epidemiology therapeutic management of carpal...

1Evans RB, carpal tunnel lecture, 2014

Therapeutic Managementof

Carpal Tunnel Syndrome

Roslyn B. Evans, Roslyn B. Evans, OTR/L, CHTOTR/L, CHT

Philadelphia: DK LecturePhiladelphia: DK Lecture20142014

EpidemiologyEpidemiology> morbidity than any other illness> morbidity than any other illness99 per 100,00099 per 100,00010% general population10% general populationMost common surgery in US… Most common surgery in US… 500,000 per year 500,000 per year

Most common Most common dxdx txtx ASHTASHTProfound economic impact > 2 Profound economic impact > 2 billion per yearbillion per year

Medline SearchMedline Searchhttp:www.ncbi.nlm.nih.gov/entrez http:www.ncbi.nlm.nih.gov/entrez

Unlimited Unlimited articlesarticles8,615 Oct 20148,615 Oct 201430 minutes?30 minutes?

rbe5

Controversy in the LiteratureControversy in the Literature

CauseCauseTechniques of Techniques of evaluationevaluationResults with Results with conservative careconservative careTechnique of Technique of surgerysurgeryValue of postValue of post--operative careoperative care

Effect of occupationEffect of occupationon CTS…on CTS…passionate debate!passionate debate!

Substantiating Our InterventionsSubstantiating Our Interventions

Calling for evidenceCalling for evidence––Insurance Insurance

CompaniesCompanies––Managed care Managed care

networksnetworks––PatientsPatients

RBE18

What is Evidence Based Practice?What is Evidence Based Practice?The integration of best research evidence The integration of best research evidence with clinical expertise and patient values with clinical expertise and patient values SackettSackett et al. 2000et al. 2000

The practice of The practice of EBP EBP consists of:consists of:Formulated clinical questionFormulated clinical questionSystematic review of literatureSystematic review of literatureCritical appraisalCritical appraisalApplication for patientsApplication for patientsPerformance reviewPerformance review

rbe9

rbe5 In Medline search 12/02 with the key words evidence based practice and carpal tunnel syndrome, only

2 papers came up...both on acupunhcture, NIH consensus statementRos Evans, 2/23/2003

Slide 5

RBE18 Be careful how you write this up...study on knee arthroscopy demonstrated that it was not effective as

no evidence based outcomes....now govt is looking into denying claims for medicare, etc and other

insurance companies will follow.Roslyn Evans, 3/1/2003

Slide 6

rbe9 Move is on from opinion based education to evidence based education.the quality or research evidence

available, the reliability of the evidence, the utility of the evidence, how valid is the evedence, how

reliable....this was a plot on the part of the program committee to make me realize how bad my

research is, and to reinforce my thoughts about being put out to pasture....however we can take hope

in the fact that there are levels of research depending on quality...1 to 4 (see MacDermid)...back to

levedl 3. Ros Evans, 2/23/2003


MetaMeta--analysisanalysis

A statistical method for combining the A statistical method for combining the results of available research studies results of available research studies to increase statistical powerto increase statistical powerThe steps of metaThe steps of meta--analysis are:analysis are:

Identification of questionIdentification of questionSearch and selection of trialsSearch and selection of trialsAnalysisAnalysis

HinotsuHinotsu S, S, AkazaAkaza. . GanGan To Kagaku To Kagaku RyohoRyoho20022002

The Problem: The Problem: Inadequate Outcome Inadequate Outcome Measures and ReportingMeasures and Reporting

MetaMeta--analysis is only feasible if RCT’s are analysis is only feasible if RCT’s are clinically clinically homogeneous:homogeneous:

Patient populationPatient populationInterventionsInterventionsComparisonsComparisonsOutcomesOutcomesTiming of followTiming of follow--up measurementup measurement

–– GerritsenGerritsen AAM. et. al. Enabling MetaAAM. et. al. Enabling Meta--Analysis Analysis in Systematic Reviews on Carpal Tunnel in Systematic Reviews on Carpal Tunnel Syndrome. JHS 2002.Syndrome. JHS 2002.

rbe10

Clinical ExposureClinical Exposureconflicting or limiting evidenceconflicting or limiting evidence

Little evidence on the Little evidence on the reliability, validity, and reliability, validity, and responsiveness to change responsiveness to change with current non surgical with current non surgical treatments for CTStreatments for CTSStudy techniques and Study techniques and reporting of results are not reporting of results are not homogeneoushomogeneous–– Metaanalysis:Gerristen2002Metaanalysis:Gerristen2002–– SchadeSchade; 2008,Scangas ; 2008,Scangas 20082008

MetaMeta--analysisanalysisConservative Treatment CTSConservative Treatment CTS

GerritsenGerritsen AA et al. J AA et al. J NeurolNeurol 20022002Short term relief:Short term relief:

Diuretics, pyridoxine, nonDiuretics, pyridoxine, non--steroidal antisteroidal anti--inflammatoriesinflammatories, yoga, laser, yoga, laser--acupuncture ineffective acupuncture ineffective (conflicting evidence)(conflicting evidence)

Efficacy of ultrasound and oral steroids Efficacy of ultrasound and oral steroids (conflicting evidence)(conflicting evidence)SteriodSteriod injection effective injection effective (limited(limited evidence).evidence).

Long term relief:Long term relief:Efficacy of ultrasound Efficacy of ultrasound (limited evidence)(limited evidence)Splinting is less effective than surgerySplinting is less effective than surgeryLittle know about efficacy of conservative Little know about efficacy of conservative txtx

Conservative ManagementConservative ManagementLittle is known about the efficacy of Little is known about the efficacy of most most conservative treatmentsconservative treatments–– GerritsenGerritsen AA, 2002, AA, 2002, metameta--analysisanalysis

Support for therapySupport for therapy–– Level IV; case series with no controlsLevel IV; case series with no controls–– Level V; expert opinion without critical Level V; expert opinion without critical

appraisal or bench appraisal or bench researchresearch–– Splinting, US, nerve gliding, carpal bone Splinting, US, nerve gliding, carpal bone

mobs, magnets, yoga. mobs, magnets, yoga. MacDermid 2004MacDermid 2004

Surgical versus NonSurgical versus Non--Surgical Surgical Treatment for CTS. Treatment for CTS.

Verdugo Verdugo et al. et al. Cochrane Database Cochrane Database SystSyst Rev Rev 2002/ 20082002/ 2008

Surgery more effective Surgery more effective Significant number of patients treated Significant number of patients treated medically will go on to surgerymedically will go on to surgeryRisk of reoperation low Risk of reoperation low Unclear if mild Unclear if mild sxsx can be treated with can be treated with splints and injectionsplints and injection

rbe11

rbe10 Possible solutions to the problems of clinical heterogenity of outcome measures and inadequate

reporting of results for randomized controlled trials (RCT's) on CTS are presented.Meta-analysis was

impeded for 2 reviews on conservative and operative management of CTS. To resolve the problem of

clinical heterogenity of the outcomes there should be consensus on the validated outrcomes that should

be used for CTS. Ros Evans, 2/23/2003

Slide 12

rbe11 Only one randomized controlled trial found. 22 female patients...11 treated with surgery, 11 with

splinting and of those 8 of 11 required operation, none of operated in first group were reoperated at

one year. Ros Evans, 2/23/2003


Evidence Based MedicineEvidence Based Medicinefor Treatment of CTSfor Treatment of CTS

RCT’s; Systematic ReviewsRCT’s; Systematic ReviewsSurgery most effective Surgery most effective txtx

Cochrane Database Cochrane Database SystSyst Rev 2002Rev 2002AssmusAssmus 2007; 2007; AAOS 2008AAOS 2008Uchiyama J Ortho Uchiyama J Ortho SciSci: 2010: 2010

OCTR preferredOCTR preferred–– Systematic review of RCT’sSystematic review of RCT’s–– GerritsonGerritson 20012001 ; Uchiyama 2010; Uchiyama 2010

Surgical Options for CTSSurgical Options for CTS

Cochrane Database Cochrane Database SSystyst ReviewReview–– 20142014–– VasiliadisVasiliadiset alet al

–– ECTR vs OCTRECTR vs OCTR–– Low level evidence/no significant differenceLow level evidence/no significant difference–– ECTR associated with less minor ECTR associated with less minor

complication, no difference majorcomplication, no difference major–– ECTR RTW 8 days soonerECTR RTW 8 days sooner

Guidelines Guidelines DxDx and and TxTx 20072007

Evidence Based Evidence Based ssupradisciplinaryupradisciplinaryguidelinesguidelines–– Important: Important: accurate history: clinical tests, accurate history: clinical tests,

