Treatment of Carpal Tunnel Syndrome

AAOS Clinical Practice Guideline Summary Treatment of Carpal Tunnel Syndrome

Abstract Michael Warren Keith, MD In September 2008, the Board of Directors of the American Victoria Masear, MD Academy of Orthopaedic Surgeons approved a clinical practice guideline on the treatment of carpal tunnel syndrome. This Peter C. Amadio, MD guideline was subsequently endorsed by the American Association Michael Andary, MD, MS of Neurological Surgeons and the Congress of Neurological Richard W. Barth, MD Surgeons. The guideline makes nine specific recommendations: A course of nonsurgical treatment is an option in patients Brent Graham, MD diagnosed with carpal tunnel syndrome. Early surgery is an option Kevin Chung, MD, MS with clinical evidence of median nerve denervation or when the Kent Maupin, MD patient so elects. Another nonsurgical treatment or surgery is suggested when the William C. Watters III, MD current treatment fails to resolve symptoms within 2 to 7 weeks. Robert H. Haralson III, MD, Sufficient evidence is not available to provide specific treatment MBA recommendations for carpal tunnel syndrome associated with such Charles M. Turkelson, PhD conditions as diabetes mellitus and coexistent cervical Janet L. Wies, MPH radiculopathy. Local steroid injection or splinting is suggested before Richard McGowan, MLS considering surgery. Oral steroids or ultrasound are options. Carpal tunnel release is recommended as treatment. Heat therapy is not among the options to be used. Surgical treatment of carpal tunnel syndrome by complete division of the flexor retinaculum is recommended. Routine use of skin nerve preservation and epineurotomy is not suggested when carpal tunnel release is performed. Prescribing preoperative antibiotics for carpal tunnel surgery is an option. It is suggested that the wrist not be immobilized postoperatively after routine carpal tunnel surgery. It is suggested that instruments such as the Boston Carpal Tunnel Questionnaire and the Disabilities of the Arm, Shoulder, and Hand questionnaire be used to assess patient responses to carpal tunnel syndrome treatment for research.

arpal tunnel syndrome (CTS) is paralysis in some cases. Ca common disorder. In the CTS is also an important issue in the This clinical practice guideline was United States, its incidence is ap- workplace and, as the number of work- approved by the American Academy of Orthopaedic Surgeons. proximately 1 to 3 cases per 1,000 ers’ compensation cases filed increases, persons per year, and its prevalence the expense for lost productivity and J Am Acad Orthop Surg 2009;17:397- 405 is approximately 50 cases per 1,000 cost of treatment also increases. Ac- persons.1 Untreated or ill-treated cording to the National Institutes of Copyright 2009 by the American Academy of Orthopaedic Surgeons. CTS may worsen and progress to Health (NIH), the average lifetime cost permanent sensory loss and thenar of CTS, including medical bills and lost

June 2009, Vol 17, No 6 397 Treatment of Carpal Tunnel Syndrome time from work, is approximately damage characterized by irreversible lines are developed using current $30,000 for each injured worker.”2 microscopic damage to the nerve ul- standards of evidence-based practice. Hanrahan et al3 quote similar esti- trastructure. Such cases, understood The recommendations in these guide- mates by the National Council on to exist, without biopsy evidence, lines are based on systematic reviews Compensation Insurance that esti- have a worse prognosis for recovery of the available literature. The pur- mates the average CTS case costs with sustained numbness, tingling, pose of systematically performing a $29,000 in workers’ compensation paralysis, dyshidrotic changes of the review is to combat bias. Substantial benefits and medical costs. There skin, and pain. Diagnostic stratifica- documentation accompanies the re- were more than 3.8 million visits tion studies that define preoperative view and the guideline to ensure made to physicians in office-based criteria for this division between re- readers that the recommendations practices in 2003 because of CTS.4 versible and irreversible damage are, indeed, unbiased. Ideally, those Because of the importance of CTS, were not found. The clinical objec- who wish to perform an “intellectual the American Academy of Ortho- tive in the more damaged group has audit” of the guideline can examine paedic Surgeons (AAOS) has devel- lesser expectations and anticipated this documentation and indepen- oped a clinical practice guideline on outcomes by definition. The AAOS dently arrived at the same recom- it. The recommendations in this guideline on treatment of CTS rec- mendations. The appropriate docu- guideline assume that the patient has ommends that a diagnosis of CTS be mentation and details about the reversible mechanical compression of made on the basis of signs, symp- methods used to conduct the system- the median nerve based on the diag- toms, and electrodiagnostic tests, as atic review for the guideline on the nostic criteria set forth in the AAOS put forth by the AAOS Clinical treatment of CTS, as well as the full Clinical Guideline on Diagnosis of Guideline on Diagnosis of Carpal guideline, can be found at http:// Carpal Tunnel Syndrome.5 This does Tunnel Syndrome.5 www.aaos.org/Research/guidelines/ not include patients who have nerve The AAOS clinical practice guide- CTSTreatmentGuideline.pdf.

