Skip Navigation
PrintDownload PDFGet Adobe ReaderDownload to WordDownload as HTMLDownload as XMLCitation Manager
Save to Favorites
Guideline Summary
Guideline Title
Work-related carpal tunnel syndrome diagnosis and treatment guideline.
Bibliographic Source(s)
Washington State Department of Labor and Industries. Work-related carpal tunnel syndrome diagnosis and treatment guideline. Olympia (WA): Washington State Department of Labor and Industries; 2009 Apr. 16 p.
Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Scope

Disease/Condition(s)

Work-related carpal tunnel syndrome (CTS)

Guideline Category
Diagnosis
Evaluation
Risk Assessment
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Neurological Surgery
Neurology
Orthopedic Surgery
Physical Medicine and Rehabilitation
Surgery
Intended Users
Health Care Providers
Health Plans
Physicians
Utilization Management
Guideline Objective(s)

  • To present guidelines for the diagnosis and treatment of work-related carpal tunnel syndrome
  • To serve as an educational resource for physicians who treat injured workers in the Washington workers' compensation system under Title 51 RCW and as review criteria for the Department's utilization review team to help ensure diagnosis and treatment of carpal tunnel syndrome is of the highest quality

Target Population

The injured worker with carpal tunnel syndrome in the Washington workers' compensation system

Interventions and Practices Considered

Diagnosis/Evaluation

  1. Evaluation of subjective and objective clinical findings (e.g., symptoms of numbness, tingling, or burning pain of the hand, and decreased sensation to pin in palm and first 3 digits)
  2. Work-relatedness assessment
  3. Electrodiagnostic studies, including nerve conduction velocity (NCV) and needle electromyography (EMG)

Treatment

  1. Conservative care
    • Neutral position wrist splints
    • Glucocorticosteroid injections (no more than 2)
    • Forearm/wrist stretching exercise regimens
    • Job modification

    Note: The following conservative treatments were considered but not recommended: vitamin B6, oral diuretics, magnets, lasers, botulinum toxin injections, iontophoresis.

  2. Surgery
    • Open carpal tunnel release
    • Endoscopic carpal tunnel release
  3. Return to work
Major Outcomes Considered
  • Sensitivity and specificity of diagnostic assessments for carpal tunnel syndrome
  • Response to surgical decompression of the median nerve
  • Function
  • Ability to return to work

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

A systematic review of literature was conducted using PubMed. The primary literature search was conducted during April-June 2008. Additional searches were conducted in the fall of 2008.

Inclusion criteria: Papers published in the past 15 years (additional papers were contributed to search directly from subcommittee members, outside of search), papers written in English, including ALL human and adult subjects, papers written about carpal tunnel syndrome (CTS) only.

Exclusion criteria: papers not meeting above criteria.

Key questions/focus:

  • Case definition for CTS
  • Work-relatedness for CTS
  • Diagnosis, assessment, and evaluation for CTS
  • Conservative and surgical treatment options for CTS

Terms used: carpal tunnel syndrome, nerve entrapment, nerve compression, neuropathy, median nerve, wrist, case definition, diagnosis, nerve conduction, conservative, surgical, treatment, physiotherapy, physical, therapy, injections, yoga, exercise, carpal tunnel release, open, endoscopic

Number of Source Documents

Sixty-seven documents were reviewed; thirty were used.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Evidence was graded on a 1-5 scale with 1 being the highest grade:

1 = Randomized controlled trial

2 = Cohort study, prospective or historical

3 = Case-control study

4 = Cross-sectional study

5 = Case series

Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Individual review of articles by clinical experts

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Guideline Development Through Consensus

This guideline was developed in 2008 by Labor and Industries' (L&I) Industrial Insurance Medical Advisory Committee's (IIMAC's) subcommittee on Upper Extremity Entrapment Neuropathies.

The IIMAC meets with L&I's medical director and staff at least quarterly to address medical practice issues in the workers' compensation system. These meetings are subject to the Open Public Meetings Act (RCW 42.30). Subcommittees with specialty trained physicians may also meet on selected topics requiring additional expertise.

Guideline development generally occurs through a combination of the best available evidence and expert consensus. The goal of the IIMAC is to develop treatment guidelines that will be implemented in a fair manner. The committee tries to distinguish between clear-cut indications for procedures and those that are questionable.

Once consensus is reached on the principles of the guideline, they are placed in an algorithm format consisting of 'and/or' statements that can be used by professional utilization review staff in deciding whether a particular request falls within the guideline.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Following input from community-based practicing physicians, the guideline was further refined.

Recommendations

Major Recommendations

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Review Criteria for the Diagnosis and Treatment of Work-Related Carpal Tunnel Syndrome
SURGICAL PROCEDURE CONSERVATIVE CARE CLINICAL FINDINGS
      SUBJECTIVE   OBJECTIVE   DIAGNOSTIC
Open Carpal Tunnel Release

Endoscopic Carpal Tunnel Release
Splinting, especially at night

Glucocorticoid injections (no more than 2)

Job Modification
AND Complaints of numbness, tingling, or "burning" pain of the hand or first 3 digits OR Decreased sensation to pin in palm and first 3 digits

Weakness or atrophy of the thenar eminence muscles
AND Abnormal EDS as demonstrated by any abnormality in one of the following*.

