Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Carpal Tunnel Release


Related Terms

  • CTR

Specialists

Comorbid Conditions

Factors Influencing Duration

Factors that alter the duration of disability include the severity of the individual’s case and the duration of symptoms before CTR was performed. The longer and more severely the median nerve was compressed, the longer it may take for the nerve to improve. Recovery times are variable. Any postoperative complications will increase length of disability. The length of disability relates to tolerance and hand activity (repetitive motion, awkward posture, grip force used) and may not directly relate to the amount of weight lifted.

Older individuals, those with severe preoperative symptoms, and individuals involved in heavy manual labor, especially those working with vibrating tools, may have longer, slower recovery times from the procedure. For additional information on factors influencing recovery times, refer to "Work Ability and Return to Work," page 198, table 12-9.

For individuals who seem to be unimproved or worse after surgery, postoperative nerve conduction studies can be obtained and compared to pre-operative nerve conduction studies. This comparison can be helpful to educate the patient and to determine if entrapment still is present. The most common complication of surgery is incomplete release (Bland, Assmus). If the entire ligament was not cut, then pressure on the nerve may not have been released, and typically there will have been no improvement in the nerve conduction studies.

If carpal tunnel syndrome is present and sufficiently symptomatic bilaterally, then typically both sides are treated with surgery, but the second wrist is operated on 2 to 6 weeks after the first surgery. The timing of the disability duration in these cases should start on the date of the second surgery. Most individuals can return to modified work activities between the two surgeries. (See the conclusion in "Work Ability and Return to Work," page 200, as well as table 12-10. The length of disability outlined in the duration table demonstrates the challenges physician face regarding return to work. Although shorter durations of disability are possible, this requires increased effort by the treating physician.)

For additional discussions of the physician's challenge, please refer to "Work Ability and Return to Work," pages 1, 9, 23.

Medical Codes

ICD-9-CM:
04.43 - Lysis of Adhesions and Decompression of Cranial and Peripheral Nerves; Carpal Tunnel Release

Overview

© Reed Group
Carpal tunnel release (CTR) is a surgical treatment for carpal tunnel syndrome. This surgery creates more space for the median nerve and tendons that bend (flex) the fingers. Releasing or cutting the transverse carpal ligament (the roof of the tunnel) creates more space for the compressed nerve and tendons.

Techniques for the procedure include open release (either the "mini-palm" or the traditional longer incision technique) and endoscopic ("scope") release. Endoscopic release may involve a single incision or dual incision technique. An unproven, experimental technique called percutaneous balloon carpal tunnelplasty is sometimes suggested. All these techniques are usually outpatient or in office procedures. Comorbidities might require surgery in a hospital. Involvement of other structures in the wrist, as well as surgeon preference and training, influences the choice of technique used. Recovery after surgery is dependent on tolerance and accommodation of activities. The endoscopic release may result in increased costs, and a higher rate of complications. Regardless of technique, the long-term outcomes are similar.

Source: Medical Disability Advisor



Reason for Procedure

Carpal tunnel syndrome refers to symptoms of numbness (altered sensation or feeling), pain, and weakness, in that order, felt in the wrist and hand. The altered sensation is characteristically felt on the palm side of the thumb, index, middle finger, and sometime the radial (thumb) side of the ring finger. In some patients the entire hand and distal forearm can be involved. The symptoms usually occur at night and may occur with activities.

The carpal tunnel is firm and cannot expand to accommodate any swelling or gradual enlargement of the tendons. Swelling and subsequent nerve compression can result from normal age-related bony thickening; from acute injury such as dislocation or fracture of the wrist; from diseases that enlarge the tendons in the tunnel, such as rheumatoid arthritis, hypothyroidism, and diabetes; or from fluid retention (edema) in the carpal tunnel during pregnancy.

Once the diagnosis is confirmed, non-surgical treatment may be offered. Palliative treatments for CTS include use of night splints and corticosteroid injection. The only scientifically established disease modifying treatment is surgery to cut the transverse carpal ligament (Bickel). If symptoms persist, surgery is recommended to decrease the pressure on the median nerve and therefore to decrease the likelihood of permanent nerve damage (Bostrom).

