apsiingers

and the

Drop ies

NAOEMNAOEMNAOEM NAOEM 9/26/159/26/15

Di Ch bli MDDi Ch bli MDDianna Chamblin, MDDianna Chamblin, MD

NumbnessNumbness

A lecture is an occasion when you numb one yend to benefit the other.

John Gould

Chief complaint:

“I slide my arm from under the ysleeper's head and it is numb,

full of swarming pinsfull of swarming pins, on the tip of each,

waiting to be counted, the fallen angels sit ”the fallen angels sit.

Wislawa Szymborska1996 N b l P i i i i Li1996 Nobel Prize recipient in Literature

7/2/237/2/23--2/1/122/1/12

EpidemiologyEpidemiology OtherCTSLBPDiagnosed

entrapment

Women > menWomen > men

pCOST OF CARE BY

DIAGNOSIS

11--5% estimated prevalence in the general 5% estimated prevalence in the general population. population. I id i WA k l tiI id i WA k l ti Incidence in WA workers comp population Incidence in WA workers comp population peaked at approximately 2.73 per 1000 in peaked at approximately 2.73 per 1000 in the midthe mid--1990’s. 1990’s.

In 2010, 5 million workers were estimated to In 2010, 5 million workers were estimated to have CTShave CTS

Workplace incidence controversial but in Workplace incidence controversial but in top two of most costly L&I claims. top two of most costly L&I claims. COST By CLAIM

DX

Progress?Progress?Progress?Progress?

CTS b 2013CTS b 2013CTS by 2013CTS by 2013

f f Sf f SHighest median days from work from BLS Highest median days from work from BLS 11stst: Fractures= 32 days: Fractures= 32 days

dd22ndnd: Multiple traumatic injuries with fractures= 30: Multiple traumatic injuries with fractures= 3033rdrd: CTS= 28: CTS= 28

thth44thth: Amputations= 27: Amputations= 27

BLS News Release, 12/16/14: BLS News Release, 12/16/14: NONFATAL OCCUPATIONAL INJURIES NONFATAL OCCUPATIONAL INJURIES AND ILLNESSES REQUIRING DAYS AWAY AND ILLNESSES REQUIRING DAYS AWAY FROM WORKFROM WORK, 2013, 2013

EstablishingEstablishing WWork Relatednessork RelatednessEstablishing Establishing WWork Relatednessork Relatedness

ExposureExposure: workplace activities : workplace activities contrib te or ca se CTS?contrib te or ca se CTS?contribute or cause CTS?contribute or cause CTS?OutcomeOutcome: diagnosis meets criteria?: diagnosis meets criteria?OutcomeOutcome: diagnosis meets criteria?: diagnosis meets criteria?RelationshipRelationship: more probably than : more probably than not exposure contributed to or not exposure contributed to or worsened condition (the outcome)?worsened condition (the outcome)?worsened condition (the outcome)?worsened condition (the outcome)?

NonNon--OccOcc RiskRisk Factors for CTSFactors for CTSNonNon Occ Occ RiskRisk Factors for CTSFactors for CTSObesityObesityyyFemale gender (less xFemale gender (less x--sectional area of the sectional area of the proximal tunnel?)proximal tunnel?)P (fl id l i )P (fl id l i )Pregnancy (fluid accumulation)Pregnancy (fluid accumulation)DiabetesDiabetesRARARARAHypothyroidismHypothyroidismCT diseasesCT diseasesCT diseasesCT diseasesGenetics (twin studies) (vs inherited anatomy?)Genetics (twin studies) (vs inherited anatomy?)AramataseAramatase inhibitor use (tendon thickening?)inhibitor use (tendon thickening?)AramataseAramatase inhibitor use (tendon thickening?)inhibitor use (tendon thickening?)“Workplace factors”“Workplace factors”

Occupational Occupational RiskRisk Factors for CTSFactors for CTSAMA Guides to the Evaluation of Disease and Injury Causation 2nd EditionAMA Guides to the Evaluation of Disease and Injury Causation 2 Edition

Combination of risk factors such as force and titi f d t V StV Strepetition, force and posture: Very Strong Very Strong

