Clinical practice guideline provides basis for practice-changing recommendations
The AAOS 2016 Management of Carpal Tunnel Syndrome (CTS) evidence-based clinical practice guideline (CPG) has been endorsed by the American Society for Surgery of the Hand (ASSH), the American College of Radiology, and the American College of Surgeons. From this guideline, members of the Evidence-Based Quality and Value Committee, with input from the CPG work group chairs, have developed four “impactful statements.” Impactful statements call attention to AAOS CPG recommendations that are supported by strong or moderate evidence and diverge most from current practice.
The impactful statements for CTS are as follows:
- Do not use a single physical examination test (such as the Phalen test or Tinel sign) to diagnose CTS, because used alone, such tests do not satisfactorily diagnose or rule out CTS.
- Body mass index and high hand/wrist repetition rate are associated with the increased risk of developing CTS.
- Magnet therapy is not indicated for the treatment of CTS.
- Surgical treatment of CTS should have a greater treatment benefit when compared to splinting, NSAIDs/therapy, and a single steroid injection.
Although these impactful statements may not seem controversial, many patients still use magnet therapy to treat CTS. As orthopaedic surgeons, we might scoff at the idea of magnet therapy, but among our patients are true believers in this treatment. These patients may use magnet therapy despite evidence demonstrating its ineffectiveness or they may be unaware of its lack of efficacy.
This scenario provides clinicians the opportunity to educate patients on management options that might have more evidence to support their use. Shared decision-making remains an important component to best patient care, and CPGs and impactful statements can be used as guides during these discussions.
On the other hand, many orthopaedic surgeons still use only one physical examination test (such as Durkan’s compression test with flexion) to diagnose CTS. Perhaps our patients will scoff at us, if they’ve read the impactful statements for CTS or the AAOS CPG on management of CTS, and have learned that one test is insufficient.
We know we should not rely on only one physical examination maneuver to diagnose CTS, but rather should use a combination of a thorough history and multiple elements of the physical examination. However, we work in busy clinic settings, with only a finite amount of time to arrive at a diagnosis and plan, and often we develop shortcuts. As the Roman poet Juvenal queried, “Quis custodiet ipsos custodes?”, or “Who will guard the guards themselves?”
As practitioners, we are provided with evidence to guide our care, but no one is looking over our shoulders to ensure compliance with CPGs (at least not yet). Certainly, quality metrics have been developed and reimbursement is being tied to outcomes, but in the small, day-to-day decision-making, are we using evidence-based practice?
As for the impactful statement that surgical treatment should have a greater treatment benefit over the long term when compared with splinting, NSAIDs, therapy, or a single steroid injection, we should recognize that this is not a push to operate. We all understand that conservative treatments might be better options for certain patients (such as those with mild symptoms or those who are too ill to undergo surgery). Knowing the evidence is important, but understand that there is still an “art” to medicine.
Addressing contributory factors
CTS is multifactorial, in that a genetic or anatomic predisposition, one or more potential comorbidities (obesity, hypothyroidism, diabetes, age), and possibly environmental or vocational risk factors may contribute to the development of disease. Based on the most recent CPG and impactful statement, high hand/wrist repetition appears to be a risk factor for CTS. Causation is difficult to establish in epidemiologic studies due to the high prevalence of carpal tunnel disease, the heterogenous nature of work environments, and the lack of a “gold standard” for diagnosis.
Multiple studies have supported a potential relationship between certain occupations and the development of CTS. These occupations include assembly line work, poultry processing, jobs that require forceful exertion or gripping, and those with vibration exposure (eg, using a jackhammer). What makes this statement provocative is that it seems to imply that standard typing, secretarial, desk, or data entry jobs may also be associated with CTS.
Although a few high-quality studies have demonstrated an association between CTS and computer work, a recent longitudinal prospective study of 1,500 workers failed to find an association between computer work and CTS. New evidence brings new insights, and the complex and poorly understood relationship between occupational factors and the development of CTS will continue to be refined and clarified. At a minimum, work and hobbies should be routinely discussed with patients who complain of carpal tunnel-type symptoms.
The CTS CPG starts with the following disclaimer: “This Clinical Practice Guideline is not intended to be a fixed protocol, as some patients may require more or less treatment of different means of diagnosis… Patient care and treatment should always be based on a clinician’s independent medical judgment, given the individual patient’s clinical circumstances.”
As orthopaedic surgeons, we certainly have to use our clinical judgment to individualize patient care when appropriate. We also want to ensure that when sufficiently strong evidence exists, we are using it as a foundation for our shared decision-making.
Julie Samora, MD, PhD, MPH, is a pediatric hand surgeon at Nationwide Children’s Hospital, Columbus, Ohio, and a member of the AAOS Committee on Evidence-Based Quality and Value, and the ASSH Evidence-based Practice Committee. She can be reached at email@example.com.
- American Academy of Orthopaedic Surgeons: CTS Impactful Statements http://www.orthoguidelines.org/cts-impactful-statements
- American Academy of Orthopaedic Surgeons. Management of Carpal Tunnel Syndrome Evidence-Based Clinical Practice Guideline. www.aaos.org/ctsguideline. Published February 29, 2016.
- Goldfarb CA. The clinical practice guideline on carpal tunnel syndrome and worker’s compensation. J Hand Surg 2016;41(6):723-725.
- Mediouni Z, Bodin J, Dale AM, et al. Carpal tunnel syndrome and computer exposure at work in two large complementary cohorts. BMJ Open. 2015;5(9):e008156.