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Many states have grappled with benefits coverage of CTS in their workers' comp systems. Illinois, for example, included new rules that cap awards for CTS in its workers' comp reform legislation. New York's Workers' Compensation Board is seeking public input on proposed medical treatment guidelines for CTS.

Medical experts are not surprised by the confusion and frustration over workers' comp coverage of CTS. "It is a common problem," said Dr. Christopher Brigham, chairman of the San Diego-based Impairment Resources LLC. "However, often times it is associated with incorrect diagnosis, incorrect assessment of causation, and it is not appropriately managed."

"Patients would come to your office and complain of numbness and tingling in the thumb, index, and middle fingers -- classic CTS," said Dr. J. Mark Melhorn, a Kansas-based orthopedic surgeon specializing in the hands and upper extremities. "Their clinical symptoms were there, they'd have objective findings, and then you would do a nerve conduction study, and it would be positive. So with all those things put together, the person fit in a fairly classic format."

Also dissimilar was the treatment for CTS. "In the '60s, '70s and '80s, the surgery for CTS was 99.9 percent effective," said Dr. James B. Talmage, a Tennessee-based orthopedic surgeon. While CTS surgery in health insurance has positive results, he says up to 40 percent of workers' comp patients who get surgery are unhappy and are characterized as poor results.

What changed over the years, according to Melhorn, was the public perception of CTS as something that could easily be a result of work tasks. In the late '80s and '90s, people with symptoms of numbness would attribute them to their jobs and file workers' comp claims.

"Their clinical examination was not classic and/or was inconsistent with the diagnosis," Melhorn said. "They'd have a nerve conduction study that was inconclusive or not classic. The individual was convinced they had CTS. Surgery would be provided and often improvement was minimal."

The physicians say many such cases are not CTS. "It's usually considered in the category of nonspecific musculoskeletal pain," Melhorn said. "People who do physically active jobs will get some fatigue . . . having pain off and on is part of being alive."

Diagnosing CTS. There is no national standard that objectively defines CTS, making diagnosis all the more complex. Treating physicians have varying definitions of what constitutes "normal" on diagnostic tests for CTS.

"You can go to one physician who says you have CTS, and go across the street and get the same answer and yet he tells you different results. The number can be interpreted differently," Talmage says. "The other thing they don't usually tell physicians is if you see somebody on two different days and take their blood pressure, you get different numbers. With a nerve test taken on two different days, you also get two different results."

Causation. When CTS is diagnosed, the next issue is determining whether work was a factor. The physicians say it is highly unlikely that work activities alone can cause CTS.

"There are two work activities that have definitely been linked to CTS or vibration syndrome: stone quarry operator and chain saw logger," Melhorn said. "If you come in and say 'my job caused CTS,' and you do those two activities, then I would agree."

Repetitive motions, such as those associated with office work, are not causes of CTS, the physicians say. "There are at least eight good scientific studies that say people who use keyboards are no more likely to get CTS than people doing any other job," Talmage said. Instead, personal risk factors, such as genetics and obesity, are more likely to lead to CTS.

But the problem is that the symptoms may emerge when people with high-risk factors are at work.

Recent actions. Some states have reduced benefits for CTS by redefining causation. Florida, Missouri, and Arkansas recently implemented requirements that industrial exposure must be at least 51 percent of the cause of the injury or illness to be compensable.

"They've pretty much eliminated CTS," Talmage said. "CTS used to be a frequent workers' comp claim; now that they've changed the definition of injury and illness it's no longer a big issue in those states." Oklahoma, Kansas, and Tennessee are doing the same thing.

In states that say industrial exposure has to contribute but not be the primary cause of the injury or illness, CTS could be compensable.

Melhorn says education is key. "You want to treat patients and be a patient advocate. But you also want to encourage them to remain working because of the health benefits, such as improved general health and reduced rates for suicide and death."

Read more at the WorkersComp Forum homepage.

November 28, 2011

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