Abstracts & Literature Review
Carpal Tunnel Syndrome: Hand Surgeons, Hand Therapists, and Physical Medicine and Rehabilitation Physicians Agree on a Multidisciplinary Treatment Guideline – Results: From the European HANDGUIDE Study
Bionka M. Huisstede, PhD, Jan Fride´n, MD, PhD, J. Henk Coert, MD, PhD, Peter Hoogvliet, MD, PhD,
European HANDGUIDE Group
JACO Editorial Reviewer Dale G. Huntington, D.C., F.A.C.O.
Published: September 2016
Journal of the Academy of Chiropractic Orthopedists
September 2016, Volume 13, Issue 1
The original article copyright belongs to the original publisher. This review is available from: http://www.dcorthoacademy.com © 2015 Huntington and the Academy of Chiropractic Orthopedists. This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective: To achieve consensus on a multidisciplinary treatment guideline for carpal tunnel syndrome (CTS).
Design: Delphi consensus strategy.
Setting: Systematic reviews reporting on the effectiveness of surgical and nonsurgical interventions were conducted and used as an evidence based starting point for a European Delphi consensus strategy.
Participants: In total, 35 experts (hand surgeons selected from the Federation of European Societies for Surgery of the Hand, hand therapists selected from the European Federation of Societies for Hand Therapy, physical medicine and rehabilitation physicians) participated in the Delphi consensus strategy.
Interventions: Not applicable.
Main Outcome Measures: Each Delphi round consisted of a questionnaire, analysis, and feedback report.
Results: After 3 Delphi rounds, consensus was achieved on the description, symptoms, and diagnosis of CTS. The experts agreed that patients with CTS should always be instructed, and instructions combined with splinting, corticosteroid injection, corticosteroid injections plus splinting, and surgery are suitable treatments for CTS. Relevant details for the use of instructions, splinting, corticosteroid injections, and surgery were described. Main factors for selecting one of the aforementioned treatment options were identified as follows: severity and duration of the disorder and previous treatments received. A relation between the severity/duration and choice of therapy was found by the experts and reported in the guideline.
Conclusions: This multidisciplinary treatment guideline may help physicians and allied health care professionals to provide patients with CTS with the most effective and efficient treatment available.
The complex movements and tactile sensation of the hand are essential for completing everyday tasks. Consequently, hand disorders affecting these qualities have a significant impact on activities of daily living. Of those with chronic non-traumatic complaints of the arm, neck and/or shoulder, 29% reported complaints in the wrist/hand area. The most prevalent non-traumatic hand disorder is carpal tunnel syndrome (CTS).
Although the exact causative mechanism of CTS is unknown, it is safe to state that CTS is related to an increased pressure within the carpal tunnel, resulting in mechanical compression and local ischemia – mediated damage to the median nerve. The occurrence of CTS can be associated with work-related factors. The prevalence of CTS is reported to be 0.6% in men and 5.8% in women in the general population and 1 in 5 in symptomatic subjects.
Interventions used to treat CTS vary from splinting to exercise therapy and from ultrasound to all kinds of surgical interventions. Ideally, a treatment guideline for CTS is based on systematic reviews describing the long-term effects of all aspects relevant for the diagnosis and treatment of the disorder. However, systematic reviews on the treatment of CTS mainly describe short-term and mid-term effects and focus on the global picture of a treatment (eg, splinting, corticosteroid injections, open surgery), without taking into account relevant details (eg, type of splint; when to wear it; type of corticosteroid; number of injections; types of anesthesia, incision, and stitches). Because such details can have significant consequences, a Delphi consensus strategy was conducted to develop a treatment guideline for CTS. Development of evidence-based protocols and treatment guidelines can aid in optimizing care for hand disorders. Therefore, in Europe, the HANDGUIDE study was initiated with the goal to create multidisciplinary consensus on treatment guidelines for non-traumatic hand disorders: trigger finger, De Quervain disease, Dupuytren disease, CTS, and Guyon canal syndrome. In a Delphi consensus strategy, a series of sequential questionnaires (or rounds) are presented to a panel of experts, interspersed with controlled feedback, with the aim to achieve consensus of opinion among these experts. This article reports on the results for CTS.