EMG, NCSEMG, NCS–– Optional: Optional: radiography, MRI, USradiography, MRI, US

German SocietiesGerman Societies–– AssmusAssmus et al. 2007et al. 2007

AAOS 2007, 2008AAOS 2007, 2008EBM Guidelines for EvaluationEBM Guidelines for EvaluationApprovedApproved–– Patient historyPatient history

Physical examPhysical examSensory testSensory testMotor testMotor testProvocative testingProvocative testing

–– Discriminatory Discriminatory tests for tests for alternate alternate dxdx

–– EMG, NCSEMG, NCS

Not approvedNot approved––MRIMRI––CAT scanCAT scan––Pressure Pressure

sensorisensori--motor motor devices in wrist devices in wrist or handor hand

AAOS 2009AAOS 2009

Conservative optionsConservative options–– Recommend 9 guidelines for Recommend 9 guidelines for txtx CTSCTS–– Local steroid injectionLocal steroid injection–– Oral steroidsOral steroids–– UltrasoundUltrasound

CTR best option!CTR best option!––level I evidencelevel I evidence

Adherence AAOS UE CPGAdherence AAOS UE CPGMatzonMatzon et al. et al. OrthopaedicsOrthopaedics 20132013

Members of ASSH Members of ASSH do not universally do not universally adhere to the AAOS CLINICAL PRACTCE adhere to the AAOS CLINICAL PRACTCE GUIDELINES FOR CTSGUIDELINES FOR CTS–– 53% wait recommended time before operating53% wait recommended time before operating–– 32% always order 32% always order electodiagnosticelectodiagnostic testingtesting–– 30% splint PO30% splint PO

Followed: Followed: 98% nighttime splinting;98% nighttime splinting;85% corticosteroid injection85% corticosteroid injection


Practice patterns: 25 year perspectivePractice patterns: 25 year perspectiveLeinberryLeinberry et al JHS Am 2012et al JHS Am 2012

PreoperativelyPreoperatively–– Increase use splint, corticosteroid injectionsIncrease use splint, corticosteroid injections–– TxTx nonnon--operatively longeroperatively longer–– Narrowed surgical indicationsNarrowed surgical indications

PostPost--operativelyoperatively–– Use tourniquetsUse tourniquets,, corticosteroids lesscorticosteroids less–– Place deep sutures less oftenPlace deep sutures less often–– Decrease concomitant proceduresDecrease concomitant procedures–– Orthotic use and time decreasedOrthotic use and time decreased

CTS CTS DxDx and and TxTx::A Survey of members of the ASSHA Survey of members of the ASSH

Lane et al JHS AM 2014/ SeptLane et al JHS AM 2014/ Sept

AAOS 2007AAOS 2007--2009 developed 2009 developed CClinical linical Practice Guidelines/literature reviewPractice Guidelines/literature review–– Lack strong evidence; recommendations: Lack strong evidence; recommendations:

strong, weak, controversialstrong, weak, controversial

Survey ASSH membersSurvey ASSH members–– 72% operate with +72% operate with +hxhx/exam;+steroid injection/exam;+steroid injection–– 47% EDX not needed if above +47% EDX not needed if above +–– 79% order EDX based on CPG/79% order EDX based on CPG/–– 57% order EDX for medical57% order EDX for medical--legal implicationslegal implications

Why is this most common of all treated Why is this most common of all treated disorders in the upper extremity the disorders in the upper extremity the subject of so much controversy and subject of so much controversy and research?research?

Experience teaches that with a Experience teaches that with a knowledgeable therapist and skilled knowledgeable therapist and skilled surgeon is easy to diagnose, operate, and surgeon is easy to diagnose, operate, and bring to functional recovery.bring to functional recovery.

Do We Know What We Think Do We Know What We Think We Know?We Know?

EvaluationConservative ManagementSurgical ManagementPostoperative ManagementReturn to Work

Well ….what do Well ….what do we know about we know about carpal tunnel?carpal tunnel?

AnatomyAnatomyInelastic conduitInelastic conduit9 flexor tendons9 flexor tendonsMedian nerve, Median nerve, anterior portion anterior portion directly under TCLdirectly under TCLVarying Varying synoviumsynoviumFloor: carpal bones Floor: carpal bones Roof: TCL Roof: TCL PL inserts into the PL inserts into the TCLTCL

Carpal canal tendons excised


Tissue Fluid pressures in CTTissue Fluid pressures in CT2.5 mmHg in normal subjects2.5 mmHg in normal subjects

32 mmHg in patients with 32 mmHg in patients with dxdx of CTSof CTS

> 30mmHg applied over time induce nerve > 30mmHg applied over time induce nerve damagedamage

>50>50--60mmHg: complete block of sensory 60mmHg: complete block of sensory 1010--30 min before motor conduction30 min before motor conduction

Increase in Tissue Pressure:Increase in Tissue Pressure:CausesCauses

Decrease:Decrease:TransectionalTransectionalArea Area

--OROR--Increase: Increase: Volume Volume of Contentsof Contents

Carpal Tunnel with Tendons Excised

Increased Increased IntratunnelIntratunnel Pressures:Pressures:CausesCauses

Anatomic: CSA Anatomic: CSA vsvs ContentsContentsExternal ForcesExternal ForcesAltered Altered physiologyphysiologyMicrocirculationMicrocirculationAlterations in Alterations in Fluid BalanceFluid Balance

Median Nerve Fascicles

Increase in Critical Levels of Increase in Critical Levels of Tissue Pressure Tissue Pressure : : ResultsResults

Change in Change in intraneuralintraneuralmicrocirculationmicrocirculationAlterations in vascular Alterations in vascular permeabilitypermeabilityAlterations in nerve fiber Alterations in nerve fiber structurestructureNerve edemaNerve edemaRestricted tissue glidingRestricted tissue glidingDeterioration of nerve functionDeterioration of nerve function

Clinical Picture:Clinical Picture:Decreased sensibility, Decreased sensibility, > long finger,> long finger,pain, soft edema, flexor pain, soft edema, flexor inflammationinflammationmotor loss motor loss opponensopponens

Median nerve compression CT

Opponens atrophy

Elevated intraElevated intra--carpal pressurescarpal pressures

Anatomical compressionAnatomical compressionInflammatory , neuropathic conditionsInflammatory , neuropathic conditionsMechanical forcesMechanical forcesObesityObesity


Increase in CTP:Increase in CTP: Altered physiologyAltered physiology

NeuropathicNeuropathicDiabetes:Diabetes: no correlation incidence no correlation incidence Lee et al Lee et al IntInt J Rheum Dis 2014J Rheum Dis 2014alcoholismalcoholism

Inflammatory Inflammatory Rheumatoid arthritisRheumatoid arthritisGoutGoutNonNon--specific specific tenosynovitstenosynovits

Alterations fluid balanceAlterations fluid balancePregnancyPregnancyMenopauseMenopauseThyroid: Thyroid: modest correlation, meta modest correlation, meta analysis:analysis: ShiraShira: Muscle: Muscle--Nerve 2014Nerve 2014

Increase in CTPIncrease in CTPVariables Influenced by Variables Influenced by

Conservative ManagementConservative Management

PosturePostureWrist, finger, thumb, forearm positionWrist, finger, thumb, forearm position

Tendon load/muscle activityTendon load/muscle activityPalmaris Longus, FDP, FDS, FPL, Palmaris Longus, FDP, FDS, FPL, LumbricalsLumbricals

External forcesExternal forcesApplied external pressure, vibrationApplied external pressure, vibration

The effect of low and high velocity tendon The effect of low and high velocity tendon excursion on excursion on tthe mechanical properties of he mechanical properties of

human cadaver SSCThuman cadaver SSCTFiliusFilius et al et al J J OrthopOrthop Res Res 20142014

Fibrosis Fibrosis subsynovialsubsynovial connective tissue in connective tissue in CT most common histologic finding in CTCT most common histologic finding in CTLowLow--velocity tendon excursions can velocity tendon excursions can irreversibly damage SSCTirreversibly damage SSCTIncreasing velocity increases fibrosis Increasing velocity increases fibrosis SSCT, more likely to break than stretchSSCT, more likely to break than stretch

Risk factors: Obesity/SexRisk factors: Obesity/SexBody Mass IndexBody Mass Index––>29 2.5X greater>29 2.5X greater

than < 20 BMIthan < 20 BMI

––> >10 pounds> >10 poundsFemaleFemaleSquare WristsSquare Wrists

Aerobic activity and fitness should be stressed

MetaanalysisMetaanalysis for the Evaluation of Risk for the Evaluation of Risk Factors for CTS: Factors for CTS: General FactorsGeneral Factors

SpahnSpahn G et al 2012G et al 2012

CTS prevalence 10.6%CTS prevalence 10.6%Female patientsFemale patientsIncrease in age (40Increase in age (40--60 years)60 years)Overweight or obesityOverweight or obesityMore frequent dominant handMore frequent dominant hand“non“non--white race”white race”Diabetes/alcoholismDiabetes/alcoholism

MetaanalysisMetaanalysis for the evaluation of risk for the evaluation of risk factors for carpal tunnel syndrome Part II.factors for carpal tunnel syndrome Part II.

