Carpal Tunnel Syndrome: What it is and how to measure it

This article is intended for medical providers and others who are interested in carpal tunnel syndrome that is caused by workplace activity.Carpal Tunnel Syndrome

What is carpal tunnel syndrome, exactly?

Carpal tunnel syndrome, or CTS, is caused by pressure on the median nerve in your wrist. The median nerve travels from the forearm through the carpal tunnel into the hand.

What are the symptoms of CTS?

  1. Numbness
  2. Tingling
  3. Weakness
  4. Shooting pain

For further reading on the symptoms of CTS, check out this Mayo Clinic article.

How often does CTS occur?

A lot. According to the American Academy of Family Physicians, Carpal Tunnel Syndrome (CTS) occurs in approximately 3-6% of the adult population.

While CTS can be caused by genetics, diabetes, and pregnancy one major factor can be repetitive, forceful movement. As a result, CTS is a very common workplace injury.

How to measure CTS for an impairment rating

When CTS is caused by work related activities, and if an employee is permanently impaired due to CTS, then the condition requires an impairment rating.

Like all injuries, calculating an accurate impairment rating for CTS requires measurements that can be reproduced. In other words, it’s important the medical providers measure CTS in their patients multiple times to ensure that another provider would obtain the same measurements.

In California (and many other states), all impairment ratings for work-related injuries should be calculated according to the AMA Guides, 5th edition.

According to the Guides, the objective factors that affect the PR-4 impairment rating include sensory loss, grip and pinch loss, and loss of range of motion.

If you’ve used RateFast to write a PR-4 report for an injury to your patient’s wrist, then you probably remember being prompted to measure each of these factors.

CTS Factors and Measurement Tools

  • Sensory loss should be measured with two-point discrimination and monofilament testing using the Semmes Weinstein monofilaments.
  • You can measure grip and pinch loss with a dynamometer.
  • Measure the patient’s loss of range of motion with a goniometer. (Check out the RateFast Goniometer app, available for iOS and Android.)

Remember to use the proper devices to take all measurements twice to make sure your findings are compliant with the AMA Guides. When medical providers don’t take multiple measurements, then their PR-4 report will be incomplete. The result is often an inaccurate impairment rating—which can result in happy insurance carriers and unhappy patients.

The fastest occupational medicine exam ever

Hi, my name’s Dr. John Alchemy—I’m a physician, a QME, as well as the CEO and founder of RateFast.

If your outpatient/office based clinic does occupational medicine, then I’d like to share a recent experience that could benefit your workplace and speed up your workday.

Using nothing but my iPhone and my laptop, I recently gave my fastest work-injury examination ever. The crazy part is that neither my patient or myself had to leave our homes.

Here’s the story: I was at home on a Saturday when I got a phone call. It was from a patient who had recently sustained a knee injury while he was at work. I had seen him recently, ordered some basic treatment, and completed a Doctor’s First report for his claim. But now he was experiencing some new symptoms: his knee was locked. He couldn’t bend it at all. Understandably, he was pretty alarmed.

If I had received this phone call 10 years ago, then my patient would have needed somebody to drive him to the emergency room, or else wait until Monday when my clinic was open. Once he got to the clinic or hospital, he would have needed to wait until somebody was available to see him. The odds of him quickly getting an appointment with me or another provider who was already familiar with his claim and work restrictions would have been pretty slim.

But that’s all in the past. Here’s what we did:

  1. We converted the phone call to a video chat.
  2. Using his phone’s camera, I examined his knee and remotely performed a physical.
  3. I determined that he had a possible bucket handle tear.
  4. While we were on the phone, I logged into RateFast on my laptop and created a PR-2 report. All the information about his injury and his employer from his Doctor’s First report imported into the PR-2 automatically, so I didn’t need to rewrite anything. Instead, I simply added some information about his new symptoms, and updated his treatment plan—specifically, I directed my patient to go to the ER or an orthopedic consultation.
  5. Then, I placed a call for sign-out to the ER. I gave them my potential diagnosis and treatment plan, which prepped them to help my patient when he arrived at the hospital.
  6. My patient’s wife drove him to the ER. But between the time they hung up the phone and the time they got into the car, I had already updated his work restrictions in RateFast and printed out the PR-2 report. It was ready to send to his employers’ insurance carrier.
  7. The whole thing—the exam, the phone call to the ER, and the PR-2 report—was over in less than 15 minutes.

Without telemedicine, this sort of visit might have easily cost my patient more than an hour—15 minutes of driving to the clinic (assuming the clinic is open), 15 minutes in the waiting room, 15 minutes of examination, and then another drive to emergency room. Without RateFast, I would’ve needed to spend extra time refreshing myself on the details of the case and filling out the PR-2 report.