Steering committee and advisory team: A steering committee consisting of a hand surgeon (with a PhD), physical medicine and rehabilitation (PM&R) physician (with a PhD), and physiotherapist (with a PhD) was composed to initiate and guide the HANDGUIDE Study. All 3 members of the steering committee have a clinical and scientific and/or epidemiologic background. They designed the questionnaires, analyzed the responses, and formulated the feedback reports. Further, an advisory team (consisting of 2 professors of hand surgery, 1 professor of PM&R, and 1 hand therapist with a PhD) was formed that received regular updates on the progress of the HANDGUIDE Study. This team could be consulted by the steering committee if necessary and could give the steering committee their opinions and advice as they saw fit.
Preparation of the study:
Evidence for effectiveness of interventions of CTS to establish an evidence-based starting point for this study, systematic reviews were conducted reporting on the evidence for the effectiveness of nonsurgical, surgical, and postsurgical interventions to treat CTS.
Selection of experts:
The Federation of European Societies for Surgery of the Hand (FESSH) and European Federation of Societies for Hand Therapy (EFSHT) endorsed this study. The national member associations of the FESSH and EFSHT selected the experts in their respective field. Each national member association was invited to select a maximum of 3 representative experts per Delphi consensus strategy. In addition, some European PM&R physicians who specialize in hand rehabilitation were invited to participate in this study.
Delphi consensus strategy on CTS:
Description, symptoms, and diagnosis of CTS First-round questionnaire: In the first round, literature-based concepts for a short description of CTS, its symptoms, its diagnosis, and its nonsurgical and surgical treatment were presented to the experts. Subsequently, the experts were asked whether they agreed (yes/no/no opinion) with the aforementioned concepts followed by the request to explain their answer (please explain your answer). This allowed the experts at any time to object or suggest alterations to any of this steering committee’s suggestions regarding the aforementioned items.
Expert panel: A total of 112 experts (52 hand surgeons, 47 hand therapists, 13 PM&R physicians) from 17 European countries were selected to participate in 1 of the 3 Delphi consensus strategies of the HANDGUIDE Study, which was performed between June 2009 and December 2012.
For the Delphi consensus strategy on CTS, 36 experts were selected (18 hand surgeons, 13 hand therapists, 5 PM&R physicians). Of these, 1 expert did not finish any of the questionnaires. Response rates of the remaining 35 experts for rounds 1 to 3 were 89%, 94%, and 89%, respectively.
European experts (hand surgeons, hand therapists, PM&R physicians) achieved multidisciplinary consensus on a treatment guideline for CTS. This guideline may help and guide physicians and allied health care professionals to provide patients suffering from CTS with the most effective and efficient treatment available.
JACO Editorial Summary:
- This clinical research article was written by the authors; Bionka M. Huisstede, PhD, Jan Friden, MD, PhD, J. Henk Coert, MD, PhD, Peter Hoogvliet, MD PhD, of the “European Handguide Study”.
- The purpose of this 2.5 years, 17 country study was to determine the most effective ways of treating CTS via nonsurgical, surgical, and postsurgical interventions which is an evidence based starting point for the first European Delphi consensus strategy.
- This was a comprehensive study that was closely monitored to obtain the most reliable results by the hand experts to assimilate the documentation from all the Delphi groups to determine multidisciplinary results in the 3 separate interventions.
- The diagnosis of CTS is primarily based on the clinical picture. The sensitivity of special tests such as, (Phalen test and Tinel sign) are reported to be 34% to 59% and 51% to 93% and 25% to 41% and 66% to 91% respectively. These tests are of limited value which brings to point the importance of electro – diagnostic testing. There are reports of results that do not clearly demonstrate whether the origin is at the wrist, cervical spine radiculopathy or a mixed result.
- Of those who reported non-traumatic neck and upper extremity pain 29% of the complaints were in the wrist/hand area. The most prevalent non-traumatic hand disorder was carpal tunnel. In addition the study revealed the prevalence of CTS reported to be 0.6% in men and 5.8% in women. This mere fact could be a study of its own.
- The use of the cold laser has been utilized with some degree of effectiveness in North America over the past 10 plus years as a primary or adjunctive therapy procedure in the fields of the interventions that have been discussed in this clinical research model. To my knowledge there has not been a controlled clinical study performed or an article written in an indexed medical journal on that topic.
The authors of this study are to be commended for their efforts in this comprehensive clinical investigation that spanned over a period of two and one half years, seventeen countries, and 112 experts guiding this multidisciplinary study to a consensus of opinion. It is hoped that this will launch other studies of its kind in the future.