Cost Comparison | The Problem | Patient Presentation |
The Etiology| Treatment Protocol

a.r.t. cost comparison

Source: Texas Department of Insurance,
Detailed Claim Information, March 31, 1994 and
the Texas Workers' Compensation Research Center, 1994

This graph reflects the total cost of medical treatment (surgery), rehabilitation and the resultant indemnity due to wages lost.

The most unique characteristic of Active Release Technique is the cost of indemnity for the patient. Treatment methods have been developed to minimize the actual time away from work and therefore lower cost for all parties involved. In fact, most patients do not miss any work except for treatment time and have full resolution of symptoms in two to four weeks.

Those policy holders who are on Loss Sensitive Planes i.e. Retrospective, Large Deductible and those employers who are self insured have the most to gain by cutting cost and having their employees operating at a full time status as soon as possible. In addition, the cost of a claim has a direct impact on all policy holder's Workers' Compensation experience mod. Therefore, the carriers have extra incentive to help the policy holders direct employees to the physicians who practice the most effective forms of treatment.

The prevalence of Carpal Tunnel Syndrome (CTS) and other Cumulative Trauma Disorders in today's work-place is alarming. CTS now leads injuries to the lower back in cost. The United States Department of Labor - Bureau of Labor Statistics' report Work Injuries and Illnesses by Selected Characteristics, 1992 released April 26, 1994 reflect the enormity of the problem.

"Three Disabling conditions stood out as requiring the longest recuperation periods--carpal tunnel syndrome (median of 32 days lost);..." "Work disabilities resulting from a task's repetitive nature, such as key entry, meat cutting, or scanning, led all other events with a median of 20 lost workdays."
Distribution of Injuries by Type

injuries by type

CTS occured in 3.8% of all Workers' Compensation injuries in 1992.
Distribution of Time Lost

time lost

By comparison, CTS accounted for
83.8% of time lost from work!
In addition to the time lost from work, the Texas Department of Insurance and the Texas Workers' Compensation Research Center state in their report of 1991 released March 31, 1994:
Carpal Tunnel Syndrome

carpal tunnel

"Of the 883 carpal tunnel syndrome claims used in this analysis, 28% are closed and the remaining 72% ARE OPEN."
Cumulative Trauma Claims

cumulative trauma

"Of the 674 cumulative trauma claims used in this analysis, 19% are closed and the remaining 81% ARE OPEN."

One of the most important responsibilities of the Human Resource Department and/or Safety/Risk Manager is directing employees to proper health care providers. This single responsibility can have the largest impact on Workers' Compensation indemnity and medical cost. Texas Law prohibits employers from mandating the employee's choice of physicians but that does not prohibit employers from providing a list of physicians who are qualified to treat these injuries without expensive surgery and rehabilitation.

Employees may present with a wide array of symptoms depending on their task. Some common complaints leading to a Cumulative Trauma Diagnosis of the upper extremity revealed during the initial patient history have been:

  • Arm or hand aching.
  • Weak grip or arm weakness.
  • Arm pain associated with neck discomfort.
  • Numbness and/or tingling in the hand.
  • Increase of symptoms with slight direct pressure.
  • Numbness of the extremity while sleeping.

These complaints are the most common. Employees may describe their symptoms differently. The key works weak, numb, tingling, and aching should raise the awareness of a possible cumulative trauma/repetitive motion injury.

Task most commonly involved in these injuries are illustrated in the chart below.

common injuries

Motions not reported: 25%

Source: United States Department of Labor -
Bureau of Labor Statistics: USDL-94-213, April 26, 1994

Cumulative Trauma Disorder is a group of neuro-musculoskeletal syndromes resulting from the Cumulative Injury Cycle. The cumulative injury cycle may result from acute injury, repetitive injury and defined by the law of repetitive motion, and/or constant pressure/tension injury. Carpal tunnel syndrome, epicondylitis, peripheral nerve entrapment, cubital tunnel, etc. can all be the result of the cumulative injury cycle. If they are not a result of the cycle they are not a CTD and should be treated as the simple syndrome is normally treated. The one common factor for all CTD injuries is the cumulative injury cycle and it is the cycle itself that must be treated.

