Resources and Strategies

The Evidence-Informed Chiropractor

 

Carpal Tunnel Syndrome (CTS) Recommendations

 

 

The Basics

 

  • 30%-70% of patients respond to non-surgical management of CTS (some of whom continue to work with some discomfort) compared to 90% of patients who have full resolution of CTS with surgical management
  • Median nerve involvement evident on electrodiagnostic testing (EDT), specifically nerve conduction velocity (NCV) studies, strongly predicts those patients who have the best response to surgery, however, diagnostically there is inconsistent evidence for correlation to signs and symptoms of CTS.
  • Confirmation of median nerve involvement via EDT should be sought if a trial of non-surgical management is unsuccessful at reducing or eliminating symptoms AND surgery is being considered
  • The primary non-surgical approach is the use of a neutral-wrist nocturnal splinting.
  • A multimodal approach coupled with splinting should be attempted including carpal bone mobilization, soft-tissue massage/nerve gliding, and exercise.
  • If conservative management is unsuccessful, prior to surgical referral, consider work hardening or a multidisciplinary occupational rehabilitation program.

Evaluation Objectives

 

Rule out other causes and confirm CTS through history and exam

Determine possible work-related risks, and the risk for prolonged disability

 

  • Refer patients with thenar atrophy
  • Determine if the patient’s pattern of involvement indicates median nerve involvement by evaluating whether the patient’s Katz’s diagram indicates median nerve involvement or not
  • Determine if there are other sites of entrapment other than the carpal tunnel (e.g. pronator teres muscle, ligament of Struthers, etc.) and whether myofascial involvement is a cause or simulator of median nerve involvement
  • Determine if there is a cause other than carpal tunnel syndrome including trauma (fracture, instability, dissociation), systemic diseases (e.g. diabetes, rheumatoid conditions), pregnancy, or tumor
  • Perform standard tests for thumb abduction and opposition strength, provocative tests, and sensory testing and combine with history and Katz findings to determine if CTS is present
  • Order or refer for EDT if the patient is non-responsive to 6-8 weeks of conservative management
  • Measure the patient’s functional involvement using a questionnaire such as the Carpal Tunnel Syndrome Questionnaire to establish baseline effects of condition and response to care.
  • Evaluate work environment and determine the level of risk for CTS and for disability related to CTS. Consider a site inspection to determine possible work and worksite modifications.

Management Directives

 

Attempt a trial of conservative care to determine effectiveness

Modify work environment if appropriate

Obtain EDT for patients who do not respond and are considering surgery

Refer for surgical consultation if conservative management is unsuccessful and EDT findings indicate median nerve involvement

 

  • Weeks 1-2: Attempt an initial trial of conservative care with the cornerstone being neutral-wrist nocturnal splinting and worn as needed during the day. Consider a multimodal approach that includes mobilization, myofascial treatment, stretching, pulsed ultrasound, and exercise. Implement work-restrictions and modifications based on patient history and site inspection
  • Weeks 3-6: If successful at reducing symptoms, continue with an attempt at weaning the patient off of splinting. If unsuccessful at reducing symptoms, consider a different combination of splinting with the above-suggested list of options.
  • Weeks 7-8: If successful at reducing symptoms, continue with an attempt at weaning the patient off of splinting. If unsuccessful, and surgery is being considered, order EDT to determine median nerve involvement. If involvement is found, refer for surgical consult. If not, consider a work-hardening program or a multi-disciplinary occupational rehabilitation program for 1-2 months.
  • Greater than 2 months: If work-hardening or multi-disciplinary rehabilitation is unsuccessful at reducing symptoms or the patient is unable to perform required work, refer for surgical consult
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