Dr. Keith is Professor, Orthopaedics and Biomedical Engineering, and Chief, Hand Surgery Service, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH. Dr. Masear is Orthopaedic Surgeon, Orthopaedic Specialists of Alabama, Birmingham, AL. Dr. Amadio is Orthopaedic Surgeon, Mayo Clinic, and Professor of Orthopedics, Mayo Clinic College of Medicine, Rochester, MN. Dr. Andary is Professor, Department of Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI. Dr. Barth is Chief, Section of Orthopaedic Surgery, and Chief, Section of Hand Surgery, Sibley Memorial Hospital, Washington, DC, and a member of the Board of Councilors, American Academy of Orthopaedic Surgeons, Rosemont, IL. Dr. Graham is Head, University Hand Program, and Assistant Professor, Department of Surgery, University of Toronto, Toronto, ON, Canada. Dr. Chung is Professor, Plastic Surgery, University of Michigan Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI. Dr. Maupin is Orthopaedic Surgeon, Michigan Hand Center, Grand Rapids, MI. Dr. Watters is Orthopaedic Surgeon, Bone and Joint Clinic of Houston, Houston, TX. Dr. Haralson is Executive Director of Medical Affairs, American Academy of Orthopaedic Surgeons. Dr. Turkelson is Director, Department of Research and Scientiﬁc Affairs, American Academy of Orthopaedic Surgeons. Ms. Wies is Manager, Clinical Practice Guidelines Unit, American Academy of Orthopaedic Surgeons. Mr. McGowan at the time this guideline was being developed was Medical Research Librarian, American Academy of Orthopaedic Surgeons.

Dr. Masear or a member of her immediate family serves as a board member, owner, officer, or committee member of the American Society for Surgery of the Hand and is affiliated with the publication The American Journal of Orthopedics. Dr. Amadio or a member of his immediate family serves as a board member, owner, officer, or committee member of the Orthopaedic Research Society, and Immanuel St. Joseph Hospital; is affiliated with the publication/publisher Journal of Orthopaedic Research and Saunders/Mosby- Elsevier; has received research or institutional support from the Musculoskeletal Transplant Foundation and the National Institutes of Health (NIAMS and NICHD); has stock or stock options held in Johnson & Johnson, Merck, and Procter & Gamble; and has received nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related funding (such as paid travel) from the Journal of Bone and Joint Surgery American. Dr. Andary or a member of his immediate family is a member of a speakers’ bureau or has made paid presentations on behalf of Pfizer and Allergan. Dr. Barth or a member of his immediate family has stock or stock options held in Amgen, Merck, and Pfizer. Dr. Graham or a member of his immediate family is affiliated with the publications Journal of Bone and Joint Surgery American and Journal of Hand Surgery American. Dr. Chung or a member of his immediate family has received research or institutional support from Stryker. Dr. Watters or a member of his immediate family serves as a board member, owner, officer, or committee member of Bone and Joint Decade USA, North American Spine Society, Intrinsic Therapeutics, Work Loss Data Institute, and American Board of Spine Surgery; is affiliated with the publication The Spine Journal; serves as a paid consultant to or is an employee of Blackstone Medical, Medtronic Sofamor Danek, Stryker, Intrinsic Therapeutics, and McKessen Health Care Solutions; and has stock or stock options held in Intrinsic Therapeutics. Dr. Haralson or a member of his immediate family serves as a paid consultant or is an employee of Medtronic and Medtronic Sofamor Danek, and has stock or stock options held in Orthofix. Ms. Wies or a member of her immediate family has stock or stock options held in Shering Plough. None of the following authors or a member of their immediate families has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Keith, Dr. Maupin, Dr. Turkelson, and Mr. McGowan.