Occupational Risk Factors Occupational Risk Factors SpahnSpahn et al 2012et al 2012Incidence in working populationIncidence in working population–– 11% workers vs 8% general population11% workers vs 8% general population

Heterogeneity of study designs precludes Heterogeneity of study designs precludes prevalence with any job titleprevalence with any job titleRepetitionRepetitionChronic wrist flexionChronic wrist flexionPower gripPower gripChronic vibration loadChronic vibration load


Goal of TreatmentGoal of TreatmentDecrease CTPDecrease CTP

NonNon--SurgicalSurgical–– Activity modificationActivity modification–– LumbricalLumbrical block splintingblock splinting–– wrist control splintwrist control splint–– NSAIDS; InjectionNSAIDS; Injection

SurgicalSurgical–– Release TCL, OCTR or ECTRRelease TCL, OCTR or ECTR

Normal Intratunnel PressuresNormal Intratunnel Pressures

2.5 mmHg2.5 mmHg wrist wrist neutralneutral31 mmHg31 mmHg wrist wrist flexionflexion30 mmHg30 mmHg wrist wrist extensionextension>90 mmHg>90 mmHg in CTS in in CTS in wrist flex or wrist flex or extensionextension

Gelberman RH, et al J BJS: 1981Gelberman RH, et al J BJS: 1981

The Effect The Effect ofof

Wrist PostureWrist Posture

The Effect of Wrist PostureThe Effect of Wrist PostureBurke et al 1994; Weiss et al 1995Burke et al 1994; Weiss et al 1995

CT pressure lowest CT pressure lowest with wrist with wrist 22degreesdegrees flexion, flexion, 33degreesdegrees of ulnar of ulnar deviationdeviation2.5 mm Hg2.5 mm Hg wrist wrist neutralneutral3030--40 mm Hg40 mm Hg with with wrist in extensionwrist in extension

lowest

highest

The Effect of Wrist PostureThe Effect of Wrist PosturePL tension on FR with extensionPL tension on FR with extension

Shape of CT changes Shape of CT changes with wrist positionwith wrist position

The Effect of Wrist PostureThe Effect of Wrist Posturewith tendon loadwith tendon load

CTP higher with wrist extension than CTP higher with wrist extension than flexion regardless of loadflexion regardless of load (Keir et al. 1997, (Keir et al. 1997, 2000)2000)

Flexor tendons increase shear forces Flexor tendons increase shear forces on Median Nerve on Median Nerve (Keir, Wells, 1999)(Keir, Wells, 1999)

Extrinsic finger muscles have the Extrinsic finger muscles have the potential to move into the CT with wrist potential to move into the CT with wrist extension extension (Keir and Bach 2000)(Keir and Bach 2000)


Clinical ImplicationsClinical ImplicationsWrist PositionWrist Position

SplintingSplinting2 degrees wrist 2 degrees wrist flexionflexion3 degrees ulnar 3 degrees ulnar deviationdeviation

Work and exercise Work and exercise positionposition

NeutralNeutralAvoid wrist extension Avoid wrist extension combined with load combined with load to flexorsto flexors

?

The Effect of Wrist PostureThe Effect of Wrist PostureClinical ImplicationsClinical Implications

70 mm Hg in wrist extension70 mm Hg in wrist extension

Clinical ImplicationsClinical ImplicationsCombined Wrist and Finger PosturesCombined Wrist and Finger Postures

Flexor Muscle Flexor Muscle Incursion Incursion

Keir, Bach 2000Keir, Bach 2000

Incursion of flexor Incursion of flexor muscles into the muscles into the carpal tunnel with carpal tunnel with wrist extension is a wrist extension is a potential cause of potential cause of increased carpal increased carpal tunnel pressuretunnel pressure

The use of flexor The use of flexor muscles should be muscles should be avoided when the avoided when the wrist and fingers are wrist and fingers are extendedextended

RBE17

The Effect The Effect ofof

Finger PostureFinger Posture

The Effect of Finger PostureThe Effect of Finger PostureThe Effect of Finger PostureThe Effect of Finger Posture

Decreasing Carpal Tunnel PressuresDecreasing Carpal Tunnel PressuresLumbrical Block SplintingLumbrical Block Splinting

Wrist 0 degrees, MP 0-20 flex, IP’s free; decreases long tendon excursion, lumbrical entry into CT

RBE17 The most distal muscle fibres from the deep and superficial finger flexors were measured relative to the

pisiformbone in 8 cadaveric specimens The mean distances from the pisiform were 9.3 for the FDP, and

4.9mm for the FDS respectively. The excursions expected with wrist extension indicate that many

muscles have the potential to enter the carpal tunnel, especially those within 5 mm of the pisiform

bone.Roslyn Evans, 3/1/2003


The Effect of Finger PostureThe Effect of Finger Posture

Four lumbricals Four lumbricals originate off FDP originate off FDP tendons tendons Rest distal to CT Rest distal to CT with digits in with digits in extensionextensionRest within CT Rest within CT with fingers with fingers actively flexedactively flexed

The Effect of Finger PostureThe Effect of Finger PostureLumbrical Incursion Lumbrical Incursion Cobb et al 1994Cobb et al 1994

Finger extension:Finger extension:7.8 mm distal CT7.8 mm distal CT

50% finger flexion50% finger flexion14 mm into CT14 mm into CT75% finger flexion75% finger flexion25.5 mm into CT25.5 mm into CT100% finger flexion:100% finger flexion:30 mm into CT30 mm into CT

The Effect of Finger PostureThe Effect of Finger PostureMRI of CT at Level of Hook of HamateMRI of CT at Level of Hook of Hamate

T

HCT

The Effect of Finger PostureThe Effect of Finger PostureCTP with Intact LumbricalsCTP with Intact Lumbricals

Finger PositionFinger Position Mean PressureMean Pressure

Digits extendedDigits extended 299 mm Hg299 mm Hg50% fist50% fist 313 mm Hg313 mm Hg75% fist75% fist 326 mm Hg326 mm Hg100% fist100% fist 361 mmHg361 mmHg

No pressure change any position with excised No pressure change any position with excised lumbricalslumbricals

Greatest change between 75 and 100% finger flexionGreatest change between 75 and 100% finger flexionCobb et al, JHS 1995Cobb et al, JHS 1995

The Effect of Finger PostureThe Effect of Finger Postureplotted with and without lumbricalsplotted with and without lumbricals

Cobb et al.

The Effect of Finger PostureThe Effect of Finger PostureFinger FlexionFinger Flexion

Alters fat compressionAlters fat compression

Flattens and displaces Flattens and displaces median nerve median nerve in the in the presence of lumbrical presence of lumbrical musclesmuscles

Pressure deep and Pressure deep and superficial tendonssuperficial tendons

Ham SJ et al. JHS 21A, 1996Ham SJ et al. JHS 21A, 1996


UltrasonographicUltrasonographic median nerve changes under median nerve changes under tendon gliding exercise in patients with CTS tendon gliding exercise in patients with CTS

and healthy controlsand healthy controls

HorngHorng YS et al; JHT YS et al; JHT 20142014

Median nerve Median nerve compresses in compresses in fist position in fist position in both patients with both patients with CTS and healthy CTS and healthy controlscontrols

73 with CTS73 with CTS53 healthy controls53 healthy controlsSignificant changes Significant changes in cross sectional in cross sectional area of median area of median nerve when moving nerve when moving from straight to from straight to hook and hook to hook and hook to fist positionfist position

Clinical Significance of StudiesClinical Significance of StudiesDecreasing CTP with Finger PositionDecreasing CTP with Finger Position

In some cases:In some cases: Limit Limit 50% finger flexion, MP’s 50% finger flexion, MP’s 0 to 20 degrees0 to 20 degrees

Well developed Well developed lumbricals; + Bergerlumbricals; + BergerFlexor synovitisFlexor synovitisTriggering digitsTriggering digits“Compulsive gripper”“Compulsive gripper”

