including family history or gestational diabetes

4.2.4.7 Acromegaly

4.2.4.8 Use of corticosteroids or estrogens

4.2.4.9 Vitamin B6 deficiency

4.2.5Activities 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.

4.2.6Avocational 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.

4.2.7Social History: Exercise habits, alcohol consumption, and psychosocial factors.

4.3PHYSICAL EXAMINATION Please refer to Table 1 for respective sensitivities and specificities for findings used to diagnose CTS (a-f).

4.3.1 Sensory loss to pinprick, light touch, two-point discrimination or Semmes-Weinstein Monofilament tests in a median nerve distribution may occur

4.3.2 Thenar atrophy may appear, but usually late in the course

4.3.3 Weakness of the abductor pollicis brevis may be present

4.3.4 Phalen's / Reverse Phalen's signs may be positive

4.3.5 Tinel's sign over the carpal tunnel may be positive

4.3.6 Closed Fist test - holding fist closed for 60 seconds reproduces median nerve paresthesia

4.3.7 Evaluation of the contralateral wrist is recommended due to the frequency of bilateral involvement

4.3.8 Evaluation of the proximal upper extremity and cervical spine for other disorders including cervical radiculopathy, thoracic outlet syndrome, other peripheral neuropathies, and other musculoskeletal disorders

4.3.9 Signs of underlying medical disorders associated with CTS, e.g., diabetes mellitus, arthropathy, and hypothyroidism

4.3.10 Myofascial findings requiring treatment may present in soft tissue areas near other CTD pathology, and should be documented. Refer to the Division's Cumulative Trauma Disorder Medical Treatment Guidelines.

Table 1: Sensitivities and Specificities and Evidence Level for Physical Examination findings

Procedure	Sensitivity (%)	Specificity (%)	Validity
1. Sensory testing
Hypesthesia	15-51	85-93	Good
Katz Hand Diagram	62-89	73-88	Good
Two-point discrimination	22-33	81-100	Some
Semmes-Weinstein	52-91	59-80	Some
Vibration	20-61	71-81	None
2. Phalen's	51-88	32-86	Some
3. Tinel's	25-73	55-94	Some
4. Carpal tunnel compression	28-87	33-95	Some
5. Thenar atrophy	3-28	82-100	Good
Abductor pollicis brevis weakness	63-66	62-66	Good
6. Closed fist test	61	92	Some
7. Tourniquet test	16-65	36-87	None

4.4RISK 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.

No single epidemiologic study will fulfill all criteria for causality. The clinician must recognize that currently available epidemiologic data is based on population results, and that individual variability lies outside the scope of these studies. Many published studies are limited in design and methodology, and, thus, preclude conclusive results. Most studies' limitations tend to attenuate, rather than inflate, associations between workplace exposures and CTS.

These guidelines are based on current epidemiologic knowledge. As with any scientific work, the guidelines are expected to change with advancing knowledge. The clinician should remain flexible and incorporate new information revealed in future studies.

Table 2: Risk Factors Associated with Carpal Tunnel Syndrome

Diagnosis	Strong Evidence	Good evidence	Some evidence	Insufficient or conflicting evidence
Carpal Tunnel Syndrome	Combination of high exertional force (Varied from greater than 6 kg) and high repetition (work cycles less than 30 sec or greater than 50% of cycle time performing same task, length of shortest task less than 10 sec).	Repetition or force independently, use of vibration hand tools.	Wrist ulnar deviation and extension.	Pinch/grip, keyboarding.

4.5LABORATORY 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:

4.5.1 Serum rheumatoid factor and Antinuclear Antigen (ANA) for rheumatoid work-up;

4.5.2 Thyroid Stimulating Hormone (TSH) for hypothyroidism;

4.5.3 Fasting glucose - recommended for obese men and women over 40 years of age, patients with a history of family diabetes, those from high-risk ethnic groups, and with a previous history of impaired glucose tolerance. A fasting blood glucose greater than 125mg/dl is diagnostic for diabetes. Urine dipstick positive for glucose is a specific but not sensitive screening test. Quantitative urine glucose is sensitive and specific in high-risk populations;

4.5.4 Serum protein electrophoresis;

4.5.5 Sedimentation rate, nonspecific, but elevated in infection, neoplastic conditions and rheumatoid arthritis;

4.5.6 Serum calcium, phosphorus, uric acid, alkaline and acid phosphatase for metabolic, endocrine and neoplastic conditions;

4.5.7 Complete Blood Count (CBC), liver and kidney function profiles for metabolic or endocrine disorders or for adverse effects of various medications;

4.5.8 Bacteriological (microorganism) work-up for wound, blood and tissue;

4.5.9 Serum B6 - routine screening is not recommended due to the fact that vitamin B6 supplementation has not been proven to affect the course of carpal tunnel syndrome. However, it may be appropriate for patients on medications that interfere with the effects of vitamin B6, or for those with significant nutritional problems.

The Department recommends the above diagnostic procedures be considered, at least initially, the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established.

19 Del. Admin. Code § 1342-A-4.0