• Work Loss Data Institute. Carpal tunnel syndrome (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; 2008. 209 p. [288 references]

This is the current release of the guideline.

This guideline updates a previous version: Work Loss Data Institute. Carpal tunnel syndrome (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; 2007 Apr 24. 201 p.

The Official Disability Guidelines product line, including ODG Treatment in Workers Comp, is updated annually, as it has been since the first release in 1996.

Work-related carpal tunnel syndrome

Diagnosis
Evaluation
Management
Treatment

Family Practice
Internal Medicine
Neurology
Orthopedic Surgery

Advanced Practice Nurses
Health Care Providers
Health Plans
Nurses
Physician Assistants
Physicians

To offer evidence-based step-by-step decision protocols for the assessment and treatment of workers' compensation conditions

Workers with occupational carpal tunnel syndrome

The following interventions/procedures were considered and recommended as indicated in the original guideline document:

1. Aerobic exercise
2. Braces/splinting
3. Breaks (microbreaks)
4. Carpal tunnel release surgery (CTR) (for specific indications see original guideline document)
5. Cold packs
6. Comorbidities assessment (e.g., depression, diabetes, hypothyroidism, obesity, pregnancy)
7. Continuous cold therapy (CCT) in the postoperative setting
8. Corticosteroid injections
9. Diagnostic assessment of night pain symptoms, nocturnal paresthesias, weak thumb abduction strength, and hypalgesia
10. Diagnostic ultrasound in difficult cases
11. Diagnostic tests such as Durkan's compression test, Flick sign (shaking hand), Katz hand diagram, Semmes-Weinstein monofilament test
12. Differential diagnosis
13. Electrodiagnostic studies (EDS)
14. Electromyography (EMG) when diagnosis is difficult with nerve conduction studies
15. Endoscopic surgery
16. Hand and wrist exercises
17. Heat therapy after initial cold packs
18. Nerve conduction studies (NCS)
19. Nerve/tendon gliding exercises
20. Nonprescription medications (acetaminophen, non-steroidal anti-inflammatory drugs [NSAIDs]). NSAIDs are not recommended as first line therapy.
21. Physical therapy/occupational therapy (see original guideline document for specific indications)
22. Psychosocial management
23. Return to work
24. Severity definitions, useful for an accurate diagnosis
25. Static 2-point discrimination (>6 millimeters)
26. Thenar atrophy in diagnosis of severe cases
27. Work restrictions/modified duty
28. Yoga

The following interventions/procedures are under study and are not specifically recommended:

1. Arnica
2. Ergonomic interventions
3. Insulin
4. Iontophoresis/phonophoresis
5. Lidocaine patch
6. Ligament stretching device
7. Massage
8. Mobilization (carpal bone)
9. Mouse use
10. Oral corticosteroids
11. Polarized polychromatic light (Bioptron light)
12. Therapeutic ultrasound
13. Traumatic carpal tunnel syndrome (CTS)

The following interventions/procedures were considered, but are not currently recommended:

1. Acupuncture
2. Assessment of wrist pain
3. Astaxanthin
4. Biofeedback
5. Botulinum toxin
6. Closed fist sign
7. Current perception threshold (CPT) testing/neurometer
8. Diuretics
9. Evoked potential studies
10. Fluidotherapy
11. Gel-padded glove
12. Hospitalization
13. Hypnosis
14. Laser acupuncture
15. Low-level laser therapy (LLLT)
16. Magnets/magnet therapy
17. Magnetic resonance imaging (MRI) in the absence of ambiguous electrodiagnostic studies
18. Manipulation/chiropractic
19. Multiple extremity testing (unless CTS suspected in each limb)
20. NC-stat nerve conduction studies/NeuroMetrix (unless traditional electrodiagnostic testing is unavailable)
21. NSAIDs as first-line therapy
22. Phalen's test
23. Portable nerve conduction devices
24. Square wrist sign in diagnostic assessment
25. Surface EMG (SEMG)
26. Therapeutic touch
27. Tinel's sign in diagnostic assessment
28. Tourniquet test in diagnostic assessment
29. Transcutaneous electrical neurostimulation (TENS)
30. Vitamin B6 (pyridoxine) supplementation