EvidenceEvidence (meat packing, poultry processing, automobile assembly work)automobile assembly work)Vibration: low risk evidencelow risk evidenceHighly repetitive work alone: unclearunclearg y pHighly repetitive work in combo: SStrong Evidencetrong EvidenceForceful work: VVery ery SStrong Evidencetrong EvidenceAwkward postures: low risk evidencelow risk evidenceKeyboard activities, Cold environment, length of employment: insufficient evidenceinsufficient evidenceemployment: insufficient evidenceinsufficient evidenceJob satisfaction: some evidencesome evidence

Making the diagnosis: “Making the diagnosis: “ClassicClassic” ” Carpal Tunnel SyndromeCarpal Tunnel Syndrome

Numbness and tingling > pain in di t ib ti f th didistribution of the median nerve. Typically worse at night andTypically worse at night and disruptive for sleep (50-70%).Provoked by flexion or extension taskstasks

““ClassicClassic” CTS” CTSClassicClassic CTS CTS

Making the diagnosis: Making the diagnosis: SignsSignsg gg g gg

Objective sensoryObjective sensory deficits in median nervedeficits in median nerveObjective sensory Objective sensory deficits in median nerve deficits in median nerve distribution: distribution: Pain perception Pain perception p pp p 2 point discrimination 2 point discrimination >> 7mm abnormal7mm abnormal

Objective motor deficits in median nerve Objective motor deficits in median nerve distributiondistribution Test for strength of thumb abduction and Test for strength of thumb abduction and

oppositionoppositionoppositionopposition Look for thenar atrophy (more advanced sign)Look for thenar atrophy (more advanced sign)

Provocative maneuvers: sensitivity andProvocative maneuvers: sensitivity andProvocative maneuvers: sensitivity and Provocative maneuvers: sensitivity and specificity not greatspecificity not great

DiagnosisDiagnosisDiagnosis Diagnosis

Nerve conduction and EMG studies:Nerve conduction and EMG studies:Excludes radiculopathy, plexopathy and polyneuropathiespolyneuropathiesNCVs: Slowed median sensory

d/ t NCS land/or motor NCS across carpal tunnel can confirm CTS*EMG: helpful to exclude other processes or if significant findings p g gare consistent with CTS

*Median nerve conduction is slow *Median nerve conduction is slow across the wrist.across the wrist.across the wrist.across the wrist.

Does this patient haveDoes this patient haveDoes this patient have Does this patient have CTS? CTS?

MaybeMaybeMaybe… Maybe…

Or is limb cool? Are other nerveOr is limb cool? Are other nerveOr is limb cool? Are other nerve Or is limb cool? Are other nerve conductions in limb normal? conductions in limb normal? Know Know your your electromyographerelectromyographer!!yy y g py g p

Carpal tunnel syndrome CTS is aCarpal tunnel syndrome CTS is aCarpal tunnel syndrome, CTS, is a Carpal tunnel syndrome, CTS, is a constellationconstellation of symptoms and of symptoms and

signs resulting from mediansigns resulting from mediansigns resulting from median signs resulting from median entrapment or mononeuropathy entrapment or mononeuropathy

across the wristacross the wristacross the wrist.across the wrist.

IMAGINGIMAGINGIMAGINGIMAGING

Ultrasound sensitivity 65-97%, specificity 73 98% M l N 2012 46(2) 28773-98% Muscle Nerve. 2012;46(2):287.

MRI insufficient evidence

Treatment:Treatment: CONSERVATIVECONSERVATIVETreatment: Treatment: CONSERVATIVECONSERVATIVE

Predictors of poor response:Predictors of poor response: Longer duration of symptoms Age over 50 Age over 50 Constant paresthesias

Impaired two point discrimination > 6mm Impaired two point discrimination > 6mm Positive Phalen’s sign < 30 seconds

J H d S B 1990 15(1) 106 J Hand Surg Br. 1990;15(1):106 Prolonged motor and sensory latencies on

NCVsNCVsHarefuah.1996;130(4):241

Treatment:Treatment: CONSERVATIVECONSERVATIVETreatment: Treatment: CONSERVATIVECONSERVATIVE

SplintingSplinting: especially at night <30: especially at night <30--70% note70% noteSplintingSplinting: especially at night, <30: especially at night, <30 70% note 70% note improved symptomsimproved symptoms