MP’s 45 degreesMP’s 45 degreesKeir et al. 1998 Keir et al. 1998

Clinical Significance of StudiesClinical Significance of StudiesDecreasing CTP with Finger PositionDecreasing CTP with Finger Position

Alter work postures Alter work postures with repetitive with repetitive gripping and gripping and sustained intrinsic sustained intrinsic contractioncontractionStrengthen with Strengthen with isometric flexion at isometric flexion at 50% rather than 50% rather than repetitive flexion into repetitive flexion into DPCDPC

The Effect of The Effect of Combined Combined

Finger and Wrist Finger and Wrist Posture with Posture with

LoadLoad

Combined Effect of Posture and LoadCombined Effect of Posture and Load

Muscle load elevates CTP above critical Muscle load elevates CTP above critical pressures pressures (defined greatest to lowest)(defined greatest to lowest)

PL greatest in wrist extensionPL greatest in wrist extensionLoad to digital flexors with wrist Load to digital flexors with wrist flexionflexionFPL with wrist in ulnar deviationFPL with wrist in ulnar deviationForceful grip with wrist in ulnar Forceful grip with wrist in ulnar deviationdeviation

Keir PJ, et al. JHS 22A; 1997Keir PJ, et al. JHS 22A; 1997

Highest: PL tension on Flexor Retinaculum

2.5x< than withwrist neutral

Pressures 2x > with FPL load in UD

Forceful grip in wrist UD


Pressure Changes During Pressure Changes During Activity in Normal HandsActivity in Normal HandsNormal CT Pressure 32Normal CT Pressure 32--44 mmHg44 mmHg

Power fist/ hold small object: +223 mm HgHgWrist extension:Wrist extension: +77mm Hg+77mm HgWrist flexion:Wrist flexion: +56 mm Hg+56 mm HgHold object 10.5 cm:Hold object 10.5 cm: + 46 mm Hg+ 46 mm HgIsometric finger flexion:Isometric finger flexion: + 41 mm Hg+ 41 mm Hg

Seradge et al 1995 Seradge et al 1995

The Effect of Finger Tip MotionsThe Effect of Finger Tip Motions

Tendon force in the CT are not Tendon force in the CT are not proportional to finger tip force during proportional to finger tip force during rapid tapping as with key strokingrapid tapping as with key strokingTendon tension continues to increase Tendon tension continues to increase throughout keystroke impactthroughout keystroke impactForces are cumulative and remain Forces are cumulative and remain elevated longer than the keystroke elevated longer than the keystroke forceforce

Dennerline et al. 1999Dennerline et al. 1999

The Effect of The Effect of Thumb Thumb PosturePosture

The Effect of Thumb PostureThe Effect of Thumb Posture

The effect of thumb CMC joint inflammation, The effect of thumb CMC joint inflammation, the pull of the opponens on the flexor the pull of the opponens on the flexor retinaculum and sustained intrinsic retinaculum and sustained intrinsic contraction can increasecontraction can increase CT pressureCT pressure

Lumbrical Pinch TestLumbrical Pinch Test

Firmly pinch paper between Firmly pinch paper between thumb and distal phalanges thumb and distal phalanges of Index and Long, MP’s 90, of Index and Long, MP’s 90, wrist neutralwrist neutralNumbness Median Nerve 60 Numbness Median Nerve 60 seconds, cramping mid palmseconds, cramping mid palmCorrelates with Median nerve Correlates with Median nerve & lumbrical indentation into & lumbrical indentation into distal CTdistal CT


Clinical SignificanceClinical SignificanceEvaluate and treat Evaluate and treat CMC joint CMC joint inflammationinflammationMinimize pinch Minimize pinch and grip activitiesand grip activitiesAvoid posture that Avoid posture that combines UD and combines UD and oppositionoppositionIncrease grip size Increase grip size toolstools

The Effect of The Effect of Forearm Forearm PosturePosture

The Effect of Combined Forearm Position The Effect of Combined Forearm Position and MP Angles in Normal Subjectsand MP Angles in Normal Subjects

Position Pronation SupinationPosition Pronation Supination

MP 0 16.6mmHgMP 0 16.6mmHg 53.9 mmHg53.9 mmHg

MP 45 MP 45 11.6 mmHg11.6 mmHg 33.7 mmHg33.7 mmHg

MP 90 19.4 mmHgMP 90 19.4 mmHg 55.2 mmHg55.2 mmHg

Rempel D, et al. JHS 1998Rempel D, et al. JHS 1998

53.9mmHg

16.6mmHg

The effect of Forearm PostureThe effect of Forearm PostureClinical ImplicationsClinical Implications

The Effect of The Effect of External External PressurePressure

The Effect of External ForceThe Effect of External ForceCobb TK, An KN, Cooney WP. JHS 20A, 1995Cobb TK, An KN, Cooney WP. JHS 20A, 1995

External force on the External force on the palm increases carpal palm increases carpal tunnel pressure; the tunnel pressure; the magnitude of magnitude of pressure change is pressure change is dependent on dependent on locationlocation1 kg external force in 1 kg external force in cadaver specimencadaver specimen

Highest overHook of hamateRBE13

RBE13 Flexor retinaculm 103 mmHgRoslyn Evans, 2/16/2003


Clinical ImplicationsClinical ImplicationsTherapy Induced ProblemsTherapy Induced Problems

Pitfalls of Generic TherapyPitfalls of Generic Therapy

Inability to diagnose Inability to diagnose associated problemsassociated problemsInappropriate splint geometryInappropriate splint geometryApplication of external Application of external pressurespressuresExercise regimens that Exercise regimens that increase intraincrease intra--tunnel tunnel pressurespressures

Early dx is key

Kaplan 1990

Clinical EvaluationClinical EvaluationResponsibility shifts dependent Responsibility shifts dependent

on referral sourceon referral source

Clinical ExaminationClinical Examination

HistoryHistorySymptomsSymptomsClinical exam upper Clinical exam upper quadrantquadrantCT clinical screeningCT clinical screeningPhysical provocative Physical provocative testingtestingDiagnostic testingDiagnostic testing

“I have been coached and I know the symptoms”

Referring Referring DxDx Incorrect or Incorrect or Incomplete, often primary careIncomplete, often primary care

Thumb CMC or other carpal arthritisThumb CMC or other carpal arthritisDe’Quervains, other tendonitisDe’Quervains, other tendonitisTrigger fingersTrigger fingersEpicondylitisEpicondylitis

Double CrushDouble CrushCervicothoracic neuropathyCervicothoracic neuropathyMetabolic neuropathyMetabolic neuropathy

Gold standard??Gold standard??

ElectrodiagnosticElectrodiagnostic studies recommended studies recommended by multidisciplinary German Societies by multidisciplinary German Societies based on evidence based reviews 2007based on evidence based reviews 2007Recommended by AAOS Clinical Recommended by AAOS Clinical Guidelines 2008Guidelines 2008--9.9.2014…survey of ASSH members2014…survey of ASSH members–– 47% don’t order if 47% don’t order if hxhx and clinical and clinical evaleval ++–– 57% order for medical57% order for medical--legal reasonslegal reasons


Guidelines Guidelines DxDx and and TxTx 20072007

Evidence Based Evidence Based ssupradisciplinaryupradisciplinaryguidelinesguidelines–– Important: Important: accurate history: clinical tests, accurate history: clinical tests,

EMG, NCSEMG, NCS–– Optional: Optional: radiography, MRI, USradiography, MRI, US

German SocietiesGerman Societies–– AssmusAssmus et al. 2007et al. 2007

AAOS 2007, 2008AAOS 2007, 2008EBM Guidelines for EvaluationEBM Guidelines for EvaluationApprovedApproved–– Patient historyPatient history

Physical examPhysical examSensory testSensory testMotor testMotor testProvocative testingProvocative testing

–– Discriminatory Discriminatory tests for tests for alternate alternate dxdx

–– EMG, NCSEMG, NCS

Not approvedNot approved––MRIMRI––CAT scanCAT scan––Pressure Pressure

sensorisensori--motor motor devices in wrist devices in wrist or handor hand

Diagnostic Testing CTS…Diagnostic Testing CTS… for most pts with +for most pts with +hxhxand +PE, EDT are not clinically relevant; and +PE, EDT are not clinically relevant;

Graham B. 2008Graham B. 2008

Value of clinical exam:Value of clinical exam:–– RadovikRadoviket al 2014et al 2014

ElectrodiagnosticElectrodiagnostic…searching for …searching for gold standardgold standard

Jordan 2002,Chang 2002Jordan 2002,Chang 2002Resende Resende 20002000Rosenbaum 1999 Rosenbaum 1999

