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## Complete Summary

#### GUIDELINE TITLE

Carpal tunnel syndrome (acute & chronic).

#### BIBLIOGRAPHIC SOURCE(S)

Work Loss Data Institute. Carpal tunnel syndrome (acute & chronic).
Corpus Christi (TX): Work Loss Data Institute; 2008. 209 p. \[288
references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Work Loss Data Institute.
Carpal tunnel syndrome (acute & chronic). Corpus Christi (TX): Work Loss
Data Institute; 2007 Apr 24. 201 p.

The *Official Disability Guidelines* product line, including *ODG
Treatment in Workers Comp*, is updated annually, as it has been since
the first release in 1996.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Work-related carpal tunnel syndrome

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Neurology\
Orthopedic Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Health Care Providers\
Health Plans\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To offer evidence-based step-by-step decision protocols for the
assessment and treatment of workers\' compensation conditions

#### TARGET POPULATION

Workers with occupational carpal tunnel syndrome

#### INTERVENTIONS AND PRACTICES CONSIDERED

The following interventions/procedures were considered and recommended
as indicated in the original guideline document:

1.  Aerobic exercise

2.  Braces/splinting

3.  Breaks (microbreaks)

4.  Carpal tunnel release surgery (CTR) (*for specific indications* see
    original guideline document)

5.  Cold packs

6.  Comorbidities assessment (e.g., depression, diabetes,
    hypothyroidism, obesity, pregnancy)

7.  Continuous cold therapy (CCT) in the postoperative setting

8.  Corticosteroid injections

9.  Diagnostic assessment of night pain symptoms, nocturnal
    paresthesias, weak thumb abduction strength, and hypalgesia

10. Diagnostic ultrasound in difficult cases

11. Diagnostic tests such as Durkan\'s compression test, Flick sign
    (shaking hand), Katz hand diagram, Semmes-Weinstein monofilament
    test

12. Differential diagnosis

13. Electrodiagnostic studies (EDS)

14. Electromyography (EMG) when diagnosis is difficult with nerve
    conduction studies

15. Endoscopic surgery

16. Hand and wrist exercises

17. Heat therapy after initial cold packs

18. Nerve conduction studies (NCS)

19. Nerve/tendon gliding exercises

20. Nonprescription medications (acetaminophen, non-steroidal
    anti-inflammatory drugs \[NSAIDs\]). NSAIDs are not recommended as
    first line therapy.

21. Physical therapy/occupational therapy (see original guideline
    document for specific indications)

22. Psychosocial management

23. Return to work

24. Severity definitions, useful for an accurate diagnosis

25. Static 2-point discrimination (\>6 millimeters)

26. Thenar atrophy in diagnosis of severe cases

27. Work restrictions/modified duty

28. Yoga

The following interventions/procedures are under study and are not
specifically recommended:

1.  Arnica

2.  Ergonomic interventions

3.  Insulin

4.  Iontophoresis/phonophoresis

5.  Lidocaine patch

6.  Ligament stretching device

7.  Massage

8.  Mobilization (carpal bone)

9.  Mouse use

10. Oral corticosteroids

11. Polarized polychromatic light (Bioptron light)

12. Therapeutic ultrasound

13. Traumatic carpal tunnel syndrome (CTS)

The following interventions/procedures were considered, but are not
currently recommended:

1.  Acupuncture

2.  Assessment of wrist pain

3.  Astaxanthin

4.  Biofeedback

5.  Botulinum toxin

6.  Closed fist sign

7.  Current perception threshold (CPT) testing/neurometer

8.  Diuretics

9.  Evoked potential studies

10. Fluidotherapy

11. Gel-padded glove

12. Hospitalization

13. Hypnosis

14. Laser acupuncture

15. Low-level laser therapy (LLLT)

16. Magnets/magnet therapy

17. Magnetic resonance imaging (MRI) in the absence of ambiguous
    electrodiagnostic studies

18. Manipulation/chiropractic

19. Multiple extremity testing (unless CTS suspected in each limb)

20. NC-stat nerve conduction studies/NeuroMetrix (unless traditional
    electrodiagnostic testing is unavailable)

21. NSAIDs as first-line therapy

22. Phalen\'s test

23. Portable nerve conduction devices

24. Square wrist sign in diagnostic assessment

25. Surface EMG (SEMG)

26. Therapeutic touch

27. Tinel\'s sign in diagnostic assessment

28. Tourniquet test in diagnostic assessment

29. Transcutaneous electrical neurostimulation (TENS)

30. Vitamin B6 (pyridoxine) supplementation

#### MAJOR OUTCOMES CONSIDERED

-   Sensitivity and specificity of diagnostic tests

-   Effectiveness of treatments for relief of pain and symptoms

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Work Loss Data Institute (WLDI) conducted a comprehensive medical
literature review (now ongoing) with preference given to high quality
systematic reviews, meta-analyses, and clinical trials published since
1993, plus existing nationally recognized treatment guidelines from the
leading specialty societies. WLDI primarily searched MEDLINE and the
Cochrane Library. In addition, WLDI also reviewed other relevant
treatment guidelines, including those in the National Guideline
Clearinghouse, as well as state guidelines and proprietary guidelines
maintained in the WLDI guideline library. These guidelines were also
used to suggest references or search terms that may otherwise have been
missed. In addition, WLDI also searched other databases, including MD
Consult, eMedicine, CINAHL, and conference proceedings in occupational
health (i.e., American College of Occupational and Environmental
Medicine \[ACOEM\]) and disability evaluation (i.e., American Academy of
Disability Evaluating Physicians \[AADEP\], American Board of
Independent Medical Examiners \[ABIME\]). Search terms and questions
were diagnosis, treatment, symptom, sign, and/or body-part driven,
generated based on new or previously indexed existing evidence,
treatment parameters and experience.

In searching the medical literature, answers to the following questions
were sought: (1) If the diagnostic criteria for a given condition have
changed since 1993, what are the new diagnostic criteria? (2) What
occupational exposures or activities are associated causally with the
condition? (3) What are the most effective methods and approaches for
the early identification and diagnosis of the condition? (4) What
historical information, clinical examination findings or ancillary test
results (such as laboratory or x-ray studies) are of value in
determining whether a condition was caused by the patient\'s employment?
(5) What are the most effective methods and approaches for treating the
condition? (6) What are the specific indications, if any, for surgery as
a means of treating the condition? (7) What are the relative benefits
and harms of the various surgical and non-surgical interventions that
may be used to treat the condition? (8) What is the relationship, if
any, between a patient\'s age, gender, socioeconomic status and/or
racial or ethnic grouping and specific treatment outcomes for the
condition? (9) What instruments or techniques, if any, accurately assess
functional limitations in an individual with the condition? (10) What is
the natural history of the disorder? (11) Prior to treatment, what are
the typical functional limitations for an individual with the condition?
(12) Following treatment, what are the typical functional limitations
for an individual with the condition? (13) Following treatment, what are
the most cost-effective methods for preventing the recurrence of signs
or symptoms of the condition, and how does this vary depending upon
patient-specific matters such as underlying health problems?

**Criteria for Selecting the Evidence**

Preference was given to evidence that met the following criteria: (1)
The article was written in the English language, and the article had any
of the following attributes: (2) It was a systematic review of the
relevant medical literature, or (3) The article reported a controlled
trial -- randomized or controlled, or (4) The article reports a cohort
study, whether prospective or retrospective, or (5) The article reports
a case control series involving at least 25 subjects, in which the
assessment of outcome was determined by a person or entity independent
from the persons or institution that performed the intervention the
outcome of which is being assessed.

More information about the selection of evidence is available in
\"Appendix. ODG Treatment in Workers\' Comp. Methodology description
using the AGREE instrument\" (see \"Availability of Companion
Documents\" field).

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Ranking by Type of Evidence**

1.  Systematic Review/Meta-Analysis

2.  Controlled Trial-Randomized (RCT) or Controlled

3.  Cohort Study-Prospective or Retrospective

4.  Case Series

5.  Unstructured Review

6.  Nationally Recognized Treatment Guideline (from
    [www.guideline.gov](http://www.guideline.gov/))

7.  State Treatment Guideline

8.  Other Treatment Guideline

9.  Textbook

10. Conference Proceedings/Presentation Slides

11. Case Reports and Descriptions

**Ranking by Quality within Type of Evidence**

a.  High Quality

b.  Medium Quality

c.  Low Quality

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The Work Loss Data Institute (WLDI) reviewed each article that was
relevant to answering the question at issue, with priority given to
those that met the following criteria: (1) The article was written in
the English language, and the article had any of the following
attributes: (2) It was a systematic review of the relevant medical
literature, or (3) The article reported a controlled trial -- randomized
or controlled, or (4) The article reported a cohort study, whether
prospective or retrospective, or (5) The article reported a case control
series involving at least 10 subjects, in which the assessment of
outcome was determined by a person or entity independent from the
persons or institution that performed the intervention the outcome of
which is being assessed.