398 Journal of the American Academy of Orthopaedic Surgeons Michael Warren Keith, MD, et al

Because a systematic review com- peer reviewed by reviewers from pro- surgical therapies and has discussed bats bias, the studies included in it fessional societies other than the these options with the physician, the are not chosen on the basis of AAOS, as well as by the Evidence- informed patient choice may be to go whether they were published by an Based Practice Committee and directly to surgery. expert. Similarly, the physician Work Guidelines Oversight Committee of The AAOS Research Department, Group members who prepared this the AAOS. After addressing peer re- with the collaboration of Physician guideline did not begin work on it by view, the draft guideline was sent for Work Group members, has been in- exchanging articles from their per- commentary to volunteers from the volved with the development of Clin- sonal files. Rather, articles were iden- Board of Councilors and the Board ical Practice Guidelines based upon tified using comprehensive searches of Specialty Societies, as well as to all the existing medical literature. These of several electronic databases and members of the Council on Re- guidelines, approximately four per were included in the guideline only search, Quality Assessment and year, will be regularly presented in when they met specific criteria that Technology and the AAOS Board of the Journal of the American Acad- were developed before work on the Directors. The final guideline was emy of Orthopaedic Surgeons. They guideline began. approved by the Evidence-Based each represent more than a year’s To further combat bias, the infor- Practice Committee; Guidelines and work by AAOS staff and volunteer mation extracted from published ar- Technology Oversight Committee; committee members of the Evidence- ticles did not include the conclusions the Council on Research, Quality As- Based Practice Committee and the of the articles’ authors (who, them- sessment, and Technology; and the Guidelines and Technology Over- selves, might be biased). Rather, the AAOS Board of Directors. Addition- sight Committee. By the introduction focus of the guideline and the sys- ally, the American Association of of new statistical methodology, tematic review upon which it is Neurological Surgeons and the Con- which is discussed in the data sum- based is on the data and how they gress of Neurological Surgeons sub- maries, we have moved ahead from were collected. Thus, information for sequently endorsed this guideline. previous efforts and have created the guideline was principally derived The final guideline on treatment of state-of-the-art recommendations. from information contained in an ar- CTS should not be construed as in- While we recognize that the litera- ticle’s Methods and Results sections. cluding all proper methods of care or ture is imperfect and thus any guide- A total of 332 articles were reviewed excluding methods of care reason- line must be supplemented by experi- for this guideline, 94 of which were ably directed to obtaining the same ence, principles of good care, and ultimately included. results. The ultimate judgment re- other sources of information for de- We did not search for, or include, garding any specific procedure or cision support, these guidelines rep- all available evidence. Wherever ap- treatment must be made in light of resent the best source of defense, propriate, we searched for and in- all circumstances presented by the based on the broadest literature cluded the best available evidence. patient and the needs and resources search possible. They also represent Hence, if level II evidence was avail- particular to the locality or institu- the definition of a quality ortho- able, we did not search for or include tion. Further, the patient must be an paedic practice from an evidence- level III evidence or lower unless active participant in treatment deci- based view. There will be measurable there was very little level II evidence sions. All treatment of CTS is based improvements in patient care quality and a great deal of level III evidence. on the assumption that final deci- standards as evidence emerges and is Our analyses focused on patient- sions are predicated on patient and summarized in future guidelines. oriented outcome measures. These physician mutual communication measures are defined in clinical re- about available treatment alterna- search as “outcomes that matter to tives and procedures applicable to Recommendations patients including reduced morbidity, the individual patient. These deci- reduced mortality, symptom im- sions include an evaluation of the pa- Each recommendation in this guide- provement, or improving patients’ tient’s current quality of life with line is accompanied by a grade. quality of life.”6 By critically focus- CTS. Patients will present with con- These grades communicate the de- ing on patient-oriented outcomes, siderable variability in acceptable gree of confidence that one can have the recommendations in this guide- choices, needs, and access to nonsur- that future research will not caused line are expected to improve overall gical alternatives. It is understood the recommendation to be modified. patient care in the treatment of CTS. that after the patient has been in- The grades were assigned using the The final draft of the guideline was formed of available alternative non- following system:

June 2009, Vol 17, No 6 399 Treatment of Carpal Tunnel Syndrome

A: Good evidence (level I studies guideline recommendation is, of ne- dence to make conclusions about these with consistent findings) for or cessity, based upon expert opinion. conditions and about CTS in the work- against recommending intervention. place. These potentially treatable med- B: Fair evidence (level II or III stud- Recommendation 2 ical conditions are common exclusion ies with consistent findings) for or We suggest another nonsurgical criteria from controlled trials; for this against recommending intervention. treatment or surgery when the cur- reason, it is difficult to make specific C: Poor-quality evidence (level IV rent treatment fails to resolve the recommendations about how to treat or V) for or against recommending symptoms within 2 to 7 weeks. such patients. intervention. Grade of Recommendation: B I: There is insufficient or conflicting Considerable evidence exists sug- Recommendation 4a evidence not allowing a recommenda- gesting that patients benefit from a Local steroid injection or splinting is tion for or against intervention. variety of nonsurgical treatment and suggested when treating patients The language of each recommen- surgical options for CTS. Although with CTS, before considering sur- dation is linked to its grade.7,8 the data did not report the minimum gery. Accordingly, we use the phrase “we time for effectiveness, an analysis of Grade of Recommendation: B recommend” for grade A recommen- the level I and II data reviewed for Local steroid injection and splint- dations, “we suggest” for grade B Recommendations 4a to 4c sug- ing are effective in treating CTS. recommendations, or “is an option” gested that all effective or potentially Splinting was effective at 2, 4, and for grade C recommendations. effective nonsurgical treatments (ie, 12 weeks in reducing symptoms and local steroid injections, splinting, improving functional status.10,11 No Recommendation 1 oral steroids, ultrasound) for CTS conclusion could be drawn at the A course of nonsurgical treatment is have a measurable effect on symp- 6-month time point because the stud- an option in patients diagnosed with toms within 2 to 7 weeks of the initi- ies were underpowered. CTS. Early surgery is an option ation of treatment. If a treatment is Steroid injections are also effective when there is clinical evidence of me- not effective in reducing symptoms for treating CTS. Several factors dian nerve denervation or the patient within that time frame, then consid- were shown to improve after corti- elects to proceed directly to surgical eration should be given to trying a sone injections: patient satisfaction 12 treatment. different one, assuming, of course, (2 weeks ), clinical improvement (4 13,14 15 15 Grade of Recommendation: C that the diagnosis of CTS is not in weeks, 8 weeks, 12 weeks ), doubt.5 symptoms (2 weeks,16 4 months,17 6 Data were extracted from 3 sys- Because this recommendation con- months18), function (3 months18), tematic reviews and 23 randomized siders a variety of nonsurgical treat- and pain (8 weeks16). controlled or controlled trials for evi- ments, the levels of evidence varied. Patients with more severe or pro- dence to support this recommenda- More level II evidence exists than longed CTS, however defined, may tion. This literature supports the ef- level I evidence; hence, the grade of not benefit from prolonged nonsur- fectiveness of nonsurgical treatment recommendation is based on consis- gical treatment. Trials of nonsurgical over placebo. No data were found tent level II evidence. treatment are suggested for the treat- that clearly identified when nonsur- ing physician and should show re- gical treatment should be considered mission, as described in the recom- the only option, nor were studies Recommendation 3 mendations above at the intervals found in which nonsurgical treat- We do not have sufficient evidence to indicated. ment was clearly shown to be com- provide specific treatment recom- pletely ineffective and therefore con- mendations for CTS found in associ- traindicated. ation with the following conditions: Recommendation 4b Studies of CTS often included de- diabetes mellitus, coexistent cervical Oral steroids or ultrasound are op- nervation as an indication for sur- radiculopathy, hypothyroidism, poly- tions when treating patients with gery and as a relative contraindica- neuropathy, pregnancy, and rheuma- CTS. tion for nonsurgical treatment, so toid arthritis, or for CTS in the Grade of Recommendation: C such cases were not studied system- workplace. Oral steroid treatment is effective atically. Consequently, it was not Grade of Recommendation: I in the treatment of CTS.10,19 How- possible to make a grade A or B rec- Despite an exhaustive review of the ever, the evidence suggests that local ommendation.9 Therefore, this literature, there was insufficient evi- steroid injection is more effective

