Use of outcome instruments to compare workers' compensation and non-workers' compensation carpal tunnel syndrome

Carpal tunnel syndrome among Manitoba workers: Results from the Manitoba Occupational Disease Surveillance System

BACKGROUND

Carpal tunnel syndrome (CTS) is associated with occupational high-force repetitive tasks and vibration. This project examines the relationship between CTS and work to: (1) identify jobs and industries with increased CTS risk; (2) explore whether there is a sex difference in the risk of CTS after controlling for occupation; and (3) determine whether any observed relationships persist after excluding Workers Compensation Board (WCB) accepted time-loss CTS claims.

METHODS

We linked 95.5% of time-loss WCB claims from 2006 to 2019 to provincial administrative health data. The cohort included 143,001 unique person-occupation combinations. CTS cases were defined as at least two medical claims for (ICD-9 354) within a 12-month period or a surgical claim for CTS from 2 years before the WCB claim to 3 years after. WCB accepted CTS time-loss claims not identified by the medical claims were also included.

RESULTS

A total of 4302 individuals (3.0%) met the CTS definition. Analysis revealed that the hazard ratios (HRs) of CTS vary considerably with occupation. Sex-based differences in CTS risks were observed, both in low- and high-risk occupations. In many occupations with increased HR, the HR remained elevated after excluding accepted time-loss WCB cases.

CONCLUSIONS

The risk of developing CTS varied with occupation. Job titles with ergonomic risk factors had higher risks than those with lower exposures. This finding remained after eliminating time-loss compensated WCB cases, suggesting that all cases of CTS in high risk jobs are not identified in WCB statistics. Female workers in some job titles had excess CTS cases compared to male workers within the same job title.

Outcomes Following Carpal Tunnel Release in Patients Receiving Workers' Compensation: A Systematic Review

BACKGROUND

Carpal tunnel syndrome (CTS) is a common occupational pathology, representing a high percentage of workers' compensation (WC) claims.

METHODS

The literature was reviewed for all studies evaluating CTS outcomes including WC patients between 1993 and 2016. A total of 348 articles were identified; 25 of which met inclusion and exclusion criteria. A systematic review was generated; patient demographics, outcomes, and complications were recorded. Weighted averages were calculated for the demographic and outcome data. Categorical data such as complications were pooled from the studies and used to determine the overall complication rate. Statistical significance was determined between WC and non-WC cohorts when applicable with the chi-square statistic.

RESULTS

The WC cohort included 1586 wrists, and the non-WC cohort included 2781 wrists. The WC cohort was younger and more often involved the dominant extremity. The WC cohort was less likely to have appropriate physical exam findings confirming diagnosis and electrodiagnostic studies. WC patients took almost 5 weeks longer to return to work, were 16% less likely to return to preinjury vocation, and had lower Standard Form (SF)-36 scores. Finally, WC patients had nearly 3 times the number of complications and nearly twice the rate of persistent pain.

CONCLUSIONS

WC patients undergoing carpal tunnel release (CTR) fare poorly as compared with non-WC patients in nearly every metric. Higher rates of postoperative pain with delayed return to work can be anticipated in a WC cohort. In addition, WC patients receive suboptimal preoperative workup, and it is possible that unnecessary surgery is being completed in these cases. These findings are important to consider when treating the WC patient with CTS.

Prognostic Variables for Patient Return-to-Work Interval Following Carpal Tunnel Release in a Workers' Compensation Population

BACKGROUND

We hypothesize that depressive and anxiety disorders, chronic pain conditions, and work-related factors are significant determinants of the time interval for return to work (RTW) in the workers' compensation (WC) population following carpal tunnel release (CTR) surgery.

METHODS

We retrospectively reviewed records of all WC patients who underwent open CTR surgery over a 5-year period by 1 of 3 fellowship-trained hand surgeons. One hundred fifty-two wrists in 108 patients (64 unilateral, 44 bilateral) met the inclusion criteria. Demographic, medical, and surgical data were obtained from patient records. Bivariate and multivariate analyses were performed to assess predictors of RTW.

RESULTS

Eighty-nine percent of all patients returned to work full-duty. Average RTW duration in all wrists was 12.5 ± 11.3 weeks. Predictors of delayed RTW in bivariate and multivariate analyses were depression with or without anxiety, chronic pain disorders including fibromyalgia, preoperative opioid use, and modified preoperative work status. Job type, motor nerve conduction velocity, and bilateral surgery were not predictive of delayed RTW interval.

CONCLUSIONS

WC patients with depression, anxiety, or fibromyalgia and other chronic pain disorders were significantly more likely to have delayed RTW following CTR than were WC patients without these conditions. In addition, those who use opioid medications preoperatively and those with preoperative work restrictions were also found to have a significantly delayed RTW after CTR. Knowledge of these risk factors may help care providers and employers identify those WC patients who are most likely to have a protracted postoperative recovery period.