Treatment:Treatment: CONSERVATIVECONSERVATIVETreatment: Treatment: CONSERVATIVECONSERVATIVEGlucocorticoid injection: controversial. May j yprovide short-term reliefGlucocorticoids by mouth: may provide short-term relief however benefit< risksterm relief however, benefit< risksYoga: may reduce painNerve gliding US therapy: insufficientNerve gliding, US therapy: insufficient evidenceNSAIDs no significant benefit (one g (randomized controlled trial)No evidence for benefit from diuretics or vitamin B6vitamin B6Job modification may be of benefit

Treatment:Treatment: SURGICALSURGICALTreatment: Treatment: SURGICALSURGICAL

Evidence supports short Evidence supports short ppppand long term improvement and long term improvement in symptoms in symptoms

Post Post ––op Rehab for CTSop Rehab for CTSACOEM: Occupational Medicine Practice Guidelines 1/4/12

Soft bandages or splint for select patients (Soft bandages or splint for select patients (II))Soft bandages or splint for select patients (Soft bandages or splint for select patients (II))NSAIDS (NSAIDS (BB) or acetaminophen () or acetaminophen (II) to control ) to control painpainpainpainCryotherapy (Cryotherapy (CC))Maintenance of activity (Maintenance of activity (II))Maintenance of activity (Maintenance of activity (II))Graded exercise or home exercise program (Graded exercise or home exercise program (II))F l OT/PT if t i (F l OT/PT if t i (II))Formal OT/PT program if not progressing (Formal OT/PT program if not progressing (II))

A=Strong evidence baseA=Strong evidence baseB= Moderately RecommendedC=RecommendedI=Insufficient-recommended (consensus based)

Return to WorkReturn to WorkReturn to WorkReturn to Work

Average time to RTW after surgery (ACOEM Average time to RTW after surgery (ACOEM subcommittee consensus)subcommittee consensus)subcommittee consensus)subcommittee consensus)

22--4 weeks for clerical or light duty workers4 weeks for clerical or light duty workers

<5<5--6 weeks for heavy labor workers6 weeks for heavy labor workers

Industrial Insurance Industrial Insurance Medical AdvisoryMedical AdvisoryMedical AdvisoryMedical Advisory

CommitteeCommittee

“Advise the department on matters related to the provision of safe, effective, and cost-effective p , ,treatments for injured workers, including but not limited to the development of practice guidelines

d i i ”and coverage criteria …..”

WorkWork--Related CTSRelated CTSDiagnosis and Treatment GuidelineDiagnosis and Treatment GuidelineDiagnosis and Treatment GuidelineDiagnosis and Treatment Guideline

Effective 4/09, Updated 2/6/14Effective 4/09, Updated 2/6/14

http://www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/CarpalTunnel.pdfhttp://www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/CarpalTunnel.pdfp g p pp g p phttp://www.guideline.gov/content.aspx?id=47828&search=carpal+tunnel+entraphttp://www.guideline.gov/content.aspx?id=47828&search=carpal+tunnel+entrapmentment

UlnarUlnar Nerve EntrapmentNerve EntrapmentUlnarUlnar Nerve EntrapmentNerve Entrapment

Usually due to mechanical f th t dforces that produce:Traction or Ischemia

EstablishingEstablishing Work relatednessWork relatednessEstablishing Establishing Work relatednessWork relatedness

ExposureExposure: workplace activities? : workplace activities?

OutcomeOutcome: meets diagnostic criteria? : meets diagnostic criteria?

RelationshipRelationship: More probable than not basis: More probable than not basisRelationshipRelationship: More probable than not basis : More probable than not basis that the workplace exposure contributed to the that the workplace exposure contributed to the development or worsening of the condition?development or worsening of the condition?development or worsening of the condition?development or worsening of the condition?