The goal of surgery is to prevent or limit possible permanent damage to the nerve. Often, but not always, is a reduction in the symptoms of numbness, pain, tingling, and decreased strength. In one study, 90% of patients had relief of nighttime pain or daytime pain, while 73% reported being very satisfied with the surgical result (Netscher).

Source: Medical Disability Advisor



How Procedure is Performed

CTR is performed as an outpatient or in-office procedure under local or regional anesthesia. Several techniques are currently used to accomplish the release.

Endoscopic carpal tunnel release uses standard arthroscopic technique with specially designed, smaller optic instruments. The surgeon releases or cuts the roof of the carpal tunnel while looking through a camera positioned below the ligament itself (as opposed to the open- and mini-open techniques, in which the ligament is cut from above). However, the surgeon does not have the same view of other parts of the hand as during open procedures. Endoscopic technique and open mini-palm technique have similar functional recovery after surgery.

Again, the percutaneous balloon carpal tunnelplasty is an experimental technique in which a small balloon-tipped catheter is inserted into the tunnel through a skin incision and then inflated to stretch the ligament.

Source: Medical Disability Advisor



Prognosis

Release of pressure on the nerve can provide immediate relief from symptoms as listed above, but full recovery may take months, during which the nerve function improves and the incision heals. Again persistent symptoms are common and dependent on the amount of permanent changes that occur to the nerve before release. Regaining hand grip strength occurs gradually, and in some individuals, grip strength slowly improves for 1-2 years after surgery. However, grip strength may be permanently lessened by a small amount. In a randomized trial, surgical treatment resulted in better outcomes than non-surgical therapy (Jarvik).

Although diabetic patients are often told that surgery for CTS will not help, a level I study has found that diabetic patients did benefit from surgery (Thomsen).

Pregnant women whose carpal tunnel symptoms are related to edema often improve after delivery, but symptoms may reoccur with future pregnancies. Many will redevelop carpal tunnel syndrome years later in middle age.

Source: Medical Disability Advisor



Rehabilitation

Individuals often receive therapy from an occupational therapist, a physical therapist, or a hand therapist. This can be helpful in regaining functions post surgery (Evans).

The progression of postoperative therapy is guided by wound healing principles and the tissue response to stress. The need for therapy following carpal tunnel release is dependent on the method of surgery (open or endoscopic) and any complications (Pomerance). No study has shown that therapy after carpal tunnel release improves long term outcomes. Although controversy exists in the literature regarding the kind and the value of postoperative rehabilitation, therapy consistently focuses on the individual's preoperative status, surgical procedure, hand dominance, bilateral symptoms, associated conditions, and home and job requirements. Special attention must be paid during the recovery phase for signs of complex regional pain syndrome (Hayes). Therapy's primary benefit comes from the encouragement to return to activities at work and at home.

Therapy addresses the anatomical regions adjacent to the surgical site and the specific needs for the postoperative care. The overall aim is to restore performance of usual and customary hand function that is both comfortable and safe. The adjacent anatomical regions are monitored for maintenance of full movement, strength patterns, and bodily posture.

For the surgical site itself, the first objective of therapy is to educate the individual on how to control pain and swelling. Cryotherapy is suggested to decrease swelling (Hegmann). Thermal modalities may be used to increase muscle flexibility, to decrease pain, and to reduce edema; however, heat is contraindicated (AAOS). Individuals learn to perform scar massage to decrease the risk of forming painful adhesions (Hegmann).

The second objective of therapy is to restore any lost range of motion at the wrist and hand that corresponds with the postoperative recovery plan; attention is also directed to safe body mechanics to protect the surgical site during healing while engaging in routine daily activities. Dynamic movement patterns are then progressed, and the individual is educated in safe patterns for exercise and activity related to CTS. Soft bandages rather than splinting are generally recommended postoperatively (Hegmann; Cebesoy). The type of surgical procedure may control progression to heavy lifting, although normally by 2 to 3 weeks return to usual activities of daily living is allowed (Wright).

Concurrently, once the postoperative edema has resolved, a third objective is to monitor hand sensation, and provide a sensory re-education program when appropriate.

