RULE 17, EXHIBIT 5 Cumulative Trauma Conditions Medical Treatment Guidelines Revised: December 29, 2016 Effective: March 2, 2017 Adopted: November 4, 1996 Effective: December 30, 1996 Revised: January 8, 1998 Effective: March 15, 1998 Revised: May 27, 2003 Effective: July 30, 2003 Revised: September 29, 2005 Effective: January 1, 2006 Revised: September 16, 2010 Effective: October 30, 2010 Presented by: DIVISION OF WORKERS' COMPENSATION TABLE OF CONTENTS A. INTRODUCTION .............................................................................................................................. 1 B. GENERAL GUIDELINES PRINCIPLES .......................................................................................... 2 1. APPLICATION OF THE GUIDELINES ............................................................................... 2 2. EDUCATION ....................................................................................................................... 2 3. INFORMED DECISION MAKING ....................................................................................... 2 4. TREATMENT PARAMETER DURATION ........................................................................... 2 5. ACTIVE INTERVENTIONS ................................................................................................. 3 6. ACTIVE THERAPEUTIC EXERCISE PROGRAM .............................................................. 3 7. POSITIVE PATIENT RESPONSE ...................................................................................... 3 8. RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS ..................................................... 3 9. SURGICAL INTERVENTIONS ........................................................................................... 3 10. SIX-MONTH TIME FRAME ................................................................................................. 3 11. RETURN-TO-WORK........................................................................................................... 4 12. DELAYED RECOVERY ...................................................................................................... 4 13. GUIDELINES RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE ........ 4 14. CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI) ........................................ 5 C. DEFINITIONS AND MECHANISMS OF INJURY ........................................................................... 6 D. INITIAL DIAGNOSTIC PROCEDURES .......................................................................................... 7 1. HISTORY-TAKING AND PHYSICAL EXAMINATION (HX & PE) ...................................... 7 a. History of Present Injury ......................................................................................... 7 b. Relationship to Work and Other Activity ................................................................ 8 c. Past History ............................................................................................................ 9 d. Physical Examination ........................................................................................... 10 e. Physical Examination Findings Reference Table: Specific Musculoskeletal Diagnoses ............................................................................................................ 11 f. Physical Examination Findings Reference Table: Specific Peripheral Nerve Diagnoses ............................................................................................................ 13 2. LABORATORY TESTING ................................................................................................. 16 3. MEDICAL CAUSATION ASSESSMENT FOR CUMULATIVE TRAUMA CONDITIONS . 17 a. Foundations for Evidence of Occupational Relationships ................................... 18 b. Using Risk Factors for Medical Causation Assessment of Cumulative Trauma Conditions ............................................................................................................ 22 ii c. Algorithmic Steps for Medical Causation Assessment ....................................... 25 d. Risk Factors Definitions Table ............................................................................. 27 e. Diagnosis-Based Risk Factors Table ................................................................... 30 4. STAGING MATRIX TO CALCULATE CUMULATIVE TRAUMA CONDITION IMPAIRMENT .................................................................................................................... 37 E. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES ..................................... 40 1. ELECTRODIAGNOSTIC (EDX) STUDIES ....................................................................... 40 2. IMAGING STUDIES .......................................................................................................... 41 a. Radiographic Imaging .......................................................................................... 41 b. Magnetic Resonance Imaging (MRI) ................................................................... 41 c. Computed Axial Tomography (CT) ...................................................................... 42 d. Diagnostic Sonography ........................................................................................ 42 3. JOINT ASPIRATION ......................................................................................................... 42 4. PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL EVALUATIONS ......................... 42 5. ADJUNCTIVE TESTING ................................................................................................... 43 a. Automated Electrodiagnostic Testing .................................................................. 43 b. Pinch and Grip Strength Measurements .............................................................. 44 c. Quantitative Sensory Testing (QST) .................................................................... 44 6. SPECIAL TESTS .............................................................................................................. 45 a. Computer-enhanced Evaluations ......................................................................... 45 b. Functional Capacity Evaluation (FCE) ................................................................. 45 c. Job Site Evaluations and Alterations ................................................................... 46 d. Vocational Assessment ........................................................................................ 48 e. Work Tolerance Screening (Fitness for Duty) ...................................................... 48 F. SPECIFIC MUSCULOSKELETAL DIAGNOSIS, TESTING & TREATMENT PROCEDURES .... 49 1. AGGRAVATED OSTEOARTHRITIS OF THE DIGITS, HAND OR WRIST ...................... 49 a. Description/Definition ........................................................................................... 49 b. Occupational Relationship ................................................................................... 49 c. Specific Physical Exam Findings ......................................................................... 49 d. Diagnostic Testing Procedures ............................................................................ 50 e. Non-operative Treatment Procedures ................................................................. 50 f. Surgical Indications/Considerations ..................................................................... 52 g. Operative Procedures .......................................................................................... 55 iii h. Post-operative Treatment .................................................................................... 55 2. DE QUERVAIN’S DISEASE ............................................................................................. 56 a. Description/Definition ........................................................................................... 56 b. Occupational Relationship ................................................................................... 56 c. Specific Physical Exam Findings ......................................................................... 56 d. Diagnostic Testing Procedures ............................................................................ 57 e. Non-operative Treatment Procedures ................................................................. 57 f. Surgical Indications/Considerations ..................................................................... 59 g. Operative Procedures .......................................................................................... 60 h. Post-operative Treatment .................................................................................... 60 3. EPICONDYLITIS (EPICONDYLALGIA) – LATERAL AND MEDIAL ................................ 61 a. Description/Definition - Lateral Epicondylitis ........................................................ 61 b. Description/Definition - Medial Epicondylitis ........................................................ 61 c. Occupational Relationship ................................................................................... 61 d. Specific Physical Exam Findings - Lateral Epicondylitis ...................................... 61 e. Specific Physical Exam Findings - Medial Epicondylitis ...................................... 61 f. Diagnostic Testing Procedures ............................................................................ 62 g. Non-operative Treatment Procedures ................................................................