Risk factors predicting revision surgery after medial epicondylectomy for primary cubital tunnel syndrome

BACKGROUND

Medial epicondylectomy (ME) is one of several accepted surgical options for the treatment of cubital tunnel syndrome (CuTS). Although reported outcomes after ME are generally favorable, few data exist regarding which patients are prone to poorer outcomes requiring revision surgery. The goal of this study was to identify risk factors predicting the need for revision surgery after ME for the treatment of CuTS.

METHODS

We conducted a retrospective chart review of all patients treated at our institution with ME for CuTS from 2006 through 2011. We identified patients who underwent additional operations for recurrent or persistent ulnar nerve symptoms as the revision cohort. We performed bivariate analysis to determine which variables had a significant influence on the need for revision surgery. We examined qualitative factors associated with revision, including the degree of bony resection performed during the index ME, and intraoperative findings at the time of revision surgery.

RESULTS

Revision surgery was required in 13.3% of cases (11 of 83). On bivariate analysis, younger age, associated workers' compensation claims, lesser disease severity, and preoperative opioid use were all significant predictors of the need for revision surgery. Perineural scarring and heterotopic bone formation about the elbow were the 2 most common findings at the time of revision.

CONCLUSIONS

For patients with CuTS, the risk of revision surgery after ME is higher in younger patients, patients with less severe disease, patients taking opioid medications preoperatively, and patients with associated workers' compensation claims.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

Evidence and techniques in rehabilitation following nerve injuries

Following upper extremity peripheral nerve injury and surgery, rehabilitation is essential to optimize sensorimotor function and outcome. This review presents the evidence and related literature regarding a few key topics related to rehabilitation following peripheral nerve injury and surgery.

Conservative interventions for carpal tunnel syndrome

The assessment and conservative interventions in patients with carpal tunnel syndrome (CTS) are described in this paper. Information about surgical procedures and postoperative care has also been included. It is difficult to make definitive conclusions about the literature regarding success of treatment for CTS due to variations in outcome measures, severity of CTS, and inconsistencies in duration, dosage, and follow-up time for interventions. Based on what is known to date, this author recommends that patients with mild or moderate CTS be provided with a conservative program of splinting the wrist in neutral for nocturnal wear. In addition, intermittent exercise (nerve-gliding exercises) and activity modification, including avoidance of protracted periods of sustained gripping activities and awkward wrist positions, can be useful. This conservative program may be complemented by pain-relieving modalities during times of activity and supplemental participation in other exercise such as yoga. If symptoms are not relieved to the satisfaction of the patient, or they recur, then it is incumbent upon the therapist to refer the patient to a hand surgeon for injection or possible surgical decompression.

Exploratory analysis to identify factors impacting return-to-work outcomes in cases of cumulative trauma disorder

Current findings suggest that cumulative trauma disorders are multifaceted and have less predictable outcomes than trauma cases. The purpose of this study was to attempt to identify emerging patterns and predictive relationships in this diagnostic group that might be worthy of eventual prospective research. The data source was a comprehensive electronic database containing clinical information collected at point of care over a four-year period. A retrospective analysis was performed on 459 workers' compensation cases with upper extremity cumulative trauma disorders and a subset of 312 with carpal tunnel syndrome. The outcome criterion was return to work as a dichotomous variable. Only two significant correlations with return to work were found: the therapist's estimate of rehabilitation potential and the patient's outcome expectation of the ability to work. Further investigation of the role of beliefs and expectations in the therapeutic process would be a productive area for prospective study.

Occupational and Sport Related Traumatic Neuropathy

BACKGROUND

Sport and occupation related traumatic nerve injury is a common problem in the United States. While the physical requirements of each pursuit place participants at risk for injury to certain peripheral nervous system structures, the vast numbers of professional and recreational pursuits limits the ability to become familiar with nerve injuries specific to each. A more pragmatic approach is to apply knowledge of mechanisms of injury, physiology of nerve injury, regional anatomy, and at-risk peripheral nervous system structures to the routine neurologic history and physical assessment to arrive at a localizing and etiologic diagnosis.

REVIEW SUMMARY

The authors discuss potential mechanisms of nerve injury, the role of electrodiagnostic testing, regional peripheral nervous system anatomic considerations and lesion localization.

CONCLUSIONS

Despite the wide variety of professionally and recreationally induced peripheral nerve injuries, application of anatomic, physiologic and mechanistic considerations allow the neurologist to make an etiologic and localizing diagnosis.

Patient-based measures of outcome in plastic surgery: current approaches and future directions

OBJECTIVES

To evaluate current approaches to patient-based outcome measurement in plastic surgery and make recommendations for future research.

