19 Del. Admin. Code § 1342-C-4.0

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

Section 1342-C-4.0 - Initial Diagnostic Procedures

History and physical examination (Hx & PE) are generally accepted, well-established and widely used procedures which establish the foundation/basis for and dictate all other diagnostic and therapeutic procedures. When findings of clinical evaluations and those of other diagnostic procedures do not complement each other, the objective clinical findings should have preference.

4.1 HISTORY Should inquire about the following issues, where relevant, and document pertinent positives and negatives where appropriate. In evaluating potential CTDs, the following actions should be taken:

4.1.1 Description of Symptoms:

4.1.1.1 Onset: date of onset, sudden vs. gradual;

4.1.1.2 Nature of Symptoms: pain, numbness, weakness, swelling, stiffness, temperature change, color change;

4.1.1.3 Intensity: pain scale (0 = no pain, and 10 = worst imaginable pain) may be used.

4.1.1.4 Location and Radiation: use of a pain diagram is encouraged for characterizing sensory symptoms; use comprehensive diagrams and do not use limited diagrams depicting only the hand or arm, as it is important to solicit the reporting of more proximal symptoms;

4.1.1.5 Provocative and Alleviating Factors (occupational and non-occupational): Attempt to identify the specific physical factors that are aggravating or alleviating the problem;

4.1.1.6 Sleep disturbances;

4.1.1.7 Other associated signs and symptoms noted by the injured worker;

4.1.2 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 Risk Factors Associated with Cumulative Trauma Table. A job site evaluation may be required.

4.1.3 Demographics: age, hand dominance, gender, etc.

4.1.4 Past Medical History and Review of Systems:

4.1.4.1 Past injury/symptoms involving the upper extremities, trunk and cervical spine;

4.1.4.2 Past work-related injury or occupational disease;

4.1.4.3 Past personal injury or disease that resulted in temporary or permanent job limitation;

4.1.4.4 Medical conditions associated with CTD - A study of work-related upper extremity disorder patients showed a 30% prevalence of co-existing disease. Medical conditions commonly occurring with CTD include:

4.1.4.4.1 Pregnancy,

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

4.1.4.4.3 Amyloidosis,

4.1.4.4.4 Hypothyroidism, especially in older females,

4.1.4.4.5 Diabetes mellitus, including family history or gestational diabetes,

4.1.4.4.6 Acromegaly,

4.1.4.4.7 Use of corticosteroids.

4.1.5 Activities of Daily Living (ADLs): 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.

4.1.6 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, tennis, and gardening are included in this category.

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

4.2 PHYSICAL EXAMINATION The evaluation of any upper extremity complaint should begin at the neck and upper back and then proceed down to the fingers and include the contralateral region. It should include evaluation of vascular and neurologic status, and describe any dystrophic changes or variation in skin color or turgor.

