Guest Author - Marji Hajic
On October 27, 2008, the American Academy of Orthopaedic Surgeons (AAOS) released guidelines for the treatment of carpal tunnel syndrome.
Carpal Tunnel Syndrome (CTS) is one of the most common disorders of the upper extremity affecting up to 10% of the population. According to the National Center for Health Statistics an estimated 3.1 million people sought help from physicians for the treatment of CTS (2005). “In June 2007, the Journal of the Academy of Orthopaedic Surgeons (JAAOS) reported about 500,000 CTS surgical procedures are performed each year. The same study also reported the economic impact due to CTS is estimated to exceed $2 billion annually.”
The CTS patient care guidelines were written to help physicians improve their care for those suffering from CTS. Nine treatment recommendations were made that include both operative and non-operative treatment options as well as alternative treatment techniques. The effectiveness of these treatments was evaluated based upon evidence reviewed from studies in medical literature.
Within the guidelines, non-operative treatment is initially recommended. Effective treatments may include splinting or bracing of the wrist, ultrasound, cortisone injections into the carpal tunnel or a course of oral steroids. If treatment does not produce relief within two to seven weeks, a different treatment or a carpal tunnel release surgery may be indicated.
Surprisingly, the following treatments were inconclusive for effectiveness in resolving carpal tunnel syndrome symptoms: activity modifications, acupuncture, cold laser, diuretics, exercise, electric stimulation, fitness, stretching, massage therapy, magnet therapy, manipulation, medications (including anticonvulsants, antidepressants and NSAIDs), nutritional supplements, smoking cessation, systemic steroid injection, therapeutic touch, vitamin B6 (pyridoxine), weight reduction, or yoga.
A word of caution is given by AAOS: there was not enough evidence to provide specific treatment recommendations for carpal tunnel syndrome when found in association with the following conditions: diabetes mellitus, coexistent cervical radiculopathy, hypothyroidism, polyneuropathy, pregnancy, rheumatoid arthritis, and carpal tunnel syndrome in the workplace.
As a therapist, I know that we sometimes take a shotgun approach to treatment and provide many of the treatments listed above. I applaud the AAOS for taking a systematic approach to assessing the effectiveness of the individual treatments that we use. However, I also know that people get better with therapy. I am currently working with one woman who was in tears because of the pain. She was not only struggling to work, but had given up sports and leisure activities, hobbies and crafts, and even housework. During the 4 weeks it took to get treatment authorized, her symptoms got worse. Almost immediately upon beginning therapy, her symptoms improved. Because of her level of pain, I used threw everything in my arsenal at her: heat, ultrasound, cold laser, electrical stimulation, stretches and exercises (gentle), manual therapy and massage, and education in positioning and ergonomics. Sure, I can’t pinpoint exactly which treatment was the most effective. Likely, it is a combination of everything. So, in spite of the guidelines, I’ll keep using the tools that I have. Every body responds differently. Every situation is unique. I only hope that these guidelines will be used as just that and not as a way for insurances to deny treatment.
AAOS Clinical Guidelines on the Treatment of Carpal Tunnel Syndrome - Summary
American Academy Of Orthopaedic Surgeons Clinical Practice Guideline On The Treatment Of Carpal Tunnel Syndrome – complete 84 page guideline document
Marji Hajic is an Occupational Therapist and a Certified Hand Therapist practicing at the Hand Therapy & Occupational Fitness Center in Santa Barbara, California. For more information on hand and upper extremity injuries, prevention and recovery, visit Hand Health Resources.