400 Journal of the American Academy of Orthopaedic Surgeons Michael Warren Keith, MD, et al than oral steroids.14 Because the evi- tions and anticipated outcomes by questioned because the Graston in- dence supports other, more effective definition. strument was compared with an un- treatments, the Work Group down- proven alternative treatment. This graded the recommendation about Recommendation 4d was the only study looking at the oral steroids to grade C, “optional.” Heat therapy is not among the op- Graston instrument that met the in- Ultrasound was also shown to be tions that should be used to treat pa- clusion criteria. The grade of recom- effective in the treatment of CTS in tients with carpal tunnel syndrome. mendation was downgraded because 10,20 20 two studies. One of the studies, Grade of Recommendation: C the evidence was inconclusive. however, compared ultrasound with Heat therapy was less effective One systematic review10 examined laser treatment, an unproven modal- than placebo control in treating the comparison of vitamin B (pyri- ity, rather than with a control. CTS.24 The grade of recommenda- doxine) with placebo. The applica- Hence, there was only one level II tion is based on a single level II bility of the outcome measure was study supporting ultrasound. Based study; therefore, it was assigned questioned because it was not con- on this methodological flaw, the grade C, “optional.” sidered to be critical to determining Work Group chose to downgrade whether vitamin B was beneficial in this recommendation on ultrasound Recommendation 4e the treatment of CTS. The grade of to grade C, “optional.” The following treatments carry no recommendation was downgraded Recommendation 4c recommendation for or against their because the evidence was inconclu- use: activity modifications, acupunc- sive. We recommend carpal tunnel release ture, cognitive behavioral therapy, All of these modalities require fur- as treatment of CTS. cold laser, diuretics, exercise, electric ther investigation in appropriately Grade of Recommendation: A stimulation, fitness, Graston instru- designed studies to determine their Level I evidence demonstrates that ment, iontophoresis, laser, stretching, efficacy in the treatment of CTS. surgical release of the flexor retinac- massage therapy, magnet therapy, ulum is an extremely effective treat- manipulation, medications (includ- Recommendation 5 18,21-23 ment of patients with CTS. The ing anticonvulsants, antidepressants, We recommend surgical treatment of evaluation of surgical versus nonsur- and nonsteroidal anti-inflammatory CTS by complete division of the gical treatment of CTS demonstrated drugs), nutritional supplements, flexor retinaculum, regardless of the the effectiveness of the surgical treat- phonophoresis, smoking cessation, specific surgical technique. ment. systemic steroid injection, therapeu- Grade of Recommendation: A These recommendations assume that tic touch, vitamin B6 (pyridoxine), Complete division of the flexor ret- the patient has reversible mechanical weight reduction, yoga. inaculum is an effective method for compression of the median nerve based Grade of Recommendation: I treating CTS. Two systematic re- on the diagnostic criteria set forth in Despite an extensive review of the views26,27 and six randomized con- the AAOS Clinical Guideline on Diag- literature, there was insufficient evi- trolled trials28-33 examined compari- nosis of Carpal Tunnel Syndrome.5 dence to make conclusions about sons between open carpal tunnel This does not include patients who these modalities. For some treat- release, endoscopic carpal tunnel re- have nerve damage characterized by ments, there were simply no studies lease, or minimal incision carpal tun- irreversible microscopic damage to that met the inclusion criteria. For nel release. Using meta-analysis, we the nerve ultrastructure. Such cases, others, the studies had too little sta- compared several patient-oriented understood to exist, without biopsy tistical power to allow for meaning- outcome measures, (including symp- evidence, have a worse prognosis ful conclusions. Still other studies tom severity and functional status at for recovery, with sustained numb- were downgraded from a higher 52 weeks postoperatively, residual ness, tingling, paralysis, dyshidrotic grade of recommendation because pain at 12 weeks postoperatively, re- changes of the skin, and pain. Diag- their applicability was questioned. versible nerve damage, return to nostic stratification studies, which Consequently, we are unable to work, and wound-related complica- define preoperative criteria for this make recommendations for or tions) after open or endoscopic car- division between reversible and irre- against the use of these treatments. pal tunnel release. Endoscopic reversible damage, were not found. One study compared the Graston lease was favored in residual pain at The clinical objective in the more instrument with manual therapy.25 12 weeks postoperatively, return-to- damaged group has lesser expecta- The applicability of this study was work time, and wound-related com-