Nonoccupational Nonoccupational RiskRisk FactorsFactorsAMA G id t th E l ti f Di d I j C ti 2nd EditiAMA Guides to the Evaluation of Disease and Injury Causation 2nd Edition

Age:Age: SStrong evidencetrong evidence; risk increases with increasing ; risk increases with increasing gg gg ggageageBMI:BMI: low risk evidencelow risk evidence; risk increases with higher BMI ; risk increases with higher BMI (although according to Landau study* across elbow(although according to Landau study* across elbow(although according to Landau study across elbow (although according to Landau study across elbow ulnar motor NCV may be falsely increased in patients ulnar motor NCV may be falsely increased in patients with high BMI, due to distance measurement factors.with high BMI, due to distance measurement factors.Gender:Gender: some evidencesome evidenceGender:Gender: some evidencesome evidenceBiopsychosocial factors: Biopsychosocial factors: insufficient evidenceinsufficient evidenceDiabetes:Diabetes: some evidencesome evidenceDominant hand: Dominant hand: iinsufficient evidencensufficient evidenceSmoking:Smoking: some evidencesome evidence

LandauLandau ME Barner KC Campbell WW Effect of body mass index on ulnarME Barner KC Campbell WW Effect of body mass index on ulnar nervenerveLandau Landau ME, Barner KC, Campbell WW. Effect of body mass index on ulnar ME, Barner KC, Campbell WW. Effect of body mass index on ulnar nerve nerve conduction conduction velocity, ulnar neuropathy at the elbow, and carpal tunnel syndrome.velocity, ulnar neuropathy at the elbow, and carpal tunnel syndrome.Muscle Muscle Nerve 2005;32(3):360Nerve 2005;32(3):360––33..

Occupational Occupational RiskRisk Factors Factors ppAMA Guides to the Evaluation of Disease and Injury Causation 2nd Edition

Combination of risk factors: Combination of risk factors: some evidencesome evidenceVibration: Vibration: insufficient evidenceinsufficient evidenceHighly repetitive work alone or in combo Highly repetitive work alone or in combo with other factors: with other factors: insufficient evidenceinsufficient evidenceForceful work: Forceful work: insufficient evidenceinsufficient evidenceAwkward postures: Awkward postures: ““ppKeyboard activities: Keyboard activities: ““Cold environment:Cold environment: ““Cold environment: Cold environment: Length of employment: Length of employment: ““

Entrapment at ElbowEntrapment at ElbowCl iCl i SSClassic Classic SymptomsSymptoms

Decreased or abnormal sensation in the ring Decreased or abnormal sensation in the ring or small fingersor small fingersPain at the proximal medial aspect of the Pain at the proximal medial aspect of the p pp pelbowelbowWeakness of fingers and poor dexterityWeakness of fingers and poor dexterityWeakness of fingers and poor dexterityWeakness of fingers and poor dexterityProvocative maneuvers neither sensitive nor Provocative maneuvers neither sensitive nor specific (specific (TTinel’s flexion testing)inel’s flexion testing)specific (specific (TTinel s, flexion testing)inel s, flexion testing)

Ulnar Nerve Entrapment at the Ulnar Nerve Entrapment at the Wrist (less common than at theWrist (less common than at theWrist (less common than at the Wrist (less common than at the

elbow). elbow). Symptoms: Symptoms:

Typically presents with hand weakness andTypically presents with hand weakness andTypically presents with hand weakness and Typically presents with hand weakness and atrophy, loss of dexterity and variable atrophy, loss of dexterity and variable sensory involvement Clawing can be moresensory involvement Clawing can be moresensory involvement. Clawing can be more sensory involvement. Clawing can be more pronounced with wrist that elbow entrapment pronounced with wrist that elbow entrapment due to FDP sparing and 3due to FDP sparing and 3rdrd and 4and 4thth lumbricalslumbricalsdue to FDP sparing and 3due to FDP sparing and 3 and 4and 4 lumbricals lumbricals weaknessweakness

FourFour primary sites of primary sites of entrapmententrapment

11 In or proximal to Guyon’s canal (motor andIn or proximal to Guyon’s canal (motor and1. 1. In or proximal to Guyon s canal (motor andIn or proximal to Guyon s canal (motor andsensory)sensory)2 Deep motor branch proximal to hypothenar2 Deep motor branch proximal to hypothenar2. Deep motor branch proximal to hypothenar2. Deep motor branch proximal to hypothenarmuscles muscles (motor but no sensory symptoms)(motor but no sensory symptoms)3. Deep motor branch distal to 3. Deep motor branch distal to hypothenarhypothenarmuscles (weak muscles (weak intrinsics but spared hypothenar intrinsics but spared hypothenar

ll ttmuscles, no muscles, no sensory symptomssensory symptoms4. Superficial branch, sensory, no motor.4. Superficial branch, sensory, no motor.

