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Guideline Summary
Guideline Title
Work-related radial nerve entrapment: diagnosis and treatment.
Bibliographic Source(s)
Washington State Department of Labor and Industries. Work-related radial nerve entrapment: diagnosis and treatment. Olympia (WA): Washington State Department of Labor and Industries; 2010 Apr 1. 10 p. [22 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Radial nerve entrapment (RNE), including:

  • Radial tunnel syndrome (RTS)
  • Posterior interosseous nerve syndrome (PINS)
Guideline Category
Diagnosis
Evaluation
Management
Rehabilitation
Treatment
Clinical Specialty
Family Practice
Neurological Surgery
Neurology
Orthopedic Surgery
Physical Medicine and Rehabilitation
Surgery
Intended Users
Health Care Providers
Health Plans
Managed Care Organizations
Nurses
Occupational Therapists
Physician Assistants
Physicians
Utilization Management
Guideline Objective(s)
  • To provide standards that ensure a uniformly high quality of care for injured workers in Washington State
  • To present recommendations for diagnosis and treatment of radial nerve entrapment (RNE)
Target Population

Injured workers with radial nerve entrapment (RNE)

Interventions and Practices Considered

Diagnosis/Evaluation

  1. Establishing work-relatedness
  2. Assessment of symptoms and signs
  3. Provocative tests
  4. Differential diagnosis*
  5. Electrodiagnostic studies (EDS)
    • Nerve conduction velocity (NCV)
    • Electromyography (EMG)
  6. Other diagnostic tests
    • Magnetic resonance imaging (MRI) neurography (recommended only in research settings)

Treatment

  1. Conservative treatment including
    • Modified activities
    • Splinting
    • Physical therapy
    • Anti-inflammatory drugs
  2. Surgical treatment
  3. Return to work

*Note: Every effort should be made to objectively confirm the diagnosis of radial nerve entrapment (RNE) before considering surgery. A differential diagnosis for RNE includes extensor tendinitis and lateral epicondylitis (which can coexist with RNE), neuralgic amyotrophy, brachial plexopathy, or cervical radiculopathy.

Major Outcomes Considered
  • Utility of diagnostic tests
  • Duration of disability

Methodology

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

The bulk of the literature search and review was conducted during July 22nd, 2009 and August 18th, 2009. Additional searches were conducted as requested by the Industrial Insurance Medical Advisory Committee Subcommittee members.

Search results were limited to human studies and English language only. Articles published in 1990 and later (arbitrarily chosen) were considered. Search results were not limited to adults only because many studies defined "adults" as 18 years and older whereas PubMed defines this category as 19 years and older.

The following keywords were used in PubMed. Terms for radial nerve entrapment (RNE) were searched in combination with terms for each of the other categories (work-relatedness, diagnosis, treatment).

The condition: radial nerve, posterior interosseous nerve, entrapment, compression, neuropathy, forearm, radial tunnel syndrome, posterior interosseous nerve syndrome.

Work-relatedness: occupational health, injury, disease, work, active worker, job*, employ*, workers compensation, activity, daily living, return to work, disability, daily activity.

Diagnosis: diagnose, diagnosis, diagnostic, gold standard, sensitivity, specificity, likelihood, predictive value, true positive, true negative, false positive, false negative, nerve conduction, electrodiagnostic, electromyography, symptoms, signs, reliability, validity, assessment, evaluation, physical, clinical, test, exam, ultrasound, ultrasonography, magnetic resonance OR imaging.

Treatment: therap*, treatment, outcome, outcome assessment, relative risk, adverse events, effects, conservative, nonsurgical, surgical, surgery, decompression, effectiveness, efficacy, results.

Number of Source Documents

Not stated

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

For articles pertaining to treatment, the following criteria* were used:

Class I: Prospective, randomized, controlled clinical trial (RCT) with masked outcome assessment, in a representative population. The following are required:

  • Primary outcome(s) clearly defined
  • Exclusion/inclusion criteria clearly defined
  • Adequate accounting for drop-outs and cross-overs with numbers sufficiently low to have minimal potential for bias
  • Relevant baseline characteristics are presented and substantially equivalent among treatment groups or there is appropriate statistical adjustment for differences.

Class II: Prospective matched group cohort study in a representative population with masked outcome assessment that meets a-d above OR a RCT in a representative population that lacks one criteria a-d.

Class III: All other controlled trials (including well-defined natural history controls or patients serving as own controls) in a representative population, where outcome is independently assessed, or independently derived by objective outcome measurement.

Class IV: Evidence from uncontrolled studies, case series, case reports, or expert opinion.

For articles pertaining to diagnosis, the following criteria* were used:

Class I: Evidence provided by a prospective study in a broad spectrum of persons with the suspected condition, using a reference (gold) standard for case definition, where test is applied in a blinded evaluation, and enabling the assessment of appropriate tests of diagnostic accuracy. All patients undergoing the diagnostic test have the presence or absence of the disease determined.