June 2009, Vol 17, No 6 401 Treatment of Carpal Tunnel Syndrome plications. Open release was favored palmar fascia. The Patient Evalua- that did report antibiotic use reported when reversible nerve damage was tion Measure (PEM) indicated a that 6.03% of patients developed a the outcome compared. No differ- slight advantage in favor of the stan- postoperative infection, even though all ence in the techniques was found in dard approach at the 3-month as- patients received antibiotics.38 symptom severity or functional sta- sessment. The PEM is a broader An examination of the various tri- tus at 52 weeks, in complications, evaluation of outcome than the Vi- als addressing CTS treatment did not and in infections. sual Analog Scale (VAS), suggesting provide insight on whether there are In addition, minimal incision re- that the advantages for a standard conditions or comorbidities that pre- lease was compared with open or en- carpal-tunnel-release incision refer to dispose patients to postsurgical in- doscopic release in level I studies. a domain other than pain. fection. Patients with diabetes melli- Compared with open release, mini- Epineurotomy was studied in a sys- tus, for example, were excluded from mal incision was favored in symptom tematic review and in a single level II the trials.9 A single level IV study39 severity, functional status, and scar study. In the systematic review the looked at rates of postoperative in- tenderness. Compared with endo- outcome was described as “overall fections in persons with and without scopic release, minimal incision was improvement” at 12 months;26 in the diabetes and found that the rate was favored when pain at 2 or 4 weeks single level II study, the outcomes similar in the two groups. was the outcome measure. were “nocturnal pain” and “pares- Infection rates from controlled trials The Work Group discussed the thesia” at 3 months following sur- of surgical treatments, included in Rec- studies and agreed that not all rele- gery.35 Both studies indicated a mild ommendations 5 and 6, and controlled vant outcomes were available, ad- effect favoring no epineurotomy. trials of postsurgical treatments, in- dressed, and/or analyzed by the evi- Tenosynovectomy and internal neu- cluded in Recommendation 8, were ex- dence comparing the various surgical rolysis were compared in a systematic tracted from studies. Additionally, other techniques. Nevertheless, level I and review,26 and the data were inconclu- study designs (eg, prospective cohorts, level II evidence clearly indicates the sive. Lengthening of the flexor reti- case series) describing surgical or post- effectiveness of complete division of naculum was studied in a level I surgical treatments (and passing exclu- the flexor retinaculum, regardless of study36 that used the Boston Carpal sion and inclusion criteria) were exam- surgical technique, as a treatment of Tunnel Questionnaire (BCTQ) as the ined for infection rates. CTS. outcome measure. The results were inconclusive because the study had Recommendation 8 Recommendation 6 too little power to allow for statisti- We suggest that the wrist not be im- cally meaningful comparison. A sin- We suggest that surgeons do not rou- mobilized postoperatively after rou- gle level I study37 examining ulnar tinely use the following procedures tine carpal tunnel surgery. bursa preservation, with VAS and when performing carpal tunnel re- Grade of Recommendation: B PEM as the outcome measures at 8 lease: skin nerve preservation (grade: We make no recommendation for weeks, also had too little power to B), epineurotomy (grade: C). or against the use of postoperative allow for meaningful statistical com- The following procedures carry no rehabilitation. parisons. The study was therefore in- recommendation for or against use: Grade of Recommendation: I conclusive. flexor retinaculum lengthening, in- The wrist should not be immobi- ternal neurolysis, tenosynovectomy, Recommendation 7 lized postoperatively after routine ulnar bursa preservation. carpal tunnel release. Several level II Grade of Recommendation: I The physician has the option of pre- studies suggest that postoperative A single level I study34 evaluated scribing preoperative antibiotics for splinting for longer than 2 weeks did the effect of preserving cutaneous carpal tunnel surgery. not offer any specific benefit in terms nerves in the path of a skin incision Grade of Recommendation: C of grip or lateral pinch strength, made in the customary location for a Our searches indicated that the cur- bowstringing, complication rates, carpal tunnel release. Preservation rent literature rarely reports whether subjective outcome, and patient was compared with a standard ap- preoperative antibiotic treatment was satisfaction.40-43 proach to making a skin incision, used in carpal tunnel release. Of 45 Clinicians may wish to provide which did not seek to preserve any studies analyzed for this recommenda- protection for the wrist in a working nerve branches encountered as the tion, 44 did not report whether preop- environment or for temporary pro- wound was deepened down to the erative antibiotics were used. The study tection. However, the evidence does