Here are some of the positive outcomes of the whole business:

  1. My patient was able to get an examination without leaving his home or waiting until Monday.
  2. I essentially extended my medical practice’s office hours without losing more than few minutes of my own weekend.
  3. I was able to examine this patient without impacting the schedules of other patients who had appointments at the clinic on Monday.
  4. Since my patient didn’t need to drive as much, the employer and insurance company saved on travel expenses.
  5. My patient’s work restrictions and work status were updated sooner than they normally would’ve been, and the PR-2 was completed without a face-to-face visit.

The bottom line is that the whole claim moved forward faster, and everybody involved saved time and energy.

If you’re not already using telemedicine in your medical practice, then I can’t recommend it enough. Your patients might thank you for it.

If you’re not already on RateFast, now’s a great time to join: RateFast Express has more features than ever, and you get 2 free PR-2 and PR-4 reports (impairment ratings included!). Doctor’s First reports are completely free. Contact us at for more information about how we can help your medical practice.

3 Questions To Ask Before Referring To A Spine Specialist

If you’re a medical provider and your patient has a spine-related injury, then it might be a good idea to refer him/her to a spine specialist.

Before you write the referral, ask yourself these questions:

  1. Can the patient return to work without exacerbating his/her back injury?
  2. Is further treatment for the spine necessary?
  3. Could the patient’s back injury benefit from a different type of physical therapy, or a different type of medication?

If you can’t answer these answer these questions, then it may be best to refer your patient to a spine specialist who can.

For more information, check out our “Spinal Injuries in Work Comp” episode of our podcast.

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How to measure range of motion for a PR-4 report

If your patient has injured a joint, then you (the medical provider) should be sure to measure the range of motion (ROM) of that joint. It’s particularly important to report the range of motion of an injured joint in a PR-4 Report (or the PRIMARY TREATING PHYSICIAN’S PERMANENT AND STATIONARY REPORT).


Measuring the range of motion for an injured joint is essential for calculating an accurate impairment rating.

If you don’t know how much motion your patient has lost, then you can’t tell how much the work injury impaired him or her.

4 Steps to taking accurate range of motion (ROM) measurements for work comp

1. Have your patient warm up by stretching for two minutes

If your patient warms up before measuring, then your measurements  will be more accurate and consistent, with greater reproducibility.

Reproducibility of measurements within 10% is necessary for measurements to be considered valid by the AMA guides.

2. Use the proper tool

If the joint is in the upper or lower extremity (arm or leg), then use a goniometer.

If the injured joint is in the spine, then use an inclinometer.

3. Measure both sides

Notice that the PR-4 report says “Include bilateral measurements – injured/uninjured – for injuries of the extremities.”

So, if your patient has injured her right shoulder, then measure the range of motion of both shoulders. This shows the contrast between the injured body joint and the uninjured joint.

Unless, of course, both sides are injured! But in this case, you should still measure both sides and report your measurements.

4. Measure multiple times!

If the injured joint is in the upper extremity, then take two measurements across each plane (flexion, extension, etc.).

If the injured joint is in the lower extremity or the spine, then take three measurements across each plane.

5. Report your results in the “Physical Examination” section of the PR-4 report

You will find the “Physical Examination” section on the second page of the PR-4 report form that’s currently on the California Department of Industrial Relation’s website.

Make sure that you present your measurements clearly so that it’s easy to read for a claims adjuster, employer, or another doctor. Indicate the plane of motion and the side of the measurement.

We like to show our measurements in a table. This is how the new version of RateFast, our PR-4 reporting web app, displays the range of motion of a body part:

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Spine Specialist Vs. Primary Care Provider: What’s the Difference?

Dr. Christian Athanassious, a recent guest on the California Work Comp Report Podcast and a trained spine expert, gave us the lowdown on spine exams in workers’ compensation. If you’ve ever wondered how a spine exam might differ from a regular trip to the doctor, then look no further.

Spine specialists look at the exam from the point-of-view of what they can treat and what they can fix: something objective that the spine specialist can take care of. This doesn’t necessarily mean they are looking for something to operate on using surgery. Rather, a spine specialist will search for a structural cause that the specialist can give an answer to, and more than likely predict the outcome for the patient.

Depending on where along the spine the patient is experiencing pain (neck, mid-back, and/or low-back) and how that motion relates to his or her disability, the spine specialist can create a plan for medical care.

The spine specialists also considers how back pain is related to the motion of the upper or lower extremities.

Every spine exam measures the patient’s sensory function, reflex function, and motor strength. This is measured using a system of dermatomes which is how nerves map throughout the body and gives it sensation, and myotomes, which is how the nerves connect to the different muscles within the body.

Once the specialist gets an idea of where the disease or pain is coming from, then he or she can determine the specific nerves that are related to the patient’s pain or disability.

