Abstract
OTs have a major role in the conservative care of carpal tunnel syndrome (CTS) before surgery; however, best treatment practices are unclear as a result of conflicting recommendations among professional disciplines. We collected and analyzed professional guideline recommendations to construct a consolidated guideline with clear ratings for the available treatments. This guideline will inform treatment procedures and develop more universal best practices for remedying CTS.
Primary Author and Speaker: Julianna E. Dole
Contributing Authors: Nancy Baker, Shawn C. Roll
Professionals from multiple disciplines—including occupational therapists—have a stake in treating carpal tunnel syndrome (CTS), yet there is dispute regarding which treatments are most appropriate in non-severe cases (Huisstede et al., 2010). Occupational therapists (OTs) most frequently address CTS in these earlier stages during which conservative care is the most popular approach (Baker et al., 2014), but the abundance of these non-surgical treatments makes determining the best practices unclear. This meta-synthesis consolidates recommendations published in professional guidelines to identify the most strongly supported treatments for CTS, which will guide OTs in their practices when treating patients with this condition and make the approach more uniform across the discipline. With improved understanding of the best treatments for CTS, OTs will be better equipped to address CTS in the earlier phases and prevent the need for surgery. This study is a systematic review of recommendations from published professional guidelines that were deemed rigorous using the Institute of Medicine (IOM) criteria for trustworthy guidelines (Institute of Medicine, 2011). We searched Google, Google Scholar, and PubMed for CTS treatment recommendations followed by a systematic hand search using various professions and geographical regions as search terms. We recorded all mentioned treatments from the gathered sources and used the IOM criteria for trustworthy guidelines to determine the most rigorous of these publications. From those primary guidelines, we extracted the specific treatment recommendations, which we recoded from their respective ratings into a universal rating system. We analyzed the cumulative data for every treatment and classified each into one of five broad ratings: strongly support, conditionally support, no consensus, conditionally against, and strongly against. Additionally, we clustered individual treatments with similar underlying mechanisms into broader categories to indicate the overall support level for general types of treatments. We located 30 sources through our search that provided 56 different treatments. Six of these sources met the IOM inclusion criteria and included recommendations for 46 of the 56 total treatments. Once classified, 12 broad categories of treatments emerged from the gathered recommendations with surgery, positioning, and steroids being the most strongly supported. Many of the conservative treatments that OTs often employ were found to be conditionally supported. These include patient education, manual therapy, therapeutic exercises, thermal treatments, and workplace alterations. Laser therapy is one of the more popular treatments provided by occupational therapists that was determined to be strongly not supported. Other conditionally or strongly unsupported treatments include non-pain pharmaceuticals, other surgical techniques, and alternative treatments, while analgesics had no consensus. Occupational therapists play a key role in the conservative care of CTS with the goal of preventing surgery. In order to provide this care as effectively as possible, discrepancies between professional guidelines must be eliminated and a clear hierarchy of treatment options must be presented. Our consolidated guideline offers this classification and allows for a common language amongst OTs and various other disciplines that treat CTS. Furthermore, it provides a stepping stone towards the identification and development of an ultimate interdisciplinary process for treating CTS.
Baker, N. A., & Livengood, H. M. (2014). Symptom severity and conservative treatment for carpal tunnel syndrome in association with eventual carpal tunnel release. The Journal of Hand Surgery, 39(9), 1792-1798. https://doi.org/10.1016/j.jhsa.2014.04.034
Huisstede, B. M., Hoogvliet, P., Randsdorp, M. S., Glerum, S., van Middelkoop, M., & Koes, B. W. (2010). Carpal tunnel syndrome. Part I: effectiveness of nonsurgical treatments–a systematic review. Archives of Physical Medicine and Rehabilitation, 91(7), 981-1004. https://doi.org/10.1016/j.apmr.2010.03.022
Institute of Medicine (US). Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Graham, R., & Mancher, M. (2011). Clinical practice guidelines we can trust (p. 266). National Academies Press. https://doi.org/10.17226/13058