UltrasoundUltrasoundDuncan 1999Duncan 1999Lee 1999Lee 1999

Magnetic Resonance ImagingMagnetic Resonance ImagingZagnoliZagnoli 19991999Andre 1999Andre 1999Jacobson 1999Jacobson 1999KirindienstKirindienst 19981998

“I’ll do it my way”

Peter Amadio 2014Peter Amadio 2014

Brent Graham: Brent Graham: EMG does not add much EMG does not add much to dx of CTS other than to help in to dx of CTS other than to help in prediction of prognosisprediction of prognosis

Patients with abnormal EMG do better Patients with abnormal EMG do better following surgery than those who had following surgery than those who had normal EMG: AAOS guidelinesnormal EMG: AAOS guidelines

Electrodiagnosis of CTSElectrodiagnosis of CTS

Electrodiagnosis is Electrodiagnosis is notnot a useful a useful diagnostic test in patients with clinical diagnostic test in patients with clinical signs of CTSsigns of CTSIn cases of clear cut clinical CTS, In cases of clear cut clinical CTS, electrodiagnosis is not warrantedelectrodiagnosis is not warrantedas a diagnostic test or indicator of as a diagnostic test or indicator of surgical outcome.surgical outcome.Jordan et al 2001Jordan et al 2001

The Value of Diagnostic TestingThe Value of Diagnostic TestingIn Carpal Tunnel SyndromeIn Carpal Tunnel Syndrome

Szabo et al. J Hand Surg 24A 1999Szabo et al. J Hand Surg 24A 1999

“I believe everything he says” RE“I believe everything he says” RE

SensitivitySensitivity SpecificitySpecificityDurkan’s compression 89%Durkan’s compression 89% Hand diagram 76%Hand diagram 76%SW after Phalen’s 83%SW after Phalen’s 83% Tinel’s sign 71%Tinel’s sign 71%Hand Diagram 73%Hand Diagram 73%Night pain 96%Night pain 96%

Electrodiagnostic testing does not improve combo of 4 Electrodiagnostic testing does not improve combo of 4 clinical testsclinical tests


The Validity of Physical TestingThe Validity of Physical Testingfor CTSfor CTS

DxDx of CTS is clinical and not of CTS is clinical and not neurophysiologicalneurophysiological KitsisKitsis 20022002

Supports clinical testing over NCS, EMSSupports clinical testing over NCS, EMSSzabo 1999; Richter 1999Szabo 1999; Richter 1999

Sensitivity, specificity vary with comparison Sensitivity, specificity vary with comparison subjectssubjectsGerrGerr et al. J Hand et al. J Hand SurgSurg (Br) 1998(Br) 1998

MasseyMassey--WestroppWestropp: : A systematic Review of the Clinical A systematic Review of the Clinical Diagnostic Tests for CTS. JHS 25A, 2000Diagnostic Tests for CTS. JHS 25A, 2000 ..

Clinical Diagnostic TestsClinical Diagnostic Tests

Tinel/PercussionTinel/PercussionVibrometry, 256 cps tuning forkVibrometry, 256 cps tuning forkStatic 2Static 2--point discriminationpoint discriminationPhalen/wrist flexionPhalen/wrist flexionDurkan/carpal compressionDurkan/carpal compressionLumbrical Incursion/BergerLumbrical Incursion/BergerReverse PhalenReverse PhalenSemmesSemmes--Weinstein monofilamentsWeinstein monofilaments

Screen for Proximal CompressionScreen for Proximal Compression

Accessory head of FPL Accessory head of FPL Fibrous bridge between heads of FDSFibrous bridge between heads of FDSBetween humeral and Between humeral and ulnarulnar heads of heads of pronatorpronator teresteresBeneatheBeneathe lacertuslacertus fibrosis; Struthers fibrosis; Struthers ligament; ligament; bicipitalbicipital aponeurosisaponeurosisThoracic outletThoracic outletC6C6--8 8 radiculopathyradiculopathy–– Pratt: J Hand Pratt: J Hand TherTher 2005; 2005; BilecenogluBilecenoglu et al, 2005et al, 2005

Clinical Diagnosis CTSClinical Diagnosis CTSSemmes Weinstein MonofilamentsSemmes Weinstein Monofilaments

Conflicting SupportConflicting SupportLight touch/deep Light touch/deep pressure pressure thresholdsthresholdsSupports use of Supports use of SW SW BellBell--Krotoski 1995Krotoski 1995

Liberal SW kit in Liberal SW kit in confirmed CTS, no confirmed CTS, no utility in diagnosis.utility in diagnosis.Pagel et al 2002Pagel et al 2002

Defines issues with PCBMN, CDN, DN

Clinical Diagnostic Tests CTSClinical Diagnostic Tests CTSLumbrical Provocation TestLumbrical Provocation Test

Hold hand in fist for 1 minute Hold hand in fist for 1 minute to evaluate changes in to evaluate changes in paresthesiaparesthesiaLPT has limited use in LPT has limited use in predicting CTS compared predicting CTS compared with electrodiagnosis and with electrodiagnosis and hand diagram.hand diagram.Karl AI, et al. Arch Phys Med Karl AI, et al. Arch Phys Med Rehabil 2001 Rehabil 2001 (blinded (blinded comparison of 3 diagnostic comparison of 3 diagnostic tests)tests) Berger Test

Carpal Compression Test (CCT)Carpal Compression Test (CCT)

�� Direct pressure on carpal Direct pressure on carpal tunnel and underlying tunnel and underlying median nerve. Highly median nerve. Highly sensitive (87%)and specific sensitive (87%)and specific 90% in diagnosis of CTS 90% in diagnosis of CTS when done with thumb when done with thumb pressure. pressure. Durkan 1991Durkan 1991

Marginal Marginal utility when utility when compared to compared to gold standard gold standard neurophysiolneurophysiologic testing.ogic testing.Kaul MP et al Kaul MP et al Muscle Nerve Muscle Nerve 2001 20012001 2001Not sensitive or Not sensitive or specific for dx specific for dx CTSCTS. Wainner et . Wainner et al 2000al 2000


Clinical Diagnosis CTSClinical Diagnosis CTSHand Elevation TestHand Elevation Test Ahn DS,2001Ahn DS,2001

Hand elevation can reproduce the Hand elevation can reproduce the symptoms of CTSsymptoms of CTSProspective study in 200 hands diagnosed Prospective study in 200 hands diagnosed with CTS, and control 200 handswith CTS, and control 200 handsUseful provocative testUseful provocative testHand ElevationHand Elevation Phalen’sPhalen’s Tinel’sTinel’s–– Sensitivity:Sensitivity: 75.5%75.5% 67.5% 67.5%67.5% 67.5%–– Specificity: Specificity: 98.5%98.5% 91.0% 90.0%91.0% 90.0%

Clinical Evaluation TestsClinical Evaluation TestsCarpal Tunnel SyndromeCarpal Tunnel Syndrome

Subjective swelling: a new sign for Subjective swelling: a new sign for carpal tunnel syndromecarpal tunnel syndrome

Burke et al. Am J Phys Med Rehab 1999Burke et al. Am J Phys Med Rehab 1999

A new provocative test for CTS: A new provocative test for CTS: Assessment of wrist flexion and nerve Assessment of wrist flexion and nerve compression.compression.

Tetro et al. 1998Tetro et al. 1998

My ApproachMy Approach …… quick screenquick screen

Subjective complaintsSubjective complaintsSemmes Weinstein neutral and after Semmes Weinstein neutral and after Phalen’sPhalen’sTinel’s (percussion)Tinel’s (percussion)Berger (lumbrical incursion)Berger (lumbrical incursion)Durkan’s (external pressure)Durkan’s (external pressure)Soft edema, inflammationSoft edema, inflammationProvocative tests for proximal Provocative tests for proximal compression (forearm, cervical)compression (forearm, cervical)

I will Recommend EMG, NCS,I will Recommend EMG, NCS,Surgical consult ….Surgical consult ….

Nocturnal painNocturnal painDaytime Daytime paresthesiaparesthesiaIncrease Increase sxsx with sustained pinch or gripwith sustained pinch or grip+ provocative tests+ provocative tests–– Phalen’sPhalen’s, Berger, , Berger, Tinel’sTinel’s, , Durkan’sDurkan’s. Pinch . Pinch

Semmes Weinstein > 3.61 Long digitSemmes Weinstein > 3.61 Long digitAtrophy Atrophy opponensopponens

Conservative ManagementConservative Management

Little is known about the Little is known about the efficacy of most efficacy of most conservative treatment conservative treatment optionsoptions

(Gerritsen AA, 2002, meta(Gerritsen AA, 2002, meta--analysis)analysis)

MetaMeta--analysisanalysisConservative Treatment CTSConservative Treatment CTS

Gerritsen AA et al. J Neurol 2002Gerritsen AA et al. J Neurol 2002Short term relief:Short term relief:

Diuretics, pyridoxine, nonDiuretics, pyridoxine, non--steroidal antisteroidal anti--inflammatories, yoga, laserinflammatories, yoga, laser--acupuncture ineffective acupuncture ineffective (conflicting evidence)(conflicting evidence)

Efficacy of ultrasound and oral steroids Efficacy of ultrasound and oral steroids (conflicting evidence)(conflicting evidence)

Steriod injection effective Steriod injection effective (limited(limitedevidence).evidence).