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One Simple Tip to Improve How Your Practice Organizes Work Comp Claims

Currently when patients come into a clinic, whether the clinic uses an EMR or paper charts, a chart is created. Notes are written- that works fine, as long as there’s only one injury being managed. The real problem comes up when patients get a second injury.

What can easily happen is that the notes for the two different dates of injury get shuffled together. Incorrect documents given to the provider can then further confuse the patient’s examination, and delay the claim being closed.

This is the problem with administering multiple claims in the clinic. So what’s the solution?

Patient’s injuries need to be organized around the date of the event. Unfortunately that’s not the way that we’ve created healthcare records. Traditionally you have a chart that is organized chronologically.

To solve this problem we have to re-organize the way we write and create our EMRs for Work Comp. Because in Workers’ Comp, each claim has it’s own universe, it’s own set of unique information. These need to be the drivers of the organization in the chart. All you really need to know is what date of injury is this patient here for? Once you know that then you know what the injured body parts are, and you can put your finger on the last, correct, and appropriate notes.

Once you’re working in a system that’s correctly organized by date of injury, it now presents an opportunity for everyone in the clinic to start contributing to the creation of the correct visit note. Now the front office has the opportunity to prepare the patient for an exam based on that specific date of injury. A medical assistant can open the EMR, verify the date of injury, and check-in about pending actions and RFAs.

This allows the doctor to focus on making medical decisions instead of doing clerical research. The patient’s visit goes really smoothly and the patient feels that the doctors are informed and the clinic cares about moving their claim forward.

Take a good look at how different members of the clinical team are helping as injured workers come into the office. It says a lot about the quality of care perceived by the injured worker.

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Understanding Disability: For Insurance Adjusters

Question: Dr. Alchemy, Based on limited range of motion for the neck in the PR-4 exam, can the injured worker return to usual and customary work duties? (This worker was provided an impairment rating WPI value, but no work limitations were clinically indicated).  Sincerely, DS

Answer: Dear DS, Impairment and disability are two independent concepts. Impairment value is a loss of an organ system or function to which a number value is assigned, whereas, “disability” is an ability to meet social or occupational demands. An individual may have impairment but no disability, or the reverse may be true.

A great example here is a knee injury with a meniscus tear. If I choose to not have surgery, but have range of motion above the ratable guidelines, I have a non-ratable knee, BUT I may not be able to stand, squat or lift to the requirements of the job. So, no impairment, but disability (eg. work limitation).

Same knee example as above, but I have surgery this time and a partial meniscus debridement is performed. My knee is perfect post operatively and no pain. I return work no problems. My impairment, however, is 1% WPI based on DBE table rating in Chapter 17, Lower Extremity Table 17-33 etc.

Summary, when an impairment value is incorporated into the California Permanent Disability Rating  (PDR) calculation, true “disability” may or may not be present.

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Adjuster’s Corner: For Insurance Adjusters

Introducing the RateFast “Adjuster’s Corner”.

Adjuster’s Corner is brought to you by, well, adjusters. This series of newsletters are based on real life letters and questions from insurance carrier adjusters seeking clarity and knowledge of the AMA Guides 5th Edition impairment rating situation in California.

Our responses are provided by Dr. John Alchemy, MD, DABFP, QME, CIME. Dr. Alchemy’s credentials include:

A) A current Qualified Medical Examiner (QME) for the State of CA

B) A certified educational provider for the State of CA DWC Medical Unit, specifically approved for content in the AMA Guides 5th Edition, Chapters 1,2,15, 16 and 17, in addition to advanced impairment report writing (12 hrs CME).

C) Currently certified by the American Board of Independent Medical Examiners (ABIME) as a Certified Independent Medical Evaluator (CIME) and have successfully passed a proctored written exam demonstrating competency in the AMA Guides 5th Edition rating system.

Got a great rating question? Send it in (info email link here)!  We love questions almost as much as answers.

Case Study #1 Submitted by adjuster DS:

Question: Dr. Alchemy, why did the cervical spine rating come out so high for a non-surgical neck?

Answer: Dear DS, Do not fall into the trap of responding to impairment values based on the result value. If one reads the rating criteria, surgery is only a subset of the DRE categories, and in no way, a single gateway for rating inclusion etc. Additionally, surgery plays only a subset in the rating determination when using the ROM spine rating.

Rather, I would urge you to focus on the data set that is presented, the validity of the measurements, and the application of the results to the tables and figures. The goal in providing AMA ratings is to provide the stakeholders a numeric value  based on statistical rigor, objectivity, and reproducibility.

If you have specific questions as to the validity of a number or the application of a table/figure, please let me know specifically which part of the data set is appears inconsistent and let’s have learning opportunity.

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Digitization of Workers’ Compensation

The process of digitization is taking information from  the real world and overlaying it with a set of digital perimeters, which allows that information to be put into a system.

This allows for meaningful content to be created for consistent conclusions across large numbers of users.