Median motor distal latency (8 cm) >4.5 msec

Note: If median motor distal latency is abnormal, then ulnar motor distal latency at 8 cm must be WNL (≤3.9 msec.)

Median sensory distal latency: either ≥ 2.3 msec (8 cm) recorded palm to wrist or ≥ 3.6 (14 cm) msec recorded index finger to wrist. If either of these tests is used alone, at least one other sensory nerve in the ipsilateral hand should be normal.

Median-ulnar motor latency difference (APB versus ADM) at 8 cm >1.6 msec
Note: In the absence of conservative care or with minimal conservative care, a request for surgery can still be considered pending clinical findings. Note: Nocturnal symptoms may be prominent. Median - ulnar sensory latency difference to digits (14 cm) – index or long finger compared to ulnar recorded at the small finger, or median-ulnar difference recorded at the ring finger >0.5 msec

Median - ulnar sensory latency difference across palm (8 cm) >0.3 msec

Median - radial sensory latency difference to thumb (10 cm) >0.6 msec

Combined sensory index >0.9 msec
Note: Nerve conduction velocity studies (NCVs) should be scheduled immediately to corroborate the clinical diagnosis. NCVs are required if time loss extends beyond two weeks or if surgery is requested. *NCVs must be done with control for skin temperature with normal appropriate control nerves (as described in section B of the original guideline document). Values are true for temperature in range of 30-34° C.

Abbreviations: ADM, abductor digiti minimi; APB, abductor pollicis brevis; EDS, electrodiagnostic testing; msec, millisecond; NCV, nerve conduction velocity study; WNL, within normal limits

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is not specifically stated for each recommendation.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate diagnosis and treatment of carpal tunnel syndrome (CTS)

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

The guideline-setting process will be iterative (i.e., although initial guidelines may be quite liberally constructed, subsequent tightening of the guideline would occur as other national guidelines are set, or other scientific evidence becomes available).

Implementation of the Guideline

Description of Implementation Strategy

Most guidelines are implemented within the utilization review (UR) program. Labor and Industries (L&I) guidelines have priority over other proprietary guidelines and criteria that may exist. Where L&I guidelines are not available, proprietary ones may be used. Reviewers apply each guideline as a standard for the majority of requests in the Washington workers' compensation program. For the minority of workers who appear to fall outside of the guideline and whose complexity of clinical findings exceeds the specificity of the guideline, further review by a physician is conducted.

When a surgical procedure is requested for a patient who meets the guideline criteria, the reviewer will recommend approval to the claim manager. If the criteria are not met, the request will be referred to a physician consultant who will review the patient's file, offer to discuss the case with the requesting physician, and make a recommendation to the claim manager. The flexibility built into this decision making process is important in two ways. First, it enables the Washington State Industrial Insurance Medical Advisory Committee (IIMAC) to develop surgical indications fairly quickly. Second, it plays a major role in legitimizing the work of the subcommittee in the eyes of practicing physicians in Washington.

Completed guidelines will be communicated to practicing physicians via L&I's website. Education and training will be provided to reviewers and staff to ensure their proper application within the UR program. Where possible, continuing medical education (CME) credits may be offered.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Washington State Department of Labor and Industries. Work-related carpal tunnel syndrome diagnosis and treatment guideline. Olympia (WA): Washington State Department of Labor and Industries; 2009 Apr. 16 p.
Adaptation

Not applicable: Guideline was not adapted from another source.

Date Released
1995 Nov (revised 2009 Apr 1)
Guideline Developer(s)
Washington State Department of Labor and Industries - State/Local Government Agency [U.S.]
Source(s) of Funding

Washington State Department of Labor and Industries

Guideline Committee

Labor and Industries' Industrial Insurance Medical Advisory Committee (IIMAC)

Upper Extremity Entrapment Neuropathies

Composition of Group That Authored the Guideline

IIMAC Committee Members: Gregory T. Carter MD, MS; Dianna Chamblin MD – Chair; G.A. DeAndrea MD, MBA; Jordan Firestone, MD, PhD, MPH; Andrew Friedman, MD

Upper Extremity Entrapment Neuropathies Committee Members: Christopher H. Allan, MD; Douglas P. Hanel, MD; Michel Kliot, MD; Lawrence R. Robinson, MD; Thomas E. Trumble, MD; Nicholas B. Vedder, MD; Michael D. Weiss, MD

Department Staff: Gary M. Franklin MD, MPH, Medical Director; Simone P. Javaher BSN, MPA, Occupational Nurse Consultant; Reshma N. Kearney MPH, Epidemiologist

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Guideline Availability

Electronic copies of the updated guideline: Available in Portable Document Format (PDF) from the Washington State Department of Labor and Industries Web site External Web Site Policy.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This summary was completed by ECRI on February 14, 2000. It was sent to the guideline developer for review on February 15, 2000; however, to date, no comments have been received. The guideline developer has given NGC permission to publish the NGC summary. This summary was updated by ECRI on May 27, 2004. The information was verified by the guideline developer on June 14, 2004. This NGC summary was updated by ECRI Institute on September 24, 2009. The information was verified by the guideline developer on October 16, 2009.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

Read full disclaimer...