Table 1: Physical Examination Findings Reference Table

DIAGNOSIS	SYMPTOMS	SIGNS
DeQuervain's Tenosynovitis	Pain and swelling in the anatomical snuffbox; pain radiating into the hand and forearm; pain worsened by thumb abduction and/or extension.	Pain worsened by active thumb abduction and/or extension; crepitus along the radial forearm; positive Finkelstein's.
Extensor Tendinous Disorders	Pain localized to the affected tendon(s); pain worsened by active and/or resisted wrist or finger extension.	Swelling along the dorsal aspects of the hand/wrist/ forearm, and pain with active and/or resisted wrist/ digit extension, or creaking/crepitus with wrist extension.
Flexor Tendinous Disorders	Pain localized to the affected tendons; pain in the affected tendons associated with wrist flexion and ulnar deviation, especially against resistance.	Pain with wrist/digit flexion and ulnar deviation, or crepitus with active motion of the flexor tendons.
Lateral Epicondylitis	Lateral elbow pain exacerbated by repetitive wrist motions; pain emanating from the lateral aspect of the elbow.	Pain localized to lateral epicondyle with resisted wrist extension and/or resisted supination.
Medial Epicondylitis	Pain emanating from the medial elbow; mild grip weakness; medial elbow pain exacerbated by repetitive wrist motions.	Pain localized to the medial epicondyle with resisted wrist flexion and resisted pronation.
Cubital tunnel syndrome	Activity-related pain/paresthesias involving the 4th and 5th fingers coupled with pain in the medial aspect of the elbow; pain/paresthesias worse at night; decreased sensation of the 5th finger and ulnar half of the ring finger (including dorsum 5th finger); progressive inability to separate fingers; loss of power grip and dexterity; atrophy/weakness of the ulnar intrinsic hand muscles (late sign).	Diminished sensation of the fifth and ulnar half of the ring fingers; elbow flexion/ulnar compression test; Tinels' sign between olecranon process and medial epicondyle; Later stages manifested by intrinsic atrophy and ulnar innervated intrinsic weakness. Specific physical signs include clawing of the ulnar 2 digits (Benediction posture), ulnar drift of the 5th finger (Wartenberg's sign), or flexion at the thumb IP joint during pinch (Froment's sign).
Hand-Arm Vibration Syndrome	Pain/paresthesias in the digits; blanching of the digits; cold intolerance; tenderness/swelling of the digits/hand/forearm; muscle weakness of the hand; joint pains in hand/wrist/elbow/neck/ shoulders; trophic skin changes and cyanotic color in hand/digits.	Sensory deficits in the digits/hand; blanching of digits; swelling of the digits/hand/forearm; muscle weakness of the hand; arthropathy at the hand/wrist/elbow; trophic skin changes and cyanotic color in hand/digits.
Guyon Canal (Tunnel) Syndrome	Numbness/tingling in ulnar nerve distribution distal to wrist.	Positive Tinel's at hook of hamate. Numbness or paresthesias of the palmar surface of the ring and small fingers. Later stages may affect ulnar innervated intrinsic muscle strength.
Pronator Syndrome	Pain/numbness/tingling in median nerve distribution distal to elbow.	Tingling in median nerve distribution on resisted pronation with elbow flexed at 90o Tenderness or Tinel's at the proximal edge of the pronator teres muscle over the median nerve.
Radial Tunnel Syndrome	Numbness/tingling or pain in the lateral posterior forearm.	Tenderness over the radial nerve near the proximal edge of the supinator muscle. Rarely, paresthesias in the radial nerve distribution or weakness of thumb or finger extension.

4.3 PAIN BEHAVIOR EVALUATION

4.3.1 Evaluate the patient's overall pain behavior. The behavior should be consistent with the current pain levels reported by the patient.

4.3.2 Use a measurement tool to quantify and/or qualify pain. Reference the pain scale (0-10) with the worst pain imaginable being the top end of the scale (10) and/or other pain scales such as the Visual Analog Scale, Pain Drawing, Neck Disability Index, or McGill Pain Questionnaire.

4.4 RISK FACTORS A critical review of epidemiologic literature identifies a number of physical exposures associated with CTDs. 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 a CTD. 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 CTD. The table at the end of this section entitled, "Risk Factors Associated CTDs," 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 CTDs.

Many specific disorders, such as ulnar neuropathy (at the elbow and wrist) and pronator teres syndrome, have not been studied sufficiently to formulate evidence statements regarding causality. Based on the present understanding of mechanism of injury and utilizing the rationale of analogy, it is generally accepted that these disorders are similar to other CTDs at the elbow and wrist and are susceptible to the same risk factors. No studies examined the relationship between the development of ganglion cysts and work activities; however, work activities may aggravate existing ganglion cysts. It is generally accepted that keyboarding less than four hours per day is unlikely to be associated with a CTD when no other risk factors are present. It remains unclear how computer mouse use affects CTDs. The posture involved in mouse use should always be evaluated when assessing risk factors.

Studies measured posture, repetition, and force in variable manners. In general, jobs that require less than 50% of maximum voluntary contractile strength for the individual are not considered "high force." Likewise, jobs with wrist postures less than or equal to 25^o flexion or extension, or ulnar deviation less than or equal to 10^o are not likely to cause posture problems.

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 consider new information revealed in future studies.

Table 2: Risk Factors Associated with Cumulative Trauma

Diagnosis	Strong evidence	Good evidence	Some evidence	Insufficient or conflicting evidence
Elbow Musculoskeletal Disorders (Epicondylitis)	Combination high force and high repetition (Exposures were based on EMG data, observation or video analysis of job tasks, or categorization by job title. Observed movements include repeated extension, flexion, pronation and supination. Repetition work cycles less than 30 sec. or greater than 50% of cycle time performing same task, and number of items assembled in one hour).	High force alone		Repetition alone, extreme wrist posture.
Wrist Tendonitis, including DeQuervain's Tenosynovitis	Combination of risk factors: High repetition, forceful hand/wrist exertions, extreme wrist postures (Assessed by direct observation, EMG, and video analysis. One study measured time spent in deviated wrist posture).	Repetition, (as previously defined), not including keyboarding or force independently	Posture
Trigger Finger			Forceful grip (Holding tools, knives. Assessed by direct observation and video analysis).

19 Del. Admin. Code § 1342-C-4.0