Long term relief:Long term relief:Efficacy of ultrasound Efficacy of ultrasound (limited evidence)(limited evidence)Splinting is less effective than surgerySplinting is less effective than surgery


Surgical versus NonSurgical versus Non--Surgical treatment Surgical treatment for CTS.for CTS.

Cochrane Database Cochrane Database SystSyst Rev Rev 2002 update 20082002 update 2008

Conclusion? Conclusion?

Surgery more effectiveSurgery more effective than than splintingsplintingFurther research to determine if Further research to determine if surgery better than steroid surgery better than steroid injection for people with mild injection for people with mild sxsx . . Verdugo, et al.Verdugo, et al.

rbe8

Conservative Management CTSConservative Management CTSnothing proven!nothing proven!

NSAIDSNSAIDSCorticosteroid Corticosteroid injection into injection into Carpal TunnelCarpal TunnelMetabolic control Metabolic control other problemsother problemsWeight lossWeight lossSplintingSplinting

Tendon and nerve Tendon and nerve glidingglidingIontophoresisIontophoresisUltrasoundUltrasoundVitaminsVitaminsChanges in Changes in posture and loadposture and loadAerobic exerciseAerobic exercise

AAOS 2009AAOS 2009

Conservative optionsConservative options–– Recommend 9 guidelines for Recommend 9 guidelines for txtx CTSCTS–– Local steroid injectionLocal steroid injection–– Oral steroidsOral steroids–– UltrasoundUltrasound

CTR best option!CTR best option!––level I evidencelevel I evidence

Surgical Options for CTSSurgical Options for CTS

Cochrane Database Cochrane Database SSystyst Review Review 20142014–– VasiliadisVasiliadiset alet al

–– ECTR vs OCTRECTR vs OCTR–– Low level evidence/no significant differenceLow level evidence/no significant difference–– ECTR associated with less minor ECTR associated with less minor

complication, no difference majorcomplication, no difference major–– ECTR RTW 8 days soonerECTR RTW 8 days sooner

Cochrane Database Cochrane Database SSystyst Review 2008Review 2008

Endoscopic Release CTSEndoscopic Release CTSVasiliadisVasiliadis et al et al

Cochrane Database Cochrane Database SystSyst Rev 2014Rev 2014

OCTR and ECTR equally effectiveOCTR and ECTR equally effectiveNo major difference in complicationsNo major difference in complicationsECTR earlier return to work (8 days)ECTR earlier return to work (8 days)ECTR slightly better grip strength, functionECTR slightly better grip strength, functionConclusions limitedConclusions limited–– “High “High risk of bias, statistical imprecision, risk of bias, statistical imprecision,

inconsistency in inconsistency in included studies”.included studies”.

Oral SteroidsOral SteroidsNSAIDSNSAIDS

Short term low dose oral steroids Short term low dose oral steroids are effective for CTSare effective for CTS..

RCTRCTChang MH et al 2002Chang MH et al 2002

rbe8 Only one randomized controlled trial found. 22 female patients...11 treated with surgery, 11 with

splinting and of those 8 of 11 required operation, none of operated in first group were reoperated at

one year. Ros Evans, 2/23/2003


Local Corticosteroid InjectionLocal Corticosteroid Injection

Greater improvement over placebo at Greater improvement over placebo at one monthone monthSymptom relief beyond one month not Symptom relief beyond one month not demonstrateddemonstratedNo improvement compared to antiNo improvement compared to anti--inflammatory inflammatory txtx and splinting or laser and splinting or laser txtxMarshall et al.Marshall et al. Cochrane Database Cochrane Database SystSystRev 2002; Rev 2002; update 2007update 2007

Local Steroid InjectionLocal Steroid Injection

Gelberman et al. Carpal tunnel syndrome. Gelberman et al. Carpal tunnel syndrome. Results of a prospective trial of steroid Results of a prospective trial of steroid injection and splinting. JBJS. 1980injection and splinting. JBJS. 1980Indexed by American Society for Surgery Indexed by American Society for Surgery of the Handof the Hand22% of 41 patients were symptom free at 22% of 41 patients were symptom free at mean 18 month followmean 18 month follow--up with steroid up with steroid injection and splinting.injection and splinting.High relapse rate with more severe sx; High relapse rate with more severe sx; sx greater than one yearsx greater than one year

The Efficacy of SplintingThe Efficacy of Splinting

Supports the wear of full time neutral wrist Supports the wear of full time neutral wrist splints over night time splinting alone. splints over night time splinting alone. RCTRCT. . Walker et al. 2000Walker et al. 2000

Splinting combined with NSAIDS and Splinting combined with NSAIDS and steroid injection into CTS resulted in steroid injection into CTS resulted in significant improvement.significant improvement. RCT.RCT. Celiker et Celiker et al. 2002al. 2002

OCTR better outcomes than wrist OCTR better outcomes than wrist splinting in patients with CTSsplinting in patients with CTS. . RCTRCTGerritsen et al 2002Gerritsen et al 2002

rbe3

rbe4


Splint that maintains the wrist in neutral Splint that maintains the wrist in neutral position while restraining the digits beyond position while restraining the digits beyond 75% of a full fist would be most effective in 75% of a full fist would be most effective in decreasing carpal tunnel.decreasing carpal tunnel. ApfelApfel et al 2002et al 2002Splint effective in reducing symptoms and Splint effective in reducing symptoms and functional loss.functional loss. RCTRCT. . ManamenteManamente G. et al G. et al 20012001Support for Splinting, RCT.Support for Splinting, RCT. ManenteManente et al et al 20012001No Benefit: No Benefit: LuchettiLuchetti 19981998

Splinting for CTSSplinting for CTSPage et al: Page et al: Cochrane Database Cochrane Database SSystyst Rev 2012Rev 2012

Compare effectiveness of splinting for Compare effectiveness of splinting for CTS with no CTS with no txtx, placebo or another , placebo or another nonsurgical interventionnonsurgical intervention

Limited evidence to support in Limited evidence to support in short termshort termSome benefit over other conservative Some benefit over other conservative txtxStudies evaluated not homogeneousStudies evaluated not homogeneous


rbe3 Ros Evans, 2/23/2003

rbe4 Walker study: Ros Evans, 2/23/2003


Sleeping PositionsSleeping Positionscervical, shoulder, elbow,cervical, shoulder, elbow,wrist, and in severe cases wrist, and in severe cases the digitsthe digits Ø

Neural Mobilization: limited evidenceNeural Mobilization: limited evidence

Efficacy not clearEfficacy not clear–– Systematic Review: Systematic Review:

Medina et al. 2008Medina et al. 2008

Duration, frequency, Duration, frequency, amplitude not confirmedamplitude not confirmedWalsh Walsh

Excessive strain with Excessive strain with functional activities functional activities may play a role in may play a role in peripheral nerve sx.peripheral nerve sx.

ExerciseExerciseNOPENOPE

Tendon gliding: 67% improvement with Tendon gliding: 67% improvement with sxsxseverity. Not RCT.severity. Not RCT. SeradgeSeradge, et al. 2002, et al. 2002Tendon and nerve gliding: No statistical Tendon and nerve gliding: No statistical improvement in full time splinting vs. full improvement in full time splinting vs. full time splinting with exercise. RCT.time splinting with exercise. RCT. AkalinAkalinet al. 2002et al. 2002Aerobic exercise: Aerobic exercise: sxsx relieved. Not RCT.relieved. Not RCT.Nathan et al. 2001Nathan et al. 2001““nerve excursion may improve axonal transport”nerve excursion may improve axonal transport”

Exercise, mobilization interventions for CTSExercise, mobilization interventions for CTSCochrane Database Cochrane Database SSystyst Rev Rev 20122012

Page et alPage et al

Compare ex and mobs to no Compare ex and mobs to no txtx, , placebo, other nonplacebo, other non--surgical surgical txtxStudies heterogeneousStudies heterogeneousLimited/low quality studiesLimited/low quality studiesNO EVIDENCE TO SUPPPORTNO EVIDENCE TO SUPPPORT

Tendon Gliding Through the CTTendon Gliding Through the CT Manual TherapyManual TherapyNo supportNo support

Carpal Bone MobilizationCarpal Bone MobilizationMedian Nerve MobilizationMedian Nerve MobilizationNo TreatmentNo TreatmentRCT, no difference in tx. RCT, no difference in tx. TalTal--Akabi A, Rushton A. Man Ther Akabi A, Rushton A. Man Ther 20002000


The Problem with Therapy ToysThe Problem with Therapy Toys

Effect of posture and Effect of posture and loadloadCT pressure < 200 CT pressure < 200 mmHg in full fistmmHg in full fist

What Are They Smoking?What Are They Smoking?This nerve is crushed!This nerve is crushed!