Electronic Medical Records (EMRs) have gained wide popularity over recent years, but to what extent have Workers’ Compensation reports been digitized in a similar way?

There really hasn’t been a concerted effort to digitize WorkComp by any one group or entity.

There are some impairment reporting softwares out there that will give you the header of the section of the report you’re supposed to fill out. But in these cases, the user is left with a blinking cursor to ask the questions and perform their own physical exam, at their current level of understanding.

We’re talking about guiding the patient and medical provider through a very specific process to make sure reports are as complete and compliant with the law as possible.

Digitization of Workers’ Comp means getting every part of the WorkComp reporting process standardized, using computer technology.

With the rise of cloud computing and centralized and data repositories, the time is now to start this process.

This benefits everyone in the workers’ comp process, but most importantly, it benefits the injured worker. Injured workers get caught in a spiral of inefficiency and errors which draws their cases out much longer than they need to be.

Digitization means faster and more accurate reports; there is currently no penalty for turning in wildly inaccurate reports. Once this process does get digitized any missing information will become blatantly clear.

Has this happened elsewhere? Yes- take a look at the automobile industry. As soon as cars appeared on the market, both new and used, there needed to be a system for determining their value. This guy Les Kelley showed up, of Kelley’s Blue Book– he didn’t have a computer, but he used a specific set of questions that determined how much a car’s value was worth and how much its resell value was. Within a couple of years he took over, his system was an industry standard.

So what does this look like in an Impairment Exam? Let’s have an example:

A QME is doing an exam for a right shoulder injury. The QME took two measurements with the goniometer in all planes of motion. This report gets submitted, and the report is digitized, meaning that someone takes the information and places it into a standardized format to confirm the opinion of the QME. However, what the QME either forgot or wasn’t aware of, is that in upper extremity injuries, you need to measure both the injured and uninjured parts of the body. Therefore half of the functional measurement set is missing, as no measurements were taken on the left shoulder. With digitization the data that’s missing is made extremely clear. This will improve accuracy and consistency in monetizing work injuries.

A study from 2006 found as much as 79% of reviewed reports for the low back were incorrect. Hopefully with the process of digitization this number will significantly decrease. Questions or comments on digitization? Write us at

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Stay Out of Fraud’s Way with RateFast

Last year the California Department of Industrial Relations, Division of Workers’ Compensation (DWC) sent out a letter to the workers’ compensation community regarding fraud. You can read the full letter from 2014 here. But in order to keep things simple, RateFast has created an easy to follow guide for understanding regulations and making sure your practice isn’t making common mistakes.

Workers’ Compensation fraud can be committed by all parties in the workers’ comp process. This includes medical providers, attorneys, claims adjusters, and employers. Below are details and real-world examples of what fraudulent activity might look like for Medical Providers. For a full discussion and review of the 2014 Fraud warning notice, please listen to our podcast “Staying Out Of Fraud’s Way”, available on the iTunes store.

Fraudulent activity for medical providers includes:

  • Billing for services that weren’t performed/ billing for procedures that weren’t indicated.

  • This can occur if an office is not in the practice of correctly documenting the amount of time a provider has spent with the patient.

  • Employing Individuals to Solicit New Patients

  • Using another individual in the community to funnel cases to you.

  • Unnecessary treatment.

  • A patient is authorized for a cortisone injection, and it doesn’t work. If the doctor continues to provide cortisone injections, that may be viewed as unnecessary treatment.

  • Self-interested referrals.

  • If a provider has stock or ownership in a physical therapy group across the street and the provider sends their patients over there, then they make an additional profit on that patient.

  • Failure to report a work injury.

  • Employers are required to report work injuries. If a doctor is not reporting an injury then be in favor in employer, then insurance premium doesn’t go up.

  • If a doctor is aware that a work injury has occurred they have to report it whether or not the patient wants to continue treatment.

Let’s take a look at a fictional, but quite possible real-world scenario:

An employer brings in an injured worker and they have a laceration on their arm. The medical provider examines the wound and makes a determination that the wound needs to be closed with sutures. If sutures are used it becomes a reportable case. If it’s closed with surface tape, the injury falls under first aid. The employer states that they would like it to be closed with butterfly tape. They will pay the provider cash for this and also promise to send other injuries to the provider’s clinic.

If the doctor complies and places the butterfly tape, then fraud has occurred because the medical recommendation was for stitches. The doctor knowingly changed their medical treatment plan to provide a first-aid remedy as opposed to a reportable one. This can be very difficult to prove after the fact.

Bottom line for medical providers concerned about fraud? Simply remember to be careful about processes in the office:

  • How you assign medical codes

  • How you interact with employers

  • What something might look like to a third party

Understand the law, familiarize yourself with the annual fraud notice, and you’ll stay out of fraud’s way!

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