The final objective of therapy is to discover if any factors in the individual's environment, either at work or home, may contribute to the CTS. If the compression can be attributed to or related to job duties or activities of daily living, education regarding the provocative positions and modifications in method or setup is provided. Such education may help abate the identified aggravating conditions, minimizing symptoms and preventing their return. The individual may benefit from an ergonomic consultation. The therapist will monitor the individual for potential complications such as severe and persistent edema, palmar pain, increased hand sensitivity, or joint stiffness (Finsen; Gerritsen).

FREQUENCY OF REHABILITATION VISITS
Surgical
SpecialistCarpal Tunnel Release
Occupational/Hand/Physical TherapistUp to 5 visits within 6 weeks
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Inflammation of the tendon sheaths of the adjacent tendons (tenosynovitis) may continue to cause pain after surgery. Infection is not common but can occur. Contracture of the skin and soft tissue can complicate recovery. Damage to the nerve during surgery is a risk in any of the techniques described. Injury to the palmar cutaneous branch of the median nerve (that leaves the main nerve prior to the carpal tunnel) can cause pain and numbness in the palm. Reflex sympathetic dystrophy (complex regional pain syndrome) is an uncommon complication that can result in pain and stiffness. Risks involved with any of the surgical techniques include damage to the median nerve or flexor tendons, increased inflammation, infection, skin contractures, and scarring. Some individuals may experience temporary loss of sensation in their fingers or recurrence of preoperative symptoms.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Modification of activities is the best approach for the treatment of musculoskeletal pain and carpal tunnel symptoms that are associated with activities at home and at work. Return to work depends on three conditions: capacity, risk, and tolerance. Capacity is the actual ability to perform activities, risk is the likelihood of either complications or recurrence of the condition from performing the activity, and tolerance is the individual's willingness to endure some discomfort in the healing phase.

Ergonomic evaluation of the work area is helpful to identify contributing risk factors, such as positioning keyboards too high, driving, or holding a telephone for repeated or extended periods of time. Eliminating these risk factors may allow early return to work, at least in a limited capacity. Some individuals may not be able to return to aggravating activities such as constant hammering or typing, and studies indicate that some individuals change jobs after surgery.

Users may find it helpful to read Chapters 1-3 in "Work Ability and Return to Work," which provide a framework for considering the benefits of staying at—or returning to—work.

Risk: The risk for reinjury is low because age, gender, and genetics are the highest risk factor for the initial development of CTS. Most cases labeled "recurrent carpal tunnel syndrome" are actually incomplete surgical release procedures, leaving persisting carpal tunnel syndrome. There may be decreased symptoms after surgery as a result of surgeon-imposed work restrictions. When activity levels finally increase, the persisting CTS becomes symptomatic. Until the wound is healed, very heavy use of the hand could cause the wound to disrupt, and very dirty work could result in wound infection.

Capacity: Most activities can be safety performed in the post operative period. Traditional wound healing considerations require avoiding contact with chemicals and no extended periods of soaking with the surgical incision site . Return to heavy activities gradually, much like a long distance runner in training, is appropriate (Melhorn).

Tolerance: Tolerance for symptoms is dependent on rewards. Self employed individuals often return to regular activities (including work) within a day or two , while employed individuals may have various lengths of disability. Outcomes for workers’ compensation patients are poorer than non-workers' compensation (Adams).

Accommodations: The key to limited unnecessary disability is communication. The employee should be made to understand what he/she can do instead of what he/she can not do (this enables). The employer should be informed of the health benefits for the employee of early return to work. If the individual can be assigned temporarily to one-handed light work, then return to work the day after surgery is common and not associated with an increased rate of complications.

Source: Medical Disability Advisor



Maximum Medical Improvement

60 to 90 days post surgery.

Continued improvement is possible over 540 days (18 months), but the amount of improvement is limited.

Source: Medical Disability Advisor



References

Cited

"AAOS Guideline on treatment of carpal tunnel syndrome." AAOS. 9 2011. American Academy of Orthopaedic Surgeons. 25 Nov. 2012 <www.aaos.org>.

Adams, M. L. , et al. "Outcome of carpal tunnel surgery in Washington state workers' compensation." American Journal of Industrial Medicine 25 (1994): 527-536.

Adams, M. L. , et al. "Outcome of carpal tunnel surgery in Washington state workers' compensation." American Journal of Industrial Medicine 25 (1994): 527-536.

Assmus, H. "Correction and reintervention in carpal tunnel syndrome. Report of 185 reoperations." Nervenarzt 67 (1996): 998.

Assmus, H. "Correction and reintervention in carpal tunnel syndrome. Report of 185 reoperations." Nervenarzt 67 (1996): 998.

Bickel, Kyle D. "Carpal Tunnel Syndrome." Journal of Hand Surgery 35 1 (2010): 147-152.

Bland, J. D. , et al. "Treatment of carpal tunnel syndrome." Muscle Nerve 36 (2007): 167.

Bland, J. D. , et al. "Treatment of carpal tunnel syndrome." Muscle Nerve 36 (2007): 167.

Bostrom, L. , and H. Lugnegard. "Surgery cures numbness of the hand. Long-term follow-up of carpal tunnel decompression." Acta Orthopaedica Scandinavia 87 32-33 (1990): 2497-2500.

Bostrom, L. , and H. Lugnegard. "Surgery cures numbness of the hand. Long-term follow-up of carpal tunnel decompression." Lakartidningen 87 32-33 (1990): 2497-2500.

Cebesoy, O. , et al. "Use of a splint following open carpal tunnel release: a comparative study." Advances in Therapy 24 3 (2007): 478-484.

Evans, R. B. "The Therapist’s Management of Carpal Tunnel Syndrome." Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc., 2002. 660-671.

Gerritsen, A. A., et al. "Splinting vs Surgery in the Treatment of Carpal Tunnel Syndrome: A Randomized Controlled Trial." Journal of American Medical Association 288 10 (2002): 1245-1251.

Hayes, E. P., et al. "Carpal Tunnel Syndrome." Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc., 2002. 643-659.

Hegmann, Kurt T., et al., eds. "Chapter 11: Hand, Wrist and Forearm Disorders." Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. 2008 Revision 2nd ed. ACOEM, 2008. 627-652.

Jarvik, J. G., et al. "Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomised parallel-group trial." Lancet 374 9695 (2009): 1074-1081.

Melhorn, J. Mark, and William Ackerman, eds. Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008.

Melhorn, J. M. "Unnecessary Disability - Why Can't I Work?" Impairment without Disability. Ed. W. G. Buchta. Mayo Clinic, 2011.

Melhorn, J. M. "Unnecessary Disability - Why Can't I Work?" Impairment without Disability. Ed. W. G. Buchta. Mayo Clinic, 2011.

Netscher, D. , et al. "Temporal changes in grip and pinch strength after open carpal tunnel release and the effect of ligament reconstruction." Journal of Hand Surgery 23 (1998): 48.

Netscher, D., et al. "Temporal changes in grip and pinch strength after open carpal tunnel release and the effect of ligament reconstruction." Journal of Hand Surgery 23 (1998): 48.

Pomerance, J., and I. Fine. "Outcomes of carpal tunnel surgery with and without supervised postoperative therapy." Journal of Hand Surgery 32 8 (2007): 1159-1163.

Szabo, R. M. , and M. Madison. "Carpal tunnel syndrome as a work-related disorder." Journal of the American Academy of Orthopaedic Surgeons (1995): 421-434.

Szabo, R. M. , et al. "Carpal Tunnel Syndrome as a Work-related Disorder." Repetitive Motion Disorders of the Upper Extremity. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1995. 421-434.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

Thomsen, N. O. , et al. "Clinical outcomes of surgical release among diabetic patients with carpal tunnel syndrome: prospective follow-up with matched controls." Journal of Hand Surgery 34 7 (2009): 1177-1187.

Thomsen, N. O. , et al. "Clinical outcomes of surgical release among diabetic patients with carpal tunnel syndrome: prospective follow-up with matched controls." Journal of Hand Surgery 34 7 (2009): 1177-1187.

Wright, Phillip E. "Chapter 73 - Carpal Tunnel, Ulna Tunnel and Stenosing Tenosynovitis." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beaty. 11th ed. Philadelphia: Mosby Elsevier, 2008.

Source: Medical Disability Advisor






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