402 Journal of the American Academy of Orthopaedic Surgeons Michael Warren Keith, MD, et al

Table 1 Psychometric Properties of Instruments Internal Consistency Reproducibility Construct Validity Responsiveness Instrument (Reliability) (Reliability) (Validity) (SRM)*

BCTQ-Total >0.8 BCTQ-SSS X X X >0.8 BCTQ-FSS X X X >0.8 AIMS2 subscales* 0.06-1.72 DASH X X X 0.76 MHQ subscales* 0.5-1.1 PEM X X >0.8 VAS X 0.51 SF-36 subscales* 0-0.86 SF-12 subscales* 0.08-0.58

*SRM refers to standardized response mean AIMS2 = Arthritis Impact Measurement Scales 2; BCTQ = Boston Carpal Tunnel Questionnaire; DASH = Disabilities of the Arm, Shoulder and Hand; FSS = Functional Status Scale; MHQ = Michigan Hand Outcomes Questionnaire; PEM = Patient Evaluation Measure; SF-12 = Medical Outcomes Study 12-Item Short Form; SF-36 = Medical Outcomes Study 36-Item Short Form; SSS = Symptom Severity Scale; VAS = Visual Analog Scale

not provide objective criteria for work hardening, work simulation, or characteristics: reliability, validity, these situations. Clinicians should be routine strengthening. interpretability, and responsiveness. aware of the detrimental effects, in- Reliability was generally measured in cluding adhesion formation, stiff- Recommendation 9 these studies by assessing internal ness, and prevention of nerve and We suggest that physicians use one consistency and reproducibility. A tendon movement, which may com- or more of the following instruments summary of these key psychometric promise the carpal tunnel release re- when assessing patients’ responses to properties for these instruments ap- sults in achieving another objective, CTS treatment of research: pears in Table 1. such as early release to work. Responsive instruments detect • Boston Carpal Tunnel Question- For postoperative rehabilitation, small changes in a given condition. naire (disease-specific) one level II study examined super- This may be important where subtle • Disabilities of the Arm, Shoulder, vised hand therapy.44 The applicabil- differences could be clinically impor- and Hand (DASH) (region-specific: ity of the outcome measure (return tant. Responsive instruments are upper limb) to work) was questioned because it helpful in the planning of trials • Michigan Hand Outcomes Ques- was not considered to be critical in where the objective may be to dem- tionnaire (MHQ) (region-specific: determining whether supervised onstrate a small difference between, hand/wrist) hand therapy was beneficial to post- for example, treatments. operative rehabilitation. The grade • Patient Evaluation Measure (re- Generally speaking, generic measures, of recommendation was downgraded gion-specific: hand) like the SF-36, look at a broadly based because the evidence was inconclu- • Medical Outcomes Study 12- assessment of health and, as a result sive. Item Short Form (SF-12) or Medical may not be very responsive to changes There were no included studies Outcomes Study 36-Item Short Form in status related to a relatively minor that looked at work hardening and (SF-36) Health Survey (generic: condition such as CTS.9 the role of various modalities for physical health component for global Disease-specific instruments such postoperative carpal tunnel manage- health impact) as the BCTQ are most responsive.9 ment. The role of supervised therapy Grade of Recommendation: B The BCTQ shows excellent respon- after carpal tunnel release in the These instruments, whether they siveness for the measurement of dis- work-related population will need are aimed at diagnosis, evaluation of ease activity in CTS. Wherever possi- further evaluation to determine disease activity, or outcome, must be ble, the full instrument should be whether there is any advantage to judged on their key psychometric used because this gives the most