Class II: Evidence provided by a prospective study of a narrow spectrum of persons with the suspected condition, or a well designed retrospective study of a broad spectrum of persons with an established condition (by "gold standard") compared to a broad spectrum of controls, where test is applied in a blinded evaluation, and enabling the assessment of appropriate tests of diagnostic accuracy.

Class III: Evidence provided by a retrospective study where either persons with the established condition or controls are of a narrow spectrum, and where the reference standard, if not objective, is applied by someone other than the person that performed the test.

Class IV: Any design where test is not applied in an independent evaluation OR evidence provided by expert opinion alone or in descriptive case series (without controls).

* Evidence was classified using criteria defined by: Edlund W, Gronseth G, So Y, Franklin G. Clinical Practice Guideline Process Manual. American Academy of Neurology 2004.

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

Not stated

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

This guideline was developed in 2010 by the Washington State Industrial Insurance Medical Advisory Committee (IIMAC) and its subcommittee on Upper Extremity Entrapment Neuropathies. The subcommittee presented its work to the full IIMAC, and the IIMAC made an advisory recommendation to the Washington State Department of Labor & Industries to adopt the guideline. This guideline was based on the weight of the best available clinical and scientific evidence from a systematic review of the literature and a consensus of expert opinion.

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

Guideline Summary

Review Criteria for the Diagnosis and Treatment of Work-Related Radial Nerve Entrapment (RNE*)
Clinical Findings Conservative Treatment Surgical Treatment
Subjective
(Symptoms)
  Objective
(Signs)
  Diagnostic

Weakness of wrist or finger extension

OR

Pain/ache over the proximal, lateral forearm

AND

Weakness in radial innervated muscles

OR

Pressure over the radial nerve provokes pain/ tenderness

AND

Needle electromyography (EMG) showing radial tunnel syndrome (RTS) or posterior interosseous nerve syndrome (PINS) by:

Evidence of denervation in muscles supplied by the posterior interosseous nerve (PIN) or radial nerve distal to the brachioradialis

AND

Normal findings in muscles innervated by the radial nerve proximal to the radial tunnel and PIN (brachioradialis, anconeus and triceps muscles)

AND

Exclusion of other potential causes of neuropathic symptoms, such as neuralgic amyotrophy, brachial plexopathy, or cervical radiculopathy

Modification of activities that exacerbate symptoms

AND

Splinting to maintain forearm supination and/or wrist extension

AND/OR

Physical therapy

AND/OR

Anti-inflammatory drug therapy

Surgical treatment should only be considered if:

  1. The patient has met the diagnostic criteria under Section III

    AND

  2. The condition interferes with work or activities of daily living

    AND

  3. The condition does not improve despite conservative treatment

Without confirmation of nerve entrapment by both objective clinical findings and abnormal electrodiagnostic studies (EDS), surgery will not be authorized.

*Work-Related Radial Nerve Entrapment: radial tunnel syndrome (RTS) or posterior interosseous nerve syndrome (PINS).

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.

The guideline was developed using the weight of the best available clinical and scientific evidence from a systematic review of the literature and a consensus of expert opinion.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Accurate diagnosis and appropriate treatment of radial nerve entrapment (RNE)

Potential Harms

Risks of surgery

Qualifying Statements

Qualifying Statements

This guideline is to be used by physicians, Labor and Industries claim managers, occupational nurses, and utilization review staff. The emphasis is on accurate diagnosis and treatment that is curative or rehabilitative.

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 helps legitimize 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 and through its provider listserv (http://www.lni.wa.gov/Main/Listservs/Provider.asp External Web Site Policy). Education and training will be provided to reviewers and staff to ensure their proper application within the Utilization Review program. Where possible, continuing medical education (CME) credits may be offered.

Implementation Tools
Chart Documentation/Checklists/Forms
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Washington State Department of Labor and Industries. Work-related radial nerve entrapment: diagnosis and treatment. Olympia (WA): Washington State Department of Labor and Industries; 2010 Apr 1. 10 p. [22 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 April 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 (L&I)

Guideline Committee

Washington State Department of Labor and Industries (L&I), Industrial Insurance Medical Advisory Committee (IIMAC)

Composition of Group That Authored the Guideline

IIMAC Committee Members: Ruth M. Bishop, DO; Walter F. Krengel III, MD; Gregory T. Carter, MD; Robert G. R. Lang, MD (Chair); Dianna Chamblin, MD (Vice-chair); Janet E. Ploss, MD; G. A. DeAndrea, MD, MBA; Mark Sullivan, MD, PhD; Jordan Firestone, MD, PhD, MPH; David J. Tauben, MD; Andrew Friedman, MD; G. Robert Waring, MD; Kirk T. Harmon, MD; Gerald N. Yorioka, MD

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

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

The following is available:

Also, an electrodiagnostic worksheet for work-related radial nerve entrapment (RNE) is included in the original guideline document External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on September 29, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is in the public domain. Washington State Department of Labor and Industries (L&I) does not copyright its medical treatment guidelines.

Disclaimer

NGC Disclaimer

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

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