• Sensitivity and specificity of diagnostic tests
• Effectiveness of treatments for relief of pain and symptoms

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

Work Loss Data Institute (WLDI) conducted a comprehensive medical literature review (now ongoing) with preference given to high quality systematic reviews, meta-analyses, and clinical trials published since 1993, plus existing nationally recognized treatment guidelines from the leading specialty societies. WLDI primarily searched MEDLINE and the Cochrane Library. In addition, WLDI also reviewed other relevant treatment guidelines, including those in the National Guideline Clearinghouse, as well as state guidelines and proprietary guidelines maintained in the WLDI guideline library. These guidelines were also used to suggest references or search terms that may otherwise have been missed. In addition, WLDI also searched other databases, including MD Consult, eMedicine, CINAHL, and conference proceedings in occupational health (i.e., American College of Occupational and Environmental Medicine [ACOEM]) and disability evaluation (i.e., American Academy of Disability Evaluating Physicians [AADEP], American Board of Independent Medical Examiners [ABIME]). Search terms and questions were diagnosis, treatment, symptom, sign, and/or body-part driven, generated based on new or previously indexed existing evidence, treatment parameters and experience.

In searching the medical literature, answers to the following questions were sought: (1) If the diagnostic criteria for a given condition have changed since 1993, what are the new diagnostic criteria? (2) What occupational exposures or activities are associated causally with the condition? (3) What are the most effective methods and approaches for the early identification and diagnosis of the condition? (4) What historical information, clinical examination findings or ancillary test results (such as laboratory or x-ray studies) are of value in determining whether a condition was caused by the patient's employment? (5) What are the most effective methods and approaches for treating the condition? (6) What are the specific indications, if any, for surgery as a means of treating the condition? (7) What are the relative benefits and harms of the various surgical and non-surgical interventions that may be used to treat the condition? (8) What is the relationship, if any, between a patient's age, gender, socioeconomic status and/or racial or ethnic grouping and specific treatment outcomes for the condition? (9) What instruments or techniques, if any, accurately assess functional limitations in an individual with the condition? (10) What is the natural history of the disorder? (11) Prior to treatment, what are the typical functional limitations for an individual with the condition? (12) Following treatment, what are the typical functional limitations for an individual with the condition? (13) Following treatment, what are the most cost-effective methods for preventing the recurrence of signs or symptoms of the condition, and how does this vary depending upon patient-specific matters such as underlying health problems?

Criteria for Selecting the Evidence

Preference was given to evidence that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reports a cohort study, whether prospective or retrospective, or (5) The article reports a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

More information about the selection of evidence is available in "Appendix. ODG Treatment in Workers' Comp. Methodology description using the AGREE instrument" (see "Availability of Companion Documents" field).

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Review of Published Meta-Analyses
Systematic Review

The Work Loss Data Institute (WLDI) reviewed each article that was relevant to answering the question at issue, with priority given to those that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reported a cohort study, whether prospective or retrospective, or (5) The article reported a case control series involving at least 10 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

Especially, when articles on a specific topic that met the above criteria were limited in number and quality, WLDI also reviewed other articles that did not meet the above criteria, but all evidence was ranked alphanumerically (see the Rating Scheme of the Strength of Evidence field) so that the quality of evidence could be clearly determined when making decisions about what to recommend in the Guidelines. Articles with a Ranking by Type of Evidence of Case Reports and Case Series were not used in the evidence base for the Guidelines. These articles were not included because of their low quality (i.e., they tend to be anecdotal descriptions of what happened with no attempt to control for variables that might affect outcome). Not all the evidence provided by WLDI was eventually listed in the bibliography of the published Guidelines. Only the higher quality references were listed. The criteria for inclusion was a final ranking of 1a to 4b (the original inclusion criteria suggested the methodology subgroup), or if the Ranking by Type of Evidence was 5 to 10, the quality ranking should be an "a."

Not stated

Not applicable

The guideline developers reviewed published cost analyses.

External Peer Review

Prior to publication, select organizations and individuals making up a cross-section of medical specialties and typical end-users externally reviewed the guideline.