cumulative cycle

Fax findings to all referring parties including Supervisor and Risk Manager
  • present status or disorder
  • areas involved based on pain drawings and clinical presentation
  • advice on possible time off or placement on light duty status
  • therapeutic stretching and advice about work station
Fax findings to all referring parties including Supervisor and Risk Manager
  • determine if disorder fits the Active Release model
  • advise on possibility of further treatment if needed
  • refer if patient is not responding to treatment
* Most patients do not miss any work while under care.
Suggestions will be based on patients clinical presentation and will be relayed to Occupational or Medical Physician if involved in the case.
Changes in the work station will be discussed with the patient. If needed, a site visit will be made available at no charge.

Repetitive motion injuries are predictable and follow physical laws. These laws have always been in effect but poorly understood and until recently had not been adequately defined. Treatment and prevention requires an understanding of the "law of repetitive motion" as defined by Leahy.

laws of repetitive motion

The factors are:

  1. I = insult to the tissues
  2. N = number of repetitions
  3. F = force of each repetition as a percent of maximum muscle contraction
  4. A = amplitude of each repetition
  5. R = relaxation time between repetitions
    (lack of pressure or tension on the tissue involved)

From the formula, one can make the following conclusions about tissue insults resulting from repetitive motion:

  • high numbers of repetitions results in high tissue insult
  • high forces result in high tissue insult
  • low amplitude of motion results in high tissue insult
  • short relaxation times result in high tissue insult

damage to tissues

Vibration for example, results in N that is very high, A that is very low and R that is very low. The result is a total insult to the tissues that is very high.

Posture that is poor and unchanging results in constant high forces in the musculature. F is high, A is near zero and R is essentially zero. The total tissue insult is therefore high.

A person that is very weak will use a higher percentage of maximum strength to accomplish a given task. F is high and total tissue insult is high.

Four stages of soft tissue change have been observed as a result of the Cumulative Injury Cycle. Each is separate and distinct but contributes in an additive fashion to the insult. These stages include:

  • muscle hypertonicity
  • inflammation of involved nerve
  • local adhesion and fibrosis
  • ischemia of nerve and muscle

Muscle hypertonicity is a predominant feature of CTD. Constant, isometric contraction of muscle and tightness of connective tissue around peripheral nerves may be the initiating factor in the cumulative injury cycle. Friction created between hypertonic musculature and the nerves leads to further insult.

In response to cumulative injury, the epineural vessels increase their permeability, which contributes to edema formation in the epineural layer. Circulating proteins are exuded and spread within the epineural space. They are readily resolved when the cause of edema is eliminated; however, if the edema becomes long-lasting, as in chronic nerve compression, a fibrous scar may form and constrict the epineural vessels.

Injury may alter the anatomy and physiology of the nerves by local or general fibrous adhesion to the surrounding tissues (fibrous fixation or neurodesis) followed by repair gradually maturing into fibrous changes in the epineural structures of the nerve and in the epineural structures around the nerve. Sheets of fibrous adhesion or specific adhesions can form anywhere along the nerve and block the ability of the nerve to be elastic and reform as muscles and tendons contract and joints move. These fibrous adhesions may also cause compression of the microvasculature of the nerve epineurium creating a ischemic environment that further decreases nerve function.

A decrease in oxygen (ischemia)has the following physiological effects on the tissues and the continuation of the cumulative trauma cycle:

  • increases in chemotaxis and proliferation of fibroblast, therefore increasing the amount of scar tissue formation
  • decreases in cell pH resulting in additional damaged cells
  • capillary endotherlial cell release of vasoconstrictors further decreasing oxygen levels
  • increased activity of messenger RNA level of alpha-1 procollagen causing increased proliferation of fibroblast and resultant increase in scar formation
  • hypoxic conditions may be involved in the transformation of myoepithelial cells into myofibroblast and resultant increase in scar tissue formation

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