Carpal Tunnel Syndrome Guidelines Published — Physician’s First Watch

Medical News |
March 4, 2016

Carpal Tunnel Syndrome Guidelines Published

By Kelly Young

Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS

The American Academy of Orthopaedic Surgeons has issued new guidelines on managing carpal tunnel syndrome.

To diagnose carpal tunnel syndrome, the group does not recommend routinely using magnetic resonance imaging or ultrasound. The following are recommended: a thorough patient history, certain physical examination maneuvers, observation, and specific diagnostic tests, such as the hand-held nerve conduction study device. The authors emphasize that no single element should be used alone to make a diagnosis.

Thenar atrophy is associated with carpal tunnel syndrome, but the syndrome cannot be ruled out in the absence of thenar atrophy.

For treatment, the group recommends immobilization, oral or injectable steroids, and ketoprofen phonophoresis gel, and recommends against magnet therapy. It also recommends surgery to release the transverse carpal ligament to help restore hand function and ease symptoms.

Reader Comments (9)

Lawrence Green MD Physician, Neurology, Crozer chester Medical center

This is nonsense,
Electroneurophysiological study is the modern gold standard for accurate diagnosis and management.of CTS

MUHAMMED KHAN , MBBS, MCPS, FRACGP Physician, Family Medicine/General Practice, australia

NICE ARTICLE

FAHAD ZAHOOR Fellow-In-Training, Surgery, Specialized, liaquat national hospital, karachi

just brilliant

Elizabeth McClain DOMP Other Healthcare Professional, Other

While I understand that the this article was specific to the American Academy of Orthopaedic Surgeons guidelines for carpal tunnel syndrome I am saddened to see that other options were not offered. I have been practicing manual therapies for 20 years and I have successfully kept people with carpal tunnel syndrome out of surgery.
I know the surgeons look at a problem with surgeon eyes but it would be more complete reporting if NEJM either did some investigating to find that there has been research done to show that manual therapies do have a place in helping orthopedic conditions such as carpal tunnel (for example: http://www.jmptonline.org/article/S0161-4754(12)00115-7/abstract and http://www.jmptonline.org/article/S0161-4754(06)00313-7/abstract )
OR, even better, if NEJM started a team of researchers to sponsor empirical research in manual therapies (of which there are many to chose from) to prove (or not) that manual therapies and modalities such as Kinesiotape have a place in the healing of orthopedic conditions.

* * Physician, Neurology, Thrissur. Kerala. India

Have you ever tried small dose of diuretic and pregabalin?

* * Physician, Neurology, Thrissur. Kerala. India

Have you ever tried small dose of diuretic and pregabalin?

Matthew Swartz Physician, Rheumatology, Private practice

Maintenance therapy grip strength should be included

Justin Graff, MD Physician, Neurology, Neurology Consultants of North Mississippi

This is in reference to the summary "Carpal Tunnel Guidelines Published" that went out on Physician's First Watch this AM. Corrections need to be mailed to the readership.

The group recommendations do NOT recommend magnetic therapy as the summary suggests. The guideline says "Strong evidence supports not using magnet therapy for the treatment of carpal tunnel syndrome."

Additionally, the second paragraph of the Journal Watch summary indicates that hand held nerve conduction studies are "recommended" and that MRI and ultrasound is not recommended. When I review the complete guidelines, however, they do not support this statement. The guidelines make a "limited evidence" level of recommendation for hand held nerve condition studies, the same as ultrasound. MRI actually met a higher level of evidence, "moderate". The Journal Watch summary says that MRI and ultrasound are not recommended.

Buried on page 140, the guidelines say that for hand-held nerve conduction studies "more high quality studies are needed to confirm the utility of this method in comparison to electrodiagnostic studies". So, I don’t understand why the Journal Watch summary indicates that hand-held nerve conduction studies are "recommended". I think this needs to be corrected as well.

Here's the compete summary of the hand-held NCS data by AAOS, which I agree with, and should be stressed in the correction:

Rationale
There was one moderate quality study (Tan, 2012) evaluating the use of a hand-held NCS device for the diagnosis of CTS. This study showed that a handheld NCS device can rule in or rule out the diagnosis of CTS, in patients with typical symptoms of CTS, using EDS following AANEM criteria as the reference standard. The hand-held NCS device closely parallels the severity of disease compared with the neurological assessment as well.
Risks and Harms of Implementing this Recommendation
The user should be aware of the limitations and specific utility of these devices. They should not be used in patients that have symptoms or signs that might suggest an alternative diagnosis or in patients who have weakness or atrophy. Use of the hand-held NCS device in those with alternative diagnosis to CTS or motor deficit may result in missed or delayed diagnosis.
Future Research
More high quality studies are needed to confirm the utility of this method in comparisoned (sp) to electrodiagnostic studies.

I would also point out that standard EMG/NCS do not appear to have been evaluated by these guidelines, presumably as it is the gold standard. I agree that ultrasound and MRI should not currently be done first line. EMG/NCS serves two functions, both to evaluate for evidence of CTS (more precisely, median mononeuropathy at the wrist) and to also exclude the other potential causes for patient symptoms and signs, which MRI and ultrasound cannot.

Although not a criticism of the Journal Watch review, but rather the AAOS guidelines, I would not have put thenar atrophy at the top of the CTS guidelines. In my opinion, it is a minor point. The vast majority of patient's with clinically significant CTS do not have thenar atrophy. I worry that some clinicians may briefly review these guidelines, make the wrong inference, and begin to wait until thenar atrophy is present to make the diagnosis. If there is thenar atrophy, the patient should probably have EMG/NCS to discriminate between the potential causes such as severe CTS, C8/T1 radiculopathy and the less likely possibilities of ALS or other anterior horn cell disorder, plexopathy, proximal median neuropathy, and disuse atrophy most commonly seen in severe rheumatoid arthritis. If they have thenar atrophy, they need to be considered for prompt median nerve decompression. Even if a patient has typical symptoms of CTS with thenar atrophy, those symptoms may overlap with one of the other disorders.

More importantly, on page 40 of the guidelines is "The individual studies, as well as the meta-analysis, showed that the absence of thenar atrophy did not rule out the diagnosis of CTS." This is a much more important point to stress to clinicians! The vast majority of patients with clinically significant CTS with pain, alteration in sensation, and weakness do not have thenar atrophy. Patients should be diagnosed as early as possible, before the onset of atrophy, when there are only symptoms or when the only sign is a reduction in sensation in median-innervated digits. In my experience, patients with thenar atrophy have less chance of complete recovery from pain, weakness, and reduction in sensation with median nerve decompression, probably due to the presence of axonal injury.

MD Physician, Family Medicine/General Practice, Falls Church

The association of CTS and Thoracic Outlet Syndrome is not emphasized..CTS patients should not have a relative weakness of the fifth finger maneuver( RWFF) in physical examination.Unfortunately this maneuver is not performed in these patients.See www-TOS-syndrome.com

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