Initial Diagnosis

• First visit: with Primary Care Physician MD/DO (100%)
• Determine severity: (see also Severity definitions in the Procedure Summary of the original guideline document)
  • Mild/moderate (Go to Initial Conservative Treatment):
    • Symptoms: pain/numbness in hand/wrist/forearm, below the elbow, with altered sensation often described as numbness or tingling that is primarily in thumb, index, and middle finger (Katz hand diagram and hypesthesia index finger compared to little finger), with nocturnal awakening, possible impaired dexterity, and often having to shake the hand for relief (the Flick sign has a sensitivity of 93% and specificity 96%)
    • Tests: Phalen's/Tinel's signs not always useful individually but when combined with the appropriate history have an increased sensitivity and specificity; also consider Semmes Weinstein monofilament test, compression testing which can be supplemented by doing Durkan's compression test. (See Table, "Sensitivity and Specificity of Diagnostic Tests for Carpal Tunnel Syndrome Measured Against Nerve Conduction Studies" in the original guideline document.)
    • Recommended: findings that best distinguish between patients with electrodiagnostic evidence of carpal tunnel syndrome (CTS) and patients without it are hypalgesia in the median nerve territory, classic or probable Katz hand diagram results, and weak thumb abduction strength (but weakness can be difficult to determine). See Table, "Sensitivity and Specificity of Diagnostic Tests for Carpal Tunnel Syndrome Measured Against Nerve Conduction Studies" in the original guideline document.
    • Muscle atrophy: mild weakness of thenar muscles (thumb abduction)
    • History/exam, comorbidities: diabetes, hypothyroidism, rheumatoid arthritis, obesity, hypertension, depression, inactivity, age, work activities, and hobbies

      Carpal tunnel syndrome seems to be primarily attributable to CTS-prone personal characteristics (e.g., obesity, diabetes, female, smoking), but symptoms can occur with physical activities at home and in the workplace. There is some evidence to conclude that CTS symptoms are associated with workplace activities, but current studies have not proven causal relationship. See "Work" in the Procedure Summary of the original guideline document.

    • Concurrent pregnancy: CTS likely to resolve on its own within 6 weeks after delivery
  • Severe (Go Directly to Electrodiagnostic Testing)
    • Muscle atrophy: severe weakness of thenar muscles (uncommon in workers' compensation cases)
    • Test: 2-point discrimination over 6 mm - helpful but semi-objective test
• Rule out diagnoses (See other treatment parameters for each of these):
  • Cervical radiculopathy (refer to the original guideline document for relevant International Classification of Diseases, Ninth Revision [ICD-9] codes for CTS and other diagnoses)
  • Tendonitis
  • Osteoarthritis
  • Thoracic outlet syndrome, brachial plexus disorders

Mild/Moderate -- Initial Conservative Treatment (70% of cases)

• Also first visit (day 1):
  • Prescribe modification of activity (home and work), breaks, stretching, night and possibly day splint, appropriate analgesia (i.e., acetaminophen) [Benchmark cost: $14], stay at work or return to work--modified duty if condition associated with job, possible ergonomic evaluation of job, patient education

• Second visit (day 7 to 14--about 2 weeks after first visit, but sooner if the patient is off work)
  • Document progress
  • If not significantly improved then may (approximately 50% of cases) prescribe occupational or physical therapy for home exercise training [Benchmark cost: $250]: Refer to Physical Therapist (50%) or Occupational Therapist (50%) for 3 visits.
• Third visit (day 20 to 30--about 1 month after first visit, but sooner if patient is off work)
  • Document progress.
  • Corticosteroid injection trial (high likelihood of relief, but may have recurrence of symptoms within several months--initial relief of symptoms can be a good indicator for success of surgery, can assist in confirmation of diagnosis) [Benchmark cost: $276]. Should be performed by musculoskeletally trained physician because of possible nerve injury. Recommend only one injection (no more than three if benefits continue.