Especially, when articles on a specific topic that met the above
criteria were limited in number and quality, WLDI also reviewed other
articles that did not meet the above criteria, but all evidence was
ranked alphanumerically (see the Rating Scheme of the Strength of
Evidence field) so that the quality of evidence could be clearly
determined when making decisions about what to recommend in the
Guidelines. Articles with a Ranking by Type of Evidence of Case Reports
and Case Series were not used in the evidence base for the Guidelines.
These articles were not included because of their low quality (i.e.,
they tend to be anecdotal descriptions of what happened with no attempt
to control for variables that might affect outcome). Not all the
evidence provided by WLDI was eventually listed in the bibliography of
the published Guidelines. Only the higher quality references were
listed. The criteria for inclusion was a final ranking of 1a to 4b (the
original inclusion criteria suggested the methodology subgroup), or if
the Ranking by Type of Evidence was 5 to 10, the quality ranking should
be an \"a.\"

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

The guideline developers reviewed published cost analyses.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Prior to publication, select organizations and individuals making up a
cross-section of medical specialties and typical end-users externally
reviewed the guideline.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Initial Diagnosis**

-   First visit: with Primary Care Physician MD/DO (100%)

-   Determine severity: (see also Severity definitions in the Procedure
    Summary of the original guideline document)

    -   Mild/moderate (*Go to Initial Conservative Treatment*):

        -   Symptoms: pain/numbness in hand/wrist/forearm, below the
            elbow, with altered sensation often described as numbness or
            tingling that is primarily in thumb, index, and middle
            finger (Katz hand diagram and hypesthesia index finger
            compared to little finger), with nocturnal awakening,
            possible impaired dexterity, and often having to shake the
            hand for relief (the Flick sign has a sensitivity of 93% and
            specificity 96%)

        -   Tests: Phalen\'s/Tinel\'s signs not always useful
            individually but when combined with the appropriate history
            have an increased sensitivity and specificity; also consider
            Semmes Weinstein monofilament test, compression testing
            which can be supplemented by doing Durkan\'s compression
            test. (See Table, \"Sensitivity and Specificity of
            Diagnostic Tests for Carpal Tunnel Syndrome Measured Against
            Nerve Conduction Studies\" in the original guideline
            document.)

        -   Recommended: findings that best distinguish between patients
            with electrodiagnostic evidence of carpal tunnel syndrome
            (CTS) and patients without it are hypalgesia in the median
            nerve territory, classic or probable Katz hand diagram
            results, and weak thumb abduction strength (but weakness can
            be difficult to determine). See Table, \"Sensitivity and
            Specificity of Diagnostic Tests for Carpal Tunnel Syndrome
            Measured Against Nerve Conduction Studies\" in the original
            guideline document.

        -   Muscle atrophy: mild weakness of thenar muscles (thumb
            abduction)

        -   History/exam, comorbidities: diabetes, hypothyroidism,
            rheumatoid arthritis, obesity, hypertension, depression,
            inactivity, age, work activities, and hobbies

> Carpal tunnel syndrome seems to be primarily attributable to CTS-prone
> personal characteristics (e.g., obesity, diabetes, female, smoking),
> but symptoms can occur with physical activities at home and in the
> workplace. There is some evidence to conclude that CTS symptoms are
> associated with workplace activities, but current studies have not
> proven causal relationship. See \"Work\" in the Procedure Summary of
> the original guideline document.

-   Concurrent pregnancy: CTS likely to resolve on its own within 6
    weeks after delivery

```{=html}
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```
-   Severe (*Go Directly to Electrodiagnostic Testing*)

    -   Muscle atrophy: severe weakness of thenar muscles (uncommon in
        workers\' compensation cases)

    -   Test: 2-point discrimination over 6 mm - helpful but
        semi-objective test