METHODS

Comprehensive review of the plastic surgery literature relevant to patient-based outcomes.

RESULTS

Two main types of patient-based outcome measure have been used in the plastic surgery literature: generic and disease-specific. The majority of studies using generic measures investigate aspects of psychological functioning with fewer studies focussing on wider aspects of health-related quality of life. Disease-specific measures are mainly used to assess symptoms. However, almost all of these are ad-hoc measures produced for a particular study, with no psychometric evaluation.

CONCLUSIONS

There is a lack of psychometrically sound measures, and there is scope for improvement in methodology used in plastic surgery research. The development and psychometric testing of new plastic surgery specific measures is encouraged.

Integration of workers' compensation and health insurance prescription drug programs: how does it work and do employees use it?

BACKGROUND

In 1998, New York State designed and developed an integrated workers' compensation (WC)/health plan prescription drug program, ONECARD Rx, in response to cost inefficiencies within the then current system and in an attempt to improve the quality of care provided to WC claimants. This paper describes the benefit's design and development process and factors related to its use.

METHODS

Users and non-users of the program were surveyed through a mailed questionnaire with appropriate telephone follow-up.

RESULTS

Eight steps were followed in the development of the benefit. Results obtained from the assessment of ONECARD Rx suggest that factors affecting use mainly relate to the knowledge of both, employees and pharmacists, of the program. The two main differences detected between users and non-users included the state agency the employee works for and the site of residence.

CONCLUSIONS

Innovative strategies that couple private and public agencies should aim at reducing the costs and eliminating inefficiencies while improving the quality of care, of which satisfaction is an important component.

Carpal tunnel release in the United States and Sweden: reimbursement patterns, cost for treatment, and return to work

Cost containment plays an increasingly important role in health care, affecting providers and recipients. The present investigation addressed a limited number of factors that relate to the total cost for surgical treatment of carpal tunnel syndrome. The purpose of this study was to compare socioeconomic factors in two different societies and how worker's compensation plays a role in the cost, rehabilitation, and operative practices. To that purpose, the authors studied hospital and insurance records from a total of 123 female patients treated in two tertiary referral centers (University of Pittsburgh, Pa., and University of Umea, Sweden). The 123 patients were referred to three subgroups. Group A comprised patients from the University of Pittsburgh with worker's compensation (n = 34), group B comprised patients from the University of Pittsburgh without worker's compensation (n = 47), and group C comprised patients from the University of Umea (n = 42). The analyzed data showed a tendency toward longer duration of postoperative sick leave for those with worker's compensation than those without worker's compensation for patients from the University of Pittsburgh. However, operating room times and operating times, operative cost, use of postoperative therapy, and duration for sick leave were substantially less for patients treated at the University of Umea. There was no statistically significant difference in time off work between group A and group B. The results may indicate that the effect of compensation on a patient's ability or willingness to recover after treatment for carpal tunnel syndrome may be less important than factors that do not primarily relate to the patient or the surgical procedure.

Evaluation of the Spanish version of the DASH and carpal tunnel syndrome health-related quality-of-life instruments: cross-cultural adaptation process and reliability

The methodologic requirements for cross-national use of specific health outcome instruments in hand surgery are presented. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire as a specific upper-extremity instrument and the Carpal Tunnel Syndrome (CTS) questionnaire as a specific disease instrument were adapted to Spanish for use in international studies. The adaptations were based on translation/back translation methodology. Meetings of translators, researchers, and patients were organized to produce successive versions. A study involving 50 people was carried out to consider the relative value (through a visual analog scale) of each response choice of the questionnaire items. Internal consistency and reproducibility of the Spanish version of both instruments were assessed by self-administering the questionnaires to 42 patients with the diagnosis of CTS on 2 different occasions 1 week apart. The average ratings of equivalence of the translated version with the original were high, regardless of the difficulty of translation. The adaptation process of the DASH and CTS instruments concluded with questionnaires conceptually equivalent to the original and with an acceptable level of reliability.

Outcomes assessment in hand surgery: when are they meaningful?

Hand surgeons currently are challenged with the task of measuring and establishing the connection between the diagnosis and treatment of health-related quality-of-life problems. Although true quality of life cannot be measured directly, instruments in the form of questionnaires have been developed that use self-reporting to account for functional performance, health status, and health-related quality of life. Instruments must be reliable, valid, responsive, and appropriate. Misunderstanding these properties often hinders interpreting the recent stream of outcome studies in the literature. Most physicians are not sure what if any outcome information should be collected routinely or if any outcome instrument is diagnostically useful. Currently there is no convincing evidence to support the routine use of patient-based outcome measures in hand surgeons' practices. Those hand surgeons who would like to carry out an outcome study should consider seeking help from others with expertise in outcomes design and analysis.