June 2009, Vol 17, No 6 403 Treatment of Carpal Tunnel Syndrome comprehensive evaluation of both biotics might be justified on the basis Rosemont, IL: American Academy of function and symptoms in CTS with- of comorbidities and cointerven- Orthopaedic Surgeons, May 2007. Available at: http://www.aaos.org/ out any loss of responsiveness. The tions. Research/guidelines/CTS_guideline.pdf. subscales of this instrument also We recognize that the issue of CTS Accessed March 10, 2009. 9 have satisfactory responsiveness but in the workplace is important. Stud- 6. Ebell MH, Siwek J, Weiss BD, et al: give a narrower view of disease ac- ies identified by the literature search Strength of recommendation taxonomy tivity. The BCTQ is fully validated in (SORT): A patient-centered approach to commonly analyze risk, prevalence, grading evidence in the medical litera- the treatment of CTS. and predictability of CTS in specific ture. J Am Board Fam Pract 2004;17:59- The region-specific DASH instru- job categories, but good evidence to 67. ment was moderate to highly respon- address the effectiveness of work- 7. Guyatt G, Gutterman D, Baumann MH, 9 et al: Grading strength of recommenda- sive and the MHQ was highly re- place modifications was not avail- 9 tions and quality of evidence in clinical sponsive in three of five subscales. able. Working patients, payors, and practice guidelines: Report from an The PEM, MHQ, and DASH are physicians clearly lack the evidence American College of Chest Physicians task force. Chest 2006;129:174-181. more broadly based region-specific base to determine “best options.” instruments that can be considered Physicians and patients must first de- 8. Steering Committee on Quality Improvement and Management: to be responsive for the evaluation of cide the desired outcome. Should the Classifying recommendations for clinical CTS. The responsiveness of the goal be permanent modification of practice guidelines. Pediatrics 2004;114: 874-877. DASH is slightly below the accept- activities for the worker, or to pro- able threshold but should be consid- ceed to surgery and return to normal 9. American Academy of Orthopaedic Surgeons: Treatment of Carpal Tunnel ered if the goal of the evaluation is a activities? Future research must rig- Syndrome: Evidence Report. Rosemont, focus on disability because it has orously address this subpopulation IL, American Academy of Orthopaedic Surgeons, 2008. Available at: http:// been evaluated in three key domains: to determine whether activity modifi- www.aaos.org/research/guidelines/ internal consistency, reproducibility, cation will result in positive out- CTSTreatmentEvidenceReport2.pdf and responsiveness. comes such as ultimately avoiding 10. O’Connor D, Marshall S, Massy- surgery. Westropp N: Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Conclusion Syst Rev 2003;1:CD003219. References 11. Premoselli S, Sioli P, Grossi A, Cerri C: Although we made every effort to Neutral wrist splinting in carpal tunnel find studies of the highest quality, syndrome: A 3- and 6-months clinical 1. Ashworth NL: Carpal tunnel syndrome. such evidence is not readily available and neurophysiologic follow-up evalua- Available at: http://emedicine.medscape. tion of night-only splint therapy. Eura at this time for CTS treatment. De- com/article/327330-overview. Last up- Medicophys 2006;42:121-126. dated November 30, 2006. Accessed velopment of this guideline has been April 21, 2009. 12. Armstrong T, Devor W, Borschel L, hindered by a relative lack of statisti- Contreras R: Intracarpal steroid injection 2. 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