```{=html}
<!-- -->
```
-   Rule out diagnoses (See other treatment parameters for each of
    these):

    -   Cervical radiculopathy (refer to the original guideline document
        for relevant International Classification of Diseases, Ninth
        Revision \[ICD-9\] codes for CTS and other diagnoses)

    -   Tendonitis

    -   Osteoarthritis

    -   Thoracic outlet syndrome, brachial plexus disorders

**Mild/Moderate \-- Initial Conservative Treatment** (70% of cases)

-   Also first visit (day 1):

    -   Prescribe modification of activity (home and work), breaks,
        stretching, night and possibly day splint, appropriate analgesia
        (i.e., acetaminophen) \[*Benchmark cost: \$14*\], stay at work
        or return to work\--modified duty if condition associated with
        job, possible ergonomic evaluation of job, patient education

+-----------------------------------------------------------------------+
| **Official Disability Guidelines (ODG) Return-To-Work Pathways**      |
|                                                                       |
| Conservative treatment, modified work (limit repetitive use of        |
| hand/wrist): 0 days                                                   |
|                                                                       |
| Conservative treatment, regular work (if not aggravating to           |
| disability/use of splint): 0 to 5 days                                |
|                                                                       |
| (See *ODG Capabilities & Activity Modifications for Restricted Work*  |
| under \"Work\" in the Procedure Summary of the original guideline     |
| document)                                                             |
+-----------------------------------------------------------------------+

-   Second visit (day 7 to 14\--about 2 weeks after first visit, but
    sooner if the patient is off work)

    -   Document progress

    -   If not significantly improved then *may* (approximately 50% of
        cases) prescribe occupational or physical therapy for home
        exercise training \[*Benchmark cost: \$250*\]: Refer to Physical
        Therapist (50%) or Occupational Therapist (50%) for 3 visits.

-   Third visit (day 20 to 30\--about 1 month after first visit, but
    sooner if patient is off work)

    -   Document progress.

    -   Corticosteroid injection trial (high likelihood of relief, but
        may have recurrence of symptoms within several months\--initial
        relief of symptoms can be a good indicator for success of
        surgery, can assist in confirmation of diagnosis) \[*Benchmark
        cost: \$276*\]. Should be performed by musculoskeletally trained
        physician because of possible nerve injury. Recommend only one
        injection (no more than three if benefits continue.

+-----------------------------------------------------------------------+
| **ODG Return-To-Work Pathways**                                       |
|                                                                       |
| Conservative treatment, regular work (if work related): 28 days       |
|                                                                       |
| Conservative treatment, regular work (with severe nerve impairment):  |
| indefinite                                                            |
+-----------------------------------------------------------------------+

-   Fourth visit (day 40 to 50\--about 6 weeks after first visit)

    -   Refer for Electrodiagnostic Testing

**Electrodiagnostic Testing** (50% of cases)\
\[*Benchmark cost: \$370*\]

-   All severe cases, plus mild/moderate cases after Initial
    Conservative Treatment above; See \"Protocols for electrodiagnostic
    studies\" in the original guideline document.

-   Refer to Neurologist (70%) or Physical Medicine (30%) specialists
    certified in electrodiagnostic medicine, for nerve conduction
    studies (NCS) and/or electromyography (EMG), the \"gold standard\"
    tests for the evaluation of CTS.

-   Positive test: refer for possible Carpal Tunnel Release depending on
    severity

-   **Note:** ODG recommends that NCS should be done to support the
    diagnosis of CTS prior to surgery. If an individual has appropriate
    responses to treatment (i.e. injections, modification of activities,
    meds) but still has symptoms with normal NCS, surgery may be
    appropriate on a case-by-case basis and reasonable documentation by
    the treating physician.

**Carpal Tunnel Release** (35% of cases)

(See also *ODG Indications for Surgery^™^ \-- Carpal Tunnel Release* in
the Procedure Summary in the original guideline document)\
\[*Benchmark cost: \$3,158*\]

-   Only after the positive diagnosis of CTS is made by history,
    physical examination, and electrodiagnostic studies

-   Performed by Hand Surgeon: Orthopaedic Surgeon (75%), Neurosurgeon
    (10%), Plastic Surgeon (10%), or General Surgeon (5%)

-   On an outpatient basis

-   May be open or endoscopic, depending on experience of surgeon (risk
    of nerve injury and incomplete release greater with endoscopic)

-   If bilateral (55% of cases), schedule separate surgeries (usually)

-   Expected outcome:

    -   Mild/moderate cases: over 90% success with complete recovery
        after failure of Initial Conservative Treatment (Outcomes in
        workers\' comp cases may not be as good as outcomes overall, but
        still support surgery.)

    -   Severe cases: Complete recovery is unlikely, but 90% will
        benefit from at least partial recovery.

-   Post-surgical treatment:

    -   Splint - day and night: not recommended

    -   Stitches out in 8 to 14 days

    -   Physical/Occupational Therapy: A short course *may* be
        appropriate; if so, then post-surgical treatment of 3 to 5
        visits.

+-----------------------------------------------------------------------+
| **ODG Return-To-Work Pathways**                                       |
|                                                                       |
| Endoscopic surgery, modified work: 3 to 5 days                        |
|                                                                       |