VitaminsVitaminsMagnetsMagnetsCarpal mobilizationCarpal mobilizationNerve glidingNerve glidingAcupuncture Acupuncture

AerobicsAerobicsAcupunctureAcupunctureLasersLasersTherapeutic touchTherapeutic touchUS/ IontoUS/ Ionto

IontophoresisIontophoresis

Administration of Administration of medications by medications by direct currentdirect currentSome reports of Some reports of ionto followed by ionto followed by pulsed ultrasoundpulsed ultrasoundControlled studies Controlled studies insufficient insufficient Fedorczyk Micklovitz Fedorczyk Micklovitz 19951995

UltrasoundUltrasoundMinimal SupportMinimal Support

Systematic review of 35 RCT’s for use Systematic review of 35 RCT’s for use of US in people with musculoskeletal of US in people with musculoskeletal injuries and soft tissue lesions.injuries and soft tissue lesions.10 RTC’s met criteria with acceptable 10 RTC’s met criteria with acceptable methodsmethodsResults of Results of 2 trials2 trials suggest that US is suggest that US is more effective in treating CTS and more effective in treating CTS and calcific tendonitis of the shoulder than calcific tendonitis of the shoulder than placebo US, but placebo US, but 8 trials8 trials suggest it is suggest it is not.not.

Robertson VJ, Baker KG. Phys Ther 2001Robertson VJ, Baker KG. Phys Ther 2001

Therapeutic Ultrasound for CTSTherapeutic Ultrasound for CTSCochrane Database Cochrane Database SSystyst Rev Rev

2013……2013…… Page et alPage et al

Poor quality evidence Poor quality evidence from limited data to from limited data to support US over support US over placebo or any other placebo or any other conservative regimenconservative regimen

Insufficient support of Insufficient support of one type US regimen one type US regimen over anotherover another

Acupuncture (Nope)Acupuncture (Nope)No evidence that acupuncture No evidence that acupuncture is an effective therapy for CTis an effective therapy for CT

Systematic review of RCT’sSystematic review of RCT’s–– SimSim et al. J Pain 2011et al. J Pain 2011

“She responded well to “She responded well to acupuncture which provided acupuncture which provided good symptomatic treatment good symptomatic treatment rather than cure and allowed her rather than cure and allowed her to continue her work as a school to continue her work as a school crossing lady whilst she awaited crossing lady whilst she awaited surgical release”surgical release”

Acupuncture Medicine Acupuncture Medicine 20022002


Low level laser plus TENSLow level laser plus TENS

Low level laser therapy Low level laser therapy (LLLT) plus TENS (LLLT) plus TENS applied to acupuncture applied to acupuncture points significantly points significantly reduced pain in reduced pain in 1111 CTS CTS subjects in VA setting subjects in VA setting who failed surgical or who failed surgical or conservative treatmentconservative treatmentRandomized Controlled Randomized Controlled TrialTrialNaeser MA. et al. Arch Naeser MA. et al. Arch Phys Med Rehabil 2002Phys Med Rehabil 2002

Would a flashlightWork as well?

Magnet TherapyMagnet Therapy

Use of a magnet for reducing pain to Use of a magnet for reducing pain to CTS was CTS was no more effectiveno more effective than the than the use of placebo. use of placebo. RCTRCT

Carter et al. J Fam Pract 2002.Carter et al. J Fam Pract 2002.

CTracCTrac“first and only clinically proven modality “first and only clinically proven modality

for treating CTS without surgery”for treating CTS without surgery”

Therapeutic Touch (TT)Therapeutic Touch (TT)Randomized Controlled TrialRandomized Controlled Trial

Sham TT vs. TTSham TT vs. TTTherapeutic touch Therapeutic touch no better than no better than placebo in placebo in influencing median influencing median motor nerve distal motor nerve distal latencies, pain latencies, pain scores, relaxation scores, relaxation scores.scores.Blankfield et al 2001

Everybody liked Everybody liked to be rubbed: to be rubbed: EvansEvans

Activity ModificationInadequate evidenceto implicate occupational Factors: Lozano 2008


National Institute for Occupational Safety National Institute for Occupational Safety and Health and Health recognizesrecognizes risk factorsrisk factors

ASSH no proven relationshipASSH no proven relationshipAustralian court system, RSI does not exist Australian court system, RSI does not exist

Ergonomic Positioning or equipment Ergonomic Positioning or equipment for treating CTSfor treating CTS

Cochrane Database Cochrane Database SSystyst Rev Rev 20122012O’Connor et alO’Connor et al

Ergonomic vs placebo keyboardsErgonomic vs placebo keyboardsInsufficient evidence Insufficient evidence from RCT’s to from RCT’s to determine if ergonomic positioning or determine if ergonomic positioning or equipment is beneficial or harmfulequipment is beneficial or harmfulNo association proven No association proven

Computers and CTSComputers and CTSMediouniMediouni Z et al, J Z et al, J OccupOccup Environ Med 2014Environ Med 2014

: :

Occupational ExposureOccupational ExposureMetaMeta----analysisanalysis

Prolonged exposure to nonProlonged exposure to non--neutral wrist neutral wrist increases risk for CTS 2xincreases risk for CTS 2x–– You et al: You et al: SafSaf Health Work Health Work 20142014

Occupational exposure to excess Occupational exposure to excess vibration, increased hand force and vibration, increased hand force and repetition increase risk of developing CTSrepetition increase risk of developing CTS–– BarcenillaBarcenilla et al et al PheumatologyPheumatology (Oxford) (Oxford) 20122012

TriggersFlexor tendonitis

CTP at 40 mmHG

CTP at 280 mmHG

Protective effect of Glove on CompressionProtective effect of Glove on CompressionNo SupportNo Support

Gel padded glove Gel padded glove does not have a does not have a protective effect on protective effect on CTS induced by CTS induced by compression in the compression in the workplace.workplace.Does provide Does provide significant comfortsignificant comfortRandomized Clinical Randomized Clinical TrialTrialDeltombe et al 2001Deltombe et al 2001

Conservative ManagementConservative ManagementMy ApproachMy Approach

Evaluate associate problems with high Evaluate associate problems with high index of suspicionindex of suspicionDecrease Carpal tunnel PressuresDecrease Carpal tunnel Pressures

SplintSplintActivity modificationActivity modificationEducationEducation

Modalities to decrease edemaModalities to decrease edemaMedications to reduce inflammationMedications to reduce inflammation


Conservative Management Conservative Management Splint the MP Joints 0Splint the MP Joints 0--40 Degrees40 Degrees

Positive lumbrical Positive lumbrical incursionincursionTriggering or Triggering or tenderness A1tenderness A1Flexor or Flexor or extensor extensor tenosynovitistenosynovitisThe inadvertant The inadvertant grippergripper

Postoperative ManagementPostoperative ManagementCarpal Tunnel ReleaseCarpal Tunnel Release

ComplicationsComplicationsOpen and Endoscopic ReleaseOpen and Endoscopic ReleaseWounds dehisce (early suture removal)Wounds dehisce (early suture removal)Infection/suture Infection/suture abcessabcess/ hematoma/ hematomaPainful scar (crossing the wrist?)Painful scar (crossing the wrist?)Pillar Pain….Pillar Pain….injury to PCBMNinjury to PCBMNIncomplete releaseIncomplete releaseTendon adhesionTendon adhesionTrigger fingers/ tendonitisTrigger fingers/ tendonitisCRPS; CRPS; neuromaneuroma in continuityin continuityPalmaris Palmaris LongusLongus inflammationinflammation

ASSH review/5 year periodASSH review/5 year periodPalmer, Palmer, TTolvonenolvonen JHS Am 1999JHS Am 1999

455 major complications from ECTR 455 major complications from ECTR txtx by by 708 respondents708 respondents–– 100 median, 88 ulnar, 77 digital nerve lacerations100 median, 88 ulnar, 77 digital nerve lacerations

