Carpal tunnel syndrome (CTS) occurs when the median nerve is compressed at the wrist in the carpal tunnel which causes symptoms of tingling and numbness in the thumb, index, middle and radial half of the ring finger. Longstanding CTS can result in thenar muscle atrophy. CTS is the commonest form of nerve entrapment. Symptoms tend to worsen during the night or during activities such as driving, holding a telephone or reading. The prevalence of Carpal Tunnel Syndrome in the UK is 7–16% and is more common in women than in men (3:1)(Royal College of Surgeons, 2013). This condition is often seen in pregnant or post partum females. 

If a patient is in the 2^nd gestational period of pregnancy or has given birth within the last 6 weeks they are able to seek advice and treatment for CTS from their local Maternity Service.

Diagnosis
History; Symptoms as detailed above

Physical Examination

• +ve Tinel test :  Tap over the median nerve as it passes through the carpal tunnel in the wrist.  Positive response: A sensation of tingling in the distribution of the median nerve over the hand. www.youtube.com/watch?v=SLVGHi1l1mg

• Phalen test :  Allow wrists to fall freely into maximum flexion and maintain the position for 60 seconds or more.  Positive response: A sensation of tingling in the distribution of the median nerve over the hand. www.youtube.com/watch?v=SLVGHi1l1mg

Recent research has demonstrated Tinel's and Phalen's to have high specificity but low sensitivity. These limitations should be taken into account when making a diagnosis of CTS. 

• Carpal Compression/ Durkan's test:  With the patient's arm in supination, the examiner applies pressure with his/her thumbs over the median nerve within the carpal tunnel. This is located just distal to the wrist crease. Positive response: Numbness and tingling in the median nerve distribution within 30 seconds.  https://www.youtube.com/watch?v=BN4W7rS45P8 

• Altered sensation to light touch in affected fingers 

• Absence of sweating 

• Loss of thenar muscle bulk 

• Weakness

Patient Reported Outcome Measure
Within some orthopaedic clinics and MSK Physiotherapy departments a questionnaire is used to aid diagnosis of CTS. This tool was developed within the Victoria Infirmary. A copy of the questionnaire and the original article can be found below.
Scoring System for CTS
Hems et al, 2009

Further tests; Nerve conduction studies are not recommended in mild cases, however, they may be used to aid decision on surgical treatment if conservative management fails and can be ordered once a patient is referred from MSK Physiotherapy to a specialist service

Differential diagnosis;

• Vibration white finger
• Median nerve compression elsewhere i.e. pronator teres syndrome, anterior interosseous nerve
• Cervical nerve root entrapment, including C6,7
• Peripheral neuropathy/ metabolic disorders (e.g. diabetic, B12 deficiency, post viral, thyroid etc)
• Post fracture, secondary complication to wrist fracture which may resolve with time.  Refer urgently to orthopaedics if constant increasing symptoms which are not abating within 48hrs. In those not classed as a clinical emergency an orthopaedic review is required if they are not showing signs of improvement within 4-6 weeks.

Signs and Symptoms

Mild - Moderate

• Intermittent paraesthesia in median nerve distribution
• Intermittent nocturnal wakening
• +/- pain
• Reversible numbness or pain
• "Weakness"/ clumsiness
• Interference with ADLs

Go to 1st line management

Moderate - Severe

• Severe +/- constant paraesthesia/ anaesthesia in the median nerve distribution
• Nocturnal wakening
• Disabling pain
• Wasting of thenar muscles
• Weakness of APB / OP

Go to 1st line management or 2nd line management or surgical opinion

Request for trial of splint for Carpal Tunnel Syndrome (CTS) – Physiotherapy only
A referral requesting a splint to be issued for CTS will be vetted as 'appliance only' and SOP for CTS will be followed.　

The Scoring System for CTS questionnaire will be completed.　 The patient will complete page 1 independently and then the support worker will complete page 2 (Guidelines for Scoring System for CTS).

• If the patient scores ≥7 (7-17) points they will be fitted with a nocturnal, neutral wrist splint, instructed in its use, skin care and activity management advice. National Patient Information Leaflet for Carpal Tunnel Syndrome.  They will be placed on hold for 6 weeks (CTS On Hold Letter).　 Letter will be sent on Trak to inform GP (Canned text for CTS).  If there is no improvement or symptoms worsen the patient will contact the local department and an appointment will be made with a physiotherapist (Booking Guidance).
• If the patient scores < 7 (0-6) points, they will be offered an appointment with a physiotherapist.　 If the patient consents CTS Physiotherapy Referral Form will be completed by the support worker.　 The referral will be added to the vetting list and patient will be contacted as per normal RMC protocol.　A letter will be sent on Trak to inform GP (Canned text for non CTS)

The support worker may wish to consult with a Physiotherapist to aid decision at any point.

Education and learning

Referral requesting splints for CTS

Wrist splints are deemed the most appropriate first line management for carpal tunnel syndrome.  MSK Physiotherapy Support Workers Training for Carpal Tunnel and Wrist Splint provision was developed to ensure that patients referred with carpal tunnel syndrome could be assessed and managed safely, effectively and efficiently.  The training was delivered on the 15th of September 2016.  The training was recorded and edited for training purposes in the future. 

