The Board of Directors of the American Academy of Orthopaedic Surgeons (AAOS) has just approved new guidelines regarding carpal tunnel syndrome (CTS). The Management of Carpal Tunnel Syndrome Evidence-Based Clinical Guidelines is endorsed by the American Society for Surgery of the Hand.
“One physical examination maneuver is not enough to definitely diagnose carpal tunnel syndrome, ” said Brent Graham, M.D., a Toronto orthopedic surgeon and chair of the AAOS Diagnosis and Treatment of Carpal Tunnel Syndrome Work Group, in the March 2, 2016 news release. “These guidelines should help doctors make an accurate diagnosis of CTS more easily and with fewer tests. This means treatment, that is based on evidence, can be started earlier and with a greater likelihood of success.”
As indicated in the news release, “Citing ‘moderate evidence, ’ the “Management of Carpal Tunnel Syndrome Evidence-Based Clinical Guidelines” does not recommend the routine use of MRI imaging for CTS diagnosis.”
“Moderate evidence supports that exercise and physical activity are associated with a decreased risk for developing CTS. Factors that may put patients at risk for CTS include obesity, and to a lesser extent: peri-menopausal status, wrist ratio/index, rheumatoid arthritis, psychosocial factors, gardening, distal upper extremity tendinopathies, hand activity, assembly line work, computer work, vibration, tendonitis, workplace forceful grip/exertion.”
“With strong evidence, the guidelines state that thenar atrophy, or diminished thumb muscle mass, is associated with CTS; however, a lack of thenar atrophy is not enough to rule out CTS. The guidelines also recommend not using single results from common tests and maneuvers (muscle testing, nerve stress tests, etc.), and/or medical history and demographic information (sex/gender, ethnicity, co-morbidities, BMI [body mass index], age, etc.) independently to affirm CTS diagnosis.”
Dr. Graham told OTW, “The Workgroup included clinicians from a wide spectrum of backgrounds—orthopedic surgery, plastic surgery, neurology, physiatry, medical imaging, allied health—and so there were substantial differences in viewpoints of how the diagnosis and treatment of CTS should be handled. However, the evidence we had was a great way to develop a consensus because, as widely divergent as our views might have been at the outset, good medical evidence from the literature was very unifying. And while the quality of evidence could always be better, it was much improved over what was available the last time a CTS guideline was developed.”
Asked how practice-changing the new guidelines may be, Dr. Graham commented to OTW, “I guess that remains to be seen. However, the previous guidelines were seen to be too weak to really provide much guidance to clinicians and I believe that both the evidence that we had to work with and the revised language used to articulate the recommendations should make them easier to adopt and to use. I expect that the recommendations relating to the diagnosis of CTS, especially with regard to the use of the validated clinical diagnostic tools and electrodiagnostic testing will have a very substantial impact. The guideline now states that either or both of these approaches—a clinical evaluation with a validated instrument and/or electrodiagnostic testing—can be used to diagnose CTS and this is clear departure from what has long been the status quo, that electrodiagnostic testing be done in a large proportion of cases.”
The full guidelines are available at orthoguidelines.org.