• Fourth visit (day 40 to 50--about 6 weeks after first visit)
  • Refer for Electrodiagnostic Testing

Electrodiagnostic Testing (50% of cases)
[Benchmark cost: $370]

• All severe cases, plus mild/moderate cases after Initial Conservative Treatment above; See "Protocols for electrodiagnostic studies" in the original guideline document.
• Refer to Neurologist (70%) or Physical Medicine (30%) specialists certified in electrodiagnostic medicine, for nerve conduction studies (NCS) and/or electromyography (EMG), the "gold standard" tests for the evaluation of CTS.
• Positive test: refer for possible Carpal Tunnel Release depending on severity
• Note: ODG recommends that NCS should be done to support the diagnosis of CTS prior to surgery. If an individual has appropriate responses to treatment (i.e. injections, modification of activities, meds) but still has symptoms with normal NCS, surgery may be appropriate on a case-by-case basis and reasonable documentation by the treating physician.

Carpal Tunnel Release (35% of cases)

(See also ODG Indications for Surgery^™ -- Carpal Tunnel Release in the Procedure Summary in the original guideline document)
[Benchmark cost: $3,158]

• Only after the positive diagnosis of CTS is made by history, physical examination, and electrodiagnostic studies
• Performed by Hand Surgeon: Orthopaedic Surgeon (75%), Neurosurgeon (10%), Plastic Surgeon (10%), or General Surgeon (5%)
• On an outpatient basis
• May be open or endoscopic, depending on experience of surgeon (risk of nerve injury and incomplete release greater with endoscopic)
• If bilateral (55% of cases), schedule separate surgeries (usually)
• Expected outcome:
  • Mild/moderate cases: over 90% success with complete recovery after failure of Initial Conservative Treatment (Outcomes in workers' comp cases may not be as good as outcomes overall, but still support surgery.)
  • Severe cases: Complete recovery is unlikely, but 90% will benefit from at least partial recovery.
• Post-surgical treatment:
  • Splint - day and night: not recommended
  • Stitches out in 8 to 14 days
  • Physical/Occupational Therapy: A short course may be appropriate; if so, then post-surgical treatment of 3 to 5 visits.

• Failed Carpal Tunnel Release (4% of cases):
  • Repeat Electrodiagnostic Testing
  • Repeat Carpal Tunnel Release (by fellowship-trained Hand Surgeon)

None provided

During the comprehensive medical literature review, preference was given to high quality systematic reviews, meta-analyses, and clinical trials over the past ten years, plus existing nationally recognized treatment guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure Summary (see the original guideline document), which provides a concise synopsis of effectiveness, if any, of each treatment method based on existing medical evidence. Each summary and subsequent recommendation is hyper-linked into the studies on which they are based, in abstract form, which have been ranked, highlighted and indexed.

These guidelines unite evidence-based protocols for medical treatment with normative expectations for disability duration. They also bridge the interests of the many professional groups involved in diagnosing and treating carpal tunnel syndrome.

Endoscopic surgery is associated with greater risk of nerve injury and incomplete release than open surgery.

The Treatment Planning sections outline the most common pathways to recovery, but there is no single approach that is right for every patient and these protocols do not mention every treatment that may be recommended. See the Procedure Summaries (in the original guideline document) for complete lists of the various options that may be available, along with links to the medical evidence.

An implementation strategy was not provided.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

• Work Loss Data Institute. Carpal tunnel syndrome (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; 2008. 209 p. [288 references]

Not applicable: The guideline was not adapted from another source.

2003 (revised 2008 May 19)

Work Loss Data Institute - Public For Profit Organization

Not stated

Not stated

There are no conflicts of interest among the guideline development members.

This is the current release of the guideline.

This guideline updates a previous version: Work Loss Data Institute. Carpal tunnel syndrome (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; 2007 Apr 24. 201 p.

The Official Disability Guidelines product line, including ODG Treatment in Workers Comp, is updated annually, as it has been since the first release in 1996.

This summary was completed by ECRI on February 2, 2004. The information was verified by the guideline developer on February 13, 2004. This NGC summary was updated by ECRI on March 24, 2005, January 3, 2006, April 11, 2006, November 9, 2006, March 28, 2007, and August 16, 2007. This summary was updated by ECRI Institute on December 17, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.