The training videos are available on the GG&C YouTube channel (links below).
 

Video 1 - Carpal Tunnel Syndrome https://www.youtube.com/watch?v=JYQ8HW6bVmI

Video 2 - Assessment and Questionnaire https://www.youtube.com/watch?v=uPnHHnn3FDc

Video 3 - Objective Tests https://www.youtube.com/watch?v=SLVGHi1l1mg

Video 4 - Wrist Splint Application https://www.youtube.com/watch?v=GkhaemtPXjg

Video 5 - TrakCare Booking Instructions https://www.youtube.com/watch?v=VYYbeOS2SJQ

These training videos can be used as a refresher for staff who attended the training or alternatively for new staff/ those who were unable to attend the training.  The training videos are only one component of the training.  All support workers must identify a mentor and complete the competency framework.  All supplementary training material can be accessed by clicking the links below.

Carpal Tunnel Syndrome Training Slides
Carpal Tunnel Syndrome Wrist Splint Application
Carpal Tunnel and Wrist Splints Competency Recording Sheets
SOP for CTS
Scoring System for CTS
Guidelines for Scoring System for CTS
National Patient Information Leaflet for Carpal Tunnel Syndrome.

CTS On Hold Letter　
Canned text for CTS
Canned text for non CTS
TrakCare Booking Guidance

CTS Physiotherapy Referral Form

Should you have any questions in regard to the training package please contact Louise Ross - Louise.Ross@ggc.scot.nhs.uk  

First line management

Information on the nature of CTS and how to reduce/ avoid aggravating activities should be given to the patient. National Patient Information Leaflet for Carpal Tunnel Syndrome

Wrist splint to be worn at night for up to 6 weeks. 

Patient advised to contact if no improvement in 6 weeks and wishing to consider 2nd line management/ surgery.

Second line management

Corticosteroid Injection

Evidence shows corticosteroid injection for carpal tunnel syndrome is effective for short term reduction in symptoms only (1 month), but with no evidence that it provides long term reduction in symptoms. Local corticosteroid injection does not significantly improve clinical outcome compared to either anti-inflammatory treatment and splinting after eight weeks (Cochrane 2007).

Corticosteroid injection can offer transient improvement so clinical judgement should be used if considering.  Evidence suggests no benefit to repeat injections. Only one corticosteroid injection should be offered to a patient.   

Within MSK physiotherapy and orthopaedic departments across NHS GG&C current practice with regards to management of CTS by corticosteroid injection does vary.  If considering a CSI do check for local management practice.

Limited evidence for

Neural mobilisation, carpal bone mobilisation, acupuncture, ultrasound, exercise.

Consideration for referral to hand surgeon

If the patient has severe symptoms or if referred from MSK Physiotherapy with poor or no response to conservative management . Ensure patient was compliant with 1st line management and that they are willing to consider surgery.

Further tests;
Repeat VI Measure. Click here to access Scoring System for CTS
Consider referral for nerve conduction studies.

Progressing as expected (up to 3 Rxs) before discharge or onward referral. 

Refer to ortho, GP, other 

Escalate if:

• Poor or no response to conservative management

• Signs of severe median nerve compression – constant/ severe symptoms, thenar muscle wasting or weakness

• Rapid progression of symptoms

• Post fracture

Surgical opinion / list for surgery

NHSGGC Hand Service Orthopaedic and Therapy Post Operative Guidelines

Carpal Tunnel Release

Day of Surgery

• Bulky dressing in situ, to be reduced in 48hrs by the patient.
• Give patient 2 mepore dressings.
• Discharge with/ without sling as per surgeon’s protocol.
• Check circulation, sensation and movement.
• Instructions on elevation of limb, mobilisation of fingers and rest of the upper limb.
• Patient provided with post operative patient information leaflet if they do not already have one.
• Specify how and who to contact at clinic, if there are any problems.
• Fit note provided for the duration of expected absence if required.

Review Clinic (10-21 days) (in some localities suture removal may be done by practice nurse with/ without additional post operative review)

• Remove dressing/ sutures as required.
• Check wound
• Any evidence of infection contact surgical team.
• Apply dressing (if required).
• Check ROM
• Stiffness of wrist and hand - is the patient able to fully open and close fist? Advise on exercises as per patient information leaflet.

• Scar Care

• Once wound has healed gently massage with an emollient hand cream 3-4 times daily.

• Returning to work
• Avoid dirty environments and ensure dressing remains dry.
• Light manual 2-3 weeks.
• Heavy manual 4-6 weeks.
• Driving

• Once feels safe to do so and they feel they are in complete control of the car.  Advice that they may want to check with their insurance company.

• Provide post operative patient information leaflet if they don’t already have one. 
• Reiterate  that up to 1 in 4 patients can expect to have problems with scar/ proximal palmar pain, and this can be variable in its duration
• Specify how and who to contact at clinic if there are any problems.
• If patient had bilateral symptoms provide relevant phone number for them to call, should they decide to have the second surgery (appointment can be provided without a further referral up to 6/12 post surgery). 

Problematic Pain

Consult the Pain pathway in the Exit/ Parallel routes [need replacement link/page for this in RDS] for information and guidelines on diagnosis and management of Complex Regional