–– 121 vessel, 69 tendon lacerations121 vessel, 69 tendon lacerations

283 major complications from OCTR 616 283 major complications from OCTR 616 respondentsrespondents–– 147 median, 29 ulnar,54 digital nerve lacerations147 median, 29 ulnar,54 digital nerve lacerations

–– 34 vessel, 19 tendon lacerations34 vessel, 19 tendon lacerations

An Outcome Protocol for CTS: An Outcome Protocol for CTS: A Comparison of A Comparison of Outcomes in Patients with and without MedicalOutcomes in Patients with and without MedicalComorbidities: Comorbidities: Cagle PJ, et al JHS Am Cagle PJ, et al JHS Am 20142014

950 OCTR950 OCTRSelf reported severity Self reported severity and functional scores and functional scores Boston Carpal Tunnel Boston Carpal Tunnel Outcomes QuestionnaireOutcomes Questionnaire2,6,12 weeks2,6,12 weeks

Significant Significant improvements in improvements in sxsxseverity and hand severity and hand functional after functional after OCTR can be OCTR can be expected expected regardless of age, regardless of age, coco--morbidity, WC morbidity, WC statusstatus

Problems to be Solved POProblems to be Solved PO

DoubleDouble--crush, compression other crush, compression other levelslevelsLoss tendon glide/ tendon adhesionLoss tendon glide/ tendon adhesionUndiagnosed, untreated trigger fingersUndiagnosed, untreated trigger fingersWeaknessWeaknessPain from basilar thumb arthritisPain from basilar thumb arthritisADL/ ergonomic issuesADL/ ergonomic issuesEmployer expectationsEmployer expectations


Value of therapy PO RehabValue of therapy PO Rehab

Limited, low evidence for PO interventionsLimited, low evidence for PO interventions–– Splint, wound care, exercise, cold or ice Splint, wound care, exercise, cold or ice

therapy, multimodal hand rehab, therapy, multimodal hand rehab, lazerlazer, , electrical modalities, scar desensitization and electrical modalities, scar desensitization and arnica.arnica.

–– Peters et al: Peters et al: Cochrane Database Review Cochrane Database Review 20132013

Faster return to work but no effect on Faster return to work but no effect on functional recoveryfunctional recovery. . ProvincialiProvinciali 20002000Cost for Cost for uncomplicateduncomplicated CTR unjustified CTR unjustified Pomerance 2007Pomerance 2007

Postoperative Therapy CTR Postoperative Therapy CTR Opinion Based (MINE)Opinion Based (MINE)

Wound care/ prevent tensionWound care/ prevent tensionEducation for edema control, exerciseEducation for edema control, exerciseWrist control splint ( MP’s/ thumb?)Wrist control splint ( MP’s/ thumb?)Address associated problemsAddress associated problems–– Double crush, triggers, OA CMCDouble crush, triggers, OA CMCScar managementScar managementCoordinate return to workCoordinate return to work

PO Splinting CTR DebatedPO Splinting CTR Debated

Finsen 1999Martins 2006Bury 1995Cebesoy 2007Huemer 2007

Does Does splintagesplintage help pain after CTR?help pain after CTR?

Randomized Clinical TrialRandomized Clinical Trial102 102 ptpt PO CTRPO CTR

No differences in pain levelsNo differences in pain levels–– Bhatia et al 2000Bhatia et al 2000

Little therapeutic benefit Little therapeutic benefit Trend away from splintingTrend away from splinting–– Henry et al, 2008Henry et al, 2008

PO Splinting 2PO Splinting 2--3 weeks 3 weeks author preferenceauthor preference

Control overuseControl overusePrevent inflammationPrevent inflammationPrevent wound site Prevent wound site tensiontensionPain relief, address Pain relief, address issues of CMC OAissues of CMC OANerve and tendon Nerve and tendon gliding addressed with gliding addressed with exercise exercise

Minimize Scar ComplicationsMinimize Scar Complications

Short incisionShort incisionMinimize tension Minimize tension with splint and with splint and exercise exercise techniquetechniqueSutures 17 daysSutures 17 daysMicroporeMicropore paper paper tapetape


Dehisced OCTR IncisionDehisced OCTR IncisionInfection.. early suture removal…Infection.. early suture removal…

Incisions that cross the wristIncisions that cross the wrist

Predictors of Return to Work.Predictors of Return to Work.Katz et al 1995Katz et al 1995

Correlation with failure RTWCorrelation with failure RTWPersistent symptomsPersistent symptomsScar tendernessScar tenderness

Work disability at 6 months is 29%Work disability at 6 months is 29%

Principal predictor is relief of sx and Principal predictor is relief of sx and scar tendernessscar tenderness

Nerve Density in the PalmNerve Density in the PalmCassidy et al 1995Cassidy et al 1995

OCTR + SynovectomyProblems with tendon glide

Wound tension, OCTR Palmaris longus nicked OCTR

Incision crossing the wristIncreased tensionCutaneous nerve density high

TenosynovectomyTenosynovectomy not indicatednot indicatedShrumShrum et al. 2002et al. 2002

A AAOS 2007A AAOS 2007

No problem

Oh, my

Scar ManagementScar ManagementPaper tapePaper tapeTopical silicone gel Topical silicone gel sheeting (SGS) sheeting (SGS) MassageMassageUltrasoundUltrasoundIontophoresisIontophoresisLidocaine Patch 5%Lidocaine Patch 5%DesensitizationDesensitization


Scar ManagementScar ManagementIontophoresisIontophoresis

Administration of Administration of medications by medications by direct currentdirect currentSome reports of Some reports of ionto followed by ionto followed by pulsed ultrasoundpulsed ultrasoundControlled studies Controlled studies insufficient insufficient Fedorczyk Micklovitz Fedorczyk Micklovitz 19951995

Scar ManagementScar ManagementUltrasoundUltrasound

Insufficient Insufficient supportsupportMichlovitz S. Michlovitz S. Rehab of the Hand Rehab of the Hand , 4th ed. 1990, 4th ed. 1990Nussbaum E. The Nussbaum E. The Influence of Influence of Ultrasound on Ultrasound on Healing Tissues. J Healing Tissues. J Hand Ther 1998Hand Ther 1998

Cold Therapy TreatmentCold Therapy Treatment

RCTRCTEfficacy ice therapy 72 patients CTREfficacy ice therapy 72 patients CTRPatients treated with Temperature Patients treated with Temperature Controlled Cooling Blanket (CCT) had Controlled Cooling Blanket (CCT) had greater reduction in pain, took fewer greater reduction in pain, took fewer narcotics, had less edema by day 3 narcotics, had less edema by day 3 PO than those treated with traditional PO than those treated with traditional ice therapy.ice therapy.Hochberg J. J Hand Ther 2001Hochberg J. J Hand Ther 2001

Tendon AdhesionTendon AdhesionPeriPeri--articular Stiffnessarticular Stiffness

Tendon Gliding Through the CTHunter and Wehbe


Sympathetic FlareSympathetic FlareSympathetic Maintained Pain SyndromeSympathetic Maintained Pain Syndrome

Contrast bathsContrast bathsStress loadingStress loadingDaily gentle Daily gentle therapytherapyNeurontinNeurontinStellate ganglion Stellate ganglion blocksblocksMissed diagnosisMissed diagnosis

Flare Reaction or NeuropraxiaFlare Reaction or Neuropraxia

Assess inciting lesionAssess inciting lesionAntiAnti--inflammatories, inflammatories, Medrol, neurontin, Medrol, neurontin, blocksblocksPatient may be Patient may be overworking, therapist overworking, therapist or splints may apply or splints may apply too much force.too much force.

Results of Rehabilitation Results of Rehabilitation FollowingFollowing

Carpal Tunnel ReleaseCarpal Tunnel ReleaseAccelerates return to workAccelerates return to workDoes not modify functional Does not modify functional recoveryrecoveryDoes not reduce symptom Does not reduce symptom occurrenceoccurrence

Provinciali et al 2000Provinciali et al 2000Keilani et al 2002Keilani et al 2002

Improved ResultsImproved ResultsObservational Observational

Atraumatic SurgeryAtraumatic SurgeryIncisions that don’t cross Incisions that don’t cross the wristthe wristEarly referral to therapyEarly referral to therapyAssessment psychoAssessment psycho--social/other agendasocial/other agendaTendon gliding Tendon gliding exercise/precautionsexercise/precautionsWrist control for OCTRWrist control for OCTR


Hands holding starsHands holding stars

epidemiology therapeutic management of carpal...

Documents