19 Del. Admin. Code § 1342-C-5.0

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

Section 1342-C-5.0 - Follow-Up Diagnostic Imagining and Testing Procedures

5.1 ELECTRODIAGNOSTIC (EDX) STUDIES

5.1.1 Electrodiagnostic (EDX) studies are well-established and widely accepted for evaluation of patients suspected of having peripheral nerve pathology. Studies may confirm the diagnosis or direct the examiner to alternative disorders. Studies may require clinical correlation due to the occurrence of false positive and false negative results. Symptoms of peripheral nerve pathology may occur with normal EDX studies, especially early in the clinical course. Findings include fibrillations, fasciculations, neurogenic recruitment, and polyphasic units (reinnervation).

5.1.2 To assure accurate testing, temperature should be maintained at 30-34C preferably recorded from the hand/digits. For temperature below 30C the hand should be warmed.

5.1.3 All studies must include normative values for their laboratories.

5.2 IMAGING STUDIES

5.2.1 Radiographic Imaging: Not generally required for most CTD 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 CTD.

5.2.2 MRI: May show increased T2-weighted signal intensity of the common extensor tendon in lateral epicondylitis, but this finding has commonly been found in the asymptomatic contralateral elbow and may not be sufficiently specific to warrant the use of MRI as a diagnostic test for epicondylitis. Its routine use for CTD is not recommended.

5.3 ADJUNCTIVE TESTING

5.3.1 Personality/Psychological/Psychosocial Evaluations: are generally accepted and well-established diagnostic procedures with selective use in the CTD population, but have more widespread use in sub-acute and chronic pain populations.

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.

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:

5.3.1.1 Employment history;

5.3.1.2 Interpersonal relationships - both social and work;

5.3.1.3 Leisure activities;

5.3.1.4 Current perception of the medical system;

5.3.1.5 Results of current treatment;

5.3.1.6 Perceived locus of control; and

5.3.1.7 Childhood history, including abuse and family history of disability.

Results should provide clinicians with a better understanding of the patient, thus allowing for more effective rehabilitation. The evaluation will determine the need for further psychosocial interventions, and in those cases, a Diagnostic Statistical Manual for Mental Disorders (DSM) diagnosis should be determined and documented. An individual with a Ph.D., PsyD, or Psychiatric MD/DO credentials may perform initial evaluations, which are generally completed within one to two hours. When issues of chronic pain are identified, the evaluation should be more extensive and follow testing procedures as outlined in the Division's Chronic Pain Disorder Medical Treatment Guidelines.

. Frequency: One time visit for evaluation. If psychometric testing is indicated as a portion of the initial evaluation, time for such testing should not exceed an additional two hours of professional time.

5.3.2 Laboratory Tests: 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. In one study of patients with cumulative trauma disorder other than Carpal Tunnel Syndrome, seen by specialists, 3% of patients were diagnosed with diabetes, 6% with hypothyroidism, and 9% 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. When a patient's history and physical examination suggest infection, metabolic or endocrinologic disorders, tumorous conditions, systemic musculoskeletal disorders (e.g., rheumatoid arthritis or ankylosing spondylitis), or problems potentially related to 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:

5.3.2.1 Serum rheumatoid factor, Antinuclear Antigen (ANA), Human Leukocyte Antigen (HLA)-B27 titre for rheumatoid work-up;

5.3.2.2 Thyroid stimulating hormone (TSH) for hypothyroidism;

5.3.2.3 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;

5.3.2.4 Serum protein electrophoresis;

5.3.2.5 Sedimentation rate and C-Reactive Protein are nonspecific, but elevated in infection, neoplastic conditions and rheumatoid arthritis;

5.3.2.6 Serum calcium, phosphorus, uric acid, alkaline and acid phosphatase for metabolic, endocrine and neo-plastic conditions;

5.3.2.7 complete blood count (CBC), liver and kidney function profiles for metabolic or endocrine disorders or for adverse effects of various medications;

5.3.2.8 Bacteriological (microorganism) work-up for wound, blood and tissue.

The Division 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. Laboratory testing may be required periodically to monitor patients on chronic medications.

5.3.3 Pinch and Grip Strength Measurements: May be accepted as a diagnostic tool for CTD. 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 exerted. When a bell-shaped curve is 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.

5.3.4 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 review of systems findings and the results of other tests and measures. QST tests the entire sensory pathway, limiting its ability to localize a deficit precisely. It depends on the patient's report of perception and may not be objective. Cutaneous conditions may alter sensory thresholds.

5.3.4.1 Threshold tests measure topognosis, the ability to exactly localize a cutaneous sensation, and pallesthesia, the ability to detect mechanical sensation using vibration discrimination testing (quickly adapting fibers); and/or Semmes-Wienstein monofilament testing (slowly adapting fibers);

5.3.4.2 Density Tests also measure topognosis and pallesthesia using static two-point discrimination (slowly adapting fibers); and/or moving two-point discrimination (quickly adapting fibers).

19 Del. Admin. Code § 1342-C-5.0