| Endoscopic surgery, regular work, non-dominant arm: 14 to 28 days     |
|                                                                       |
| Endoscopic surgery, regular/repetitive/heavy manual work, dominant    |
| arm: 42 days to indefinite                                            |
|                                                                       |
| Open surgery, mini palm technique, modified work: 1 to 5 days         |
|                                                                       |
| Open surgery, mini palm technique, regular work, non-dominant arm: 5  |
| to 20 days                                                            |
|                                                                       |
| Open surgery, mini palm technique, regular/repetitive/heavy manual    |
| work, dominant arm: 28 days to indefinite                             |
|                                                                       |
| Open surgery, traditional approach, modified work: 10 days            |
|                                                                       |
| Open surgery, traditional approach, regular work, non-dominant arm:   |
| 42 days                                                               |
|                                                                       |
| Open surgery, traditional approach, regular/repetitive/heavy manual   |
| work, dominant arm: 56 days to indefinite                             |
+-----------------------------------------------------------------------+

-   Failed Carpal Tunnel Release (4% of cases):

    -   Repeat Electrodiagnostic Testing

    -   Repeat Carpal Tunnel Release (by fellowship-trained Hand
        Surgeon)

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

During the comprehensive medical literature review, preference was given
to high quality systematic reviews, meta-analyses, and clinical trials
over the past ten years, plus existing nationally recognized treatment
guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure
Summary (see the original guideline document), which provides a concise
synopsis of effectiveness, if any, of each treatment method based on
existing medical evidence. Each summary and subsequent recommendation is
hyper-linked into the studies on which they are based, in abstract form,
which have been ranked, highlighted and indexed.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

These guidelines unite evidence-based protocols for medical treatment
with normative expectations for disability duration. They also bridge
the interests of the many professional groups involved in diagnosing and
treating carpal tunnel syndrome.

#### POTENTIAL HARMS

Endoscopic surgery is associated with greater risk of nerve injury and
incomplete release than open surgery.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The Treatment Planning sections outline the most common pathways to
recovery, but there is no single approach that is right for every
patient and these protocols do not mention every treatment that may be
recommended. See the Procedure Summaries (in the original guideline
document) for complete lists of the various options that may be
available, along with links to the medical evidence.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Patient Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Work Loss Data Institute. Carpal tunnel syndrome (acute & chronic).
Corpus Christi (TX): Work Loss Data Institute; 2008. 209 p. \[288
references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 (revised 2008 May 19)

#### GUIDELINE DEVELOPER(S)

Work Loss Data Institute - Public For Profit Organization

#### SOURCE(S) OF FUNDING

Not stated

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Editor-in-Chief, Philip L. Denniston, Jr. and Senior Medical Editor,
Charles W. Kennedy, Jr., MD, together pilot the group of approximately
80 members. See the ODG *Treatment in Workers Comp* [Editorial Advisory
Board](http://www.disabilitydurations.com/editorial_advisory_board.htm).

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

There are no conflicts of interest among the guideline development
members.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Work Loss Data Institute.
Carpal tunnel syndrome (acute & chronic). Corpus Christi (TX): Work Loss
Data Institute; 2007 Apr 24. 201 p.

The *Official Disability Guidelines* product line, including *ODG
Treatment in Workers Comp*, is updated annually, as it has been since
the first release in 1996.

#### GUIDELINE AVAILABILITY

Electronic copies: Available to subscribers from the [Work Loss Data
Institute Web site](http://www.odg-disability.com/).

Print copies: Available from the Work Loss Data Institute, 169 Saxony
Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992,
Fax: 760-753-9995; [www.worklossdata.com](http://www.worklossdata.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Background information on the development of the Official Disability
    Guidelines of the Work Loss Data Institute is available from the
    [Work Loss Data Institute Web
    site](http://www.odg-disability.com/odgtwclist.htm).

-   Appendix A. ODG Treatment in Workers\' Comp. Methodology description
    using the AGREE instrument. Available to subscribers from the [Work
    Loss Data Institute Web
    site](http://www.odg-disability.com/ODG_AGREE.htm).

#### PATIENT RESOURCES

The following is available:

-   Appendix B. ODG Treatment in Workers\' Comp. Patient information
    resources. 2008.

Electronic copies: Available to subscribers from the [Work Loss Data
Institute Web site](http://www.odg-disability.com/).

Print copies: Available from the Work Loss Data Institute, 169 Saxony
Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992,
Fax: 760-753-9995; [www.worklossdata.com](http://www.worklossdata.com/).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This summary was completed by ECRI on February 2, 2004. The information
was verified by the guideline developer on February 13, 2004. This NGC
summary was updated by ECRI on March 24, 2005, January 3, 2006, April
11, 2006, November 9, 2006, March 28, 2007, and August 16, 2007. This
summary was updated by ECRI Institute on December 17, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 1/5/2009