The association of the SF-36 health status survey with 1-year socioeconomic outcomes in a chronically disabled spinal disorder population

STUDY DESIGN

The Short Form Health Survey (SF-36) was administered to patients with chronic spinal disorders both before and after tertiary rehabilitation. The association of the SF-36 with various socioeconomic outcomes was then examined.

OBJECTIVES

To assess the correlation of scores on SF-36 with treatment program completion and clinically meaningful 1-year socioeconomic outcomes.

SUMMARY OF BACKGROUND DATA

There has been much interest in identifying variables that can predict which disabled workers with chronic spinal disorders will have good versus poor socioeconomic outcomes after tertiary rehabilitation. Results of previous research have indicated that psychosocial factors are better predictors of such outcomes than physical factors. A more recent trend in research is assessing health-related quality of life from the health care recipient's perspective.

METHODS

The SF-36 was administered to a cohort (n = 146) of patients chronically disabled by spinal disorders before entry into a tertiary functional restoration program. Of this cohort, preprogram SF-36 scores and 1-year socioeconomic data were available for 128 program completers and 18 program noncompleters. The pre- and postprogram SF-36 scores of program completers for each of the outcome variables were compared.

RESULTS

Better scores on the preprogram SF-36 Social Functioning and Bodily Pain scales were found to be associated with successful completion of the treatment program. Postprogram SF-36 scores were more frequently associated with outcomes than were preprogram scores. Most SF-36 scores, especially the physical domain scales, were associated with the variables of return to work, work retention, and use of health care resources. The overwhelming majority of significant associations were between higher (i.e., better) SF-36 scores and "good" treatment outcomes (e.g., return-to-work).

CONCLUSIONS

The large number of associations between SF-36 scores and outcome variables highlights the importance of assessing the health-related quality of life of patients, and supports the use of the SF-36 in accomplishing this task. Among the findings, perhaps the most significant was the value of assessing health-related quality of life, particularly the subjective physical components, after completion of a functional restoration program. Prediction of long-term socioeconomic outcomes is likely to be improved if assessment is conducted at the end of the treatment process. SF-36 is recommended for assessing general health status, and more spine-specific measures are recommended for assessing spinal pain and disability variables.

Evaluation of the Washington State Workers' Compensation Managed Care Pilot Project I: medical outcomes and patient satisfaction

OBJECTIVES

This study examined the effect of managed care on medical outcomes and patient satisfaction as part of an evaluation of the Washington State Workers' Compensation Managed Care Pilot.

METHODS

One hundred twenty firms (7,041 employees) agreed to have their injured workers treated in managed-care plans. Managed care introduced two changes from the fee-for-service (FFS) delivery system currently used by injured workers in Washington State: (1) experience-rated capitation, and (2) a primary occupational-medicine delivery model. The FFS control group included injured workers employed at 392 firms (12,000 employees). A total of 1,313 workers who experienced occupationally related injuries or illnesses between April 1995 and June 1996 were interviewed by telephone at 6 weeks after injury regarding their medical outcomes and satisfaction with care. Workers whose injuries resulted in four or more lost workdays (n = 372) were also interviewed at 6 months after injury on the same topics. The areas surveyed included functional outcomes and satisfaction with care, providers, and access to providers.

RESULTS

The measures of functional outcome reflected no consistent differences between the managed care and the FFS conditions. The workers who attended the managed-care system reported lower levels of satisfaction with care, particularly with access to providers. For example, 58% of managed-care patients reported satisfaction with their attending physician as compared with 69% of FFS patients (P<0.01).

CONCLUSIONS

Workers treated through managed-care arrangements were less satisfied with their care, but their medical outcomes were similar to those of workers who received traditional FFS care. The current workers' compensation system in Washington State affords injured workers great latitude in choosing providers. If provider choice is substantially restricted by managed care, worker satisfaction is likely to diminish.

The impact of workplace screening on the occurrence of cumulative trauma disorders and workers' compensation claims

Work-related musculoskeletal pain, commonly referred to more specifically as musculoskeletal disorders or cumulative trauma disorders, has continued to occur despite efforts by employers, employees, health care providers, and the government to eradicate it. The National Institute for Occupational Safety and Health has encouraged employers to establish ergonomic prevention programs; however, many employers are concerned that screening, education, and focused attention on workplace pain will cause an increase in the number of OSHA 200 events and the incidence of workers' compensation claims. This prospective cohort study demonstrated that there was no increase in the number of OSHA 200 events and no increase in the incidence of workers' compensation claims after completion of an individual risk screening program that included education and employee awareness about work-related musculoskeletal pain. Incidence of cumulative trauma disorders has been most effectively reduced by use of individual risk-screening programs. Therefore, employers should be encouraged to develop and implement prevention programs that include individual risk screening.