SUMMARY OF MAJOR SUBSTANTIVE CHANGES BETWEEN THE CURRENTLY EFFECTIVE RULE 17, EXHIBITS #2 AND #5-CARPAL TUNNEL SYNDROME AND CUMULATIVE TRAUMA DISORDER MEDICAL TREATMENT GUIDELINES AND PROPOSED EXHIBIT #5 CUMULATIVE TRAUMA CONDITIONS

Below is a Summary of Major Substantive Changes between the 2007 and 2006 Cumulative Trauma Disorder and Carpal Tunnel Syndrome (respectively) Medical Treatment Guidelines and the Proposed 2010 Cumulative Trauma Conditions Medical Treatment Guidelines. The changes that are listed below comprise mainly the following: some general comments about the guidelines as a whole; diagnoses/procedures not addressed previously; diagnoses/procedures no longer addressed in the proposed rule; procedures that have been specifically stated as, 'not recommended’ where no such statement was in the previous guidelines; procedures which no longer have a notation of, ‘not recommended;’ and interventions/procedures specifically listed as needing prior authorization. Please refer to the Cumulative Trauma Conditions Medical Treatment Guidelines (as proposed June 30th 2010) for specific and complete substantive and non-substantive changes.

SECTION / SUBSTANTIVE CHANGE
General Comments
General Comments (cont) / The Cumulative Trauma Conditions Medical Treatment Guidelines replaces two other guidelines, the Carpal Tunnel Syndrome and Cumulative Trauma Disorder.
Language has been updated according to changes in the medical literature.
The Cumulative Trauma Conditions Medical Treatment Guidelines has been organized and formatted similarly to the Shoulder Disorder and the Lower Extremity Medical Treatment Guidelines. It has two sections devoted to Specific Diagnosis, Testing and Treatment Procedures (Musculoskeletal and Neurological). This allows the reader to look up specific diagnoses and learn the Division position on the continuum of care, from diagnosis to Post-Operative Procedures.
Inclusion of language related to FDA-approval.
Operative Sections for each specific disorder have been enveloped into Specific Diagnostic Testing and Treatment Procedures. Therefore, there is no separate section for Operative Procedures.
Changes in recommendations regarding causation assessment, diagnosis, testing, and treatment procedures.
Section C: Definitions and Mechanisms of Injury / Acknowledgement that in some cases, the normal working-age population may have non-specific pain complaints. Therefore, guidance provided that in cases where there is no specific diagnosis and corresponding work-related etiology, work-up should generally be performed outside the Workers’ Compensation system.
Section D: Initial Diagnostic Procedures / This section greatly expanded to include more specific guidance regarding causation assessment. It includes: foundations for occupational relationships, specific directions on using risk factors to determine causation, and tables on specific risk factor definitions and diagnosis-based risk factors.
Section E: Follow-up Diagnostic Procedures
Section E: Follow-up Diagnostic Procedures
(cont) / Insertion of: Computerized Axial Tomography (CT scan)
Prior authorization for: Functional Capacity Evaluations performed during treatment (not needed initially for determination of baseline status or at case closure when patient unable to return to work).
Insertion of:
  • joint aspiration
Changes in Recommendations:
Magnetic Resonance Imaging (MRI): Previously effective guidelines stated as ‘not recommended.’ Proposed guidelines specify that although routine use for CTC is not recommended, that MRI may be helpful to diagnose triangular fibrocartilage complex tear (TFCC) or other suspected ligament/bone pathology when clinical findings suggest.
Section F: Specific Musculoskeletal Diagnosis, Testing, and Treatment Procedures
Section F: Specific Musculoskeletal Diagnosis, Testing, and Treatment Procedures (cont) / Insertion of:
  • 'Initial Treatment' subsections into most non-operative sections of specific disorders.
  • Discussion and related recommendations for smoking cessation where applicable
Insertion on text related to the complete continuum care (Description to Post-Operative Treatment)
  • Aggravated osteoarthritis of the wrist
  • De Quervain’s Disease*
  • Epicondylitis – Lateral*
  • Epicondylitis – Medial*
  • Extensor Tendon Disorders of the Wrist*
  • Flexor Tendon Disorders of the Wrist*
  • Triangular Fibrocartilage Complex Tear
  • Trigger Finger*
*Denotes that treatment strategies related to this disorder are addressed in the currently effective Cumulative Trauma Disorder and/or Carpal Tunnel Syndrome Medical Treatment Guideline, but on a much less extensive level.
Deleted: Hand/Arm Vibration Syndrome
Stated as ‘not recommended’:
  • s-adenosyl methionine (SAM-e)
  • continuous passive motion after metacarpal-phalangeal joint arthroplasty
  • polidocanal injections for lateral/medial epicondylitis
  • magnets or diathermy for lateral/ medial epicondylitis
  • radiofrequency microtenotomy for lateral epicondylitis

Section G: Specific Peripheral Nerve Diagnosis, Testing, and Treatment Procedures
Section G: Specific Peripheral Nerve Diagnosis, Testing, and Treatment Procedures (cont)
Section G: Specific Peripheral Nerve Diagnosis, Testing, and Treatment Procedures (cont). / Insertion of:
  • 'Initial Treatment' subsections into most non-operative sections of specific disorders.
  • Discussion and related recommendations for smoking cessation where applicable
  • Hatha yoga therapy for carpal tunnel syndrome
Insertion of text related to the complete continuum of care(Description to Post-Operative Treatment:
  • Cubital Tunnel Syndrome*
  • Guyon Canal (Tunnel) Syndrome*
  • Pronator Syndrome*
  • Radial Tunnel Syndrome*
  • Posterior Interosseus Nerve Entrapment (PIN)
*Denotes that treatment strategies related to this disorder are addressed in the currently effective Cumulative Trauma Disorder and/or Carpal Tunnel Syndrome Medical Treatment Guideline, but on a much less extensive level.
Stated as ‘not recommended’:
  • MRI, imaging, and sonography for carpal tunnel syndrome unless a space-occupying lesion is suspected.
  • magnets for carpal tunnel syndrome
  • laser acupuncture for carpal tunnel syndrome
  • chiropractic for carpal tunnel syndrome
Changes in Recommendations:
  • Oral steroids: still stated as not recommended for carpal tunnel syndrome. However may occasionally be used for patients with severe symptoms who refuse injections and who have no risk factors for adverse effects.

Section H. Therapeutic Procedures – Non-Operative
Section H. Therapeutic Procedures – Non-Operative (cont). / Insertion of text regarding:
  • autologous whole blood injections;
  • platelet-rich plasma injections;
  • botulinum toxin injections(prior authorization required);
  • viscosupplementation/intracapsular acid salts;
  • expanded text on topical drug delivery
 topical salicylates and nonsalicylates
 capsaicin
  • paraffin bath
  • manipulation (a separate section now separated from manual therapy techniques)
Deletion of text regarding:
  • tramadol
  • microcurrent transcutaneous electrical nerve stimulation (TENS)
Stated as ‘not recommended:’
  • prolotherapy
  • NSAIDs for routine use for prevention of heterotopic bone formation
  • benzodiazepines on a routine basis due to habit-forming potential
  • topical glyceryl trinitrate for epicondylitis
  • topical lidocaine patches, but may in some cases be used when primary complaint is pain and the patient refuses a steroid injection
Changes in Recommendations:
  • oral steroids: limited use but are accepted in cases requiring potent inflammatory drug effect. May be considered for patients who have frequent flare-ups of arthritic joints.
  • extracorporeal shock wave therapy (ESWT)- now an accepted treatment for lateral and medial epicondylitis.

1