Differential DiagnosisDifferential DiagnosisDifferential DiagnosisDifferential Diagnosis

Cervical radiculopathyCervical radiculopathyCervical radiculopathyCervical radiculopathyBrachial Brachial plexopathyplexopathyC i f h l hC i f h l hCompression of the ulnar nerve at the Compression of the ulnar nerve at the wristwristCTS other entrapmentsCTS other entrapmentsPolyneuropathiesPolyneuropathiesy py p

ExamExam findingsfindingsExamExam findingsfindings

Sensory impairment in ulnar distributionSensory impairment in ulnar distributionProvocative testing not sensitive orProvocative testing not sensitive orProvocative testing not sensitive or Provocative testing not sensitive or specific specific W k i i t i i h d lW k i i t i i h d lWeakness in intrinsic hand musclesWeakness in intrinsic hand musclesAtrophy of intrinsics or clawing of digits Atrophy of intrinsics or clawing of digits p y g gp y g g4 and 54 and 5

EDX testing: EDX testing: Locate, Locate, C fi i Q if S iC fi i Q if S iConfirmation, Quantify SeverityConfirmation, Quantify Severity

Motor conduction testing abnormalities, not Motor conduction testing abnormalities, not sensorysensoryyy

EMG findings with normal NCS testingEMG findings with normal NCS testingEMG findings with normal NCS testing EMG findings with normal NCS testing unusual. unusual.

Other motor and sensory nerve must be Other motor and sensory nerve must be normal to exclude polyneuropathy.normal to exclude polyneuropathy.

OOtherther diagnosticdiagnostic teststestsOOther ther diagnosticdiagnostic teststests

MRI and ultrasound utility not yet proven, considered investigationalconsidered investigational

TREATMENTTREATMENTTREATMENTTREATMENT

ConservativeConservativeActivity modificationNight time splintingNight time splintingElbow padding

Surgery Benefits > risk if confirmed electrodiagnosticallyBenefits > risk if confirmed electrodiagnosticallyRelease along length of ulnar nerve throughout its course around the elbow.

Return toReturn to workworkReturn to Return to workwork *Hashima study: *Hashima study: 7% of workers account for 75% of long

di biliterm disability.

WA state L&I predictors of long term disability:WA state L&I predictors of long term disability: lowWA state L&I predictors of long term disability: WA state L&I predictors of long term disability: low expectation of RTW, no job accommodation and high physical job demands.

Uncomplicated UNE release light duty within 3 Uncomplicated UNE release light duty within 3 weeks. weeks.

**Hashemi L, Webster BS, Clance EA, et al. Length of disability and cost of Hashemi L, Webster BS, Clance EA, et al. Length of disability and cost of workrelated workrelated musculoskeletal musculoskeletal disorders of the upper extremity. J Occup Environ disorders of the upper extremity. J Occup Environ Med 1998;40:261Med 1998;40:261––99..

WA State stats: 1995WA State stats: 1995--20002000WA State stats: 1995WA State stats: 1995 20002000

ApproximatelyApproximately 28002800 claims for workclaims for work--Approximately Approximately 28002800 claims for workclaims for work--related UNE were reported to WA state related UNE were reported to WA state L&IL&IL&IL&I ¼ of these received surgery¼ of these received surgery ¾ treated conservatively¾ treated conservatively Time loss payments were paid to Time loss payments were paid to 93% of surgery group93% of surgery group61% of conservatively treated group.61% of conservatively treated group.

WorkWork--Related Ulnar Neuropathy at the Related Ulnar Neuropathy at the p yp yElbow: Diagnosis and TreatmentElbow: Diagnosis and Treatment

Effective 1/1/10, Updated 1/22/15Effective 1/1/10, Updated 1/22/15

http://http://www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/UlnarNerve.pdfwww.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/UlnarNerve.pdf http://www.guideline.gov/content.aspx?id=15524&search=ulnar+nerve+entrahttp://www.guideline.gov/content.aspx?id=15524&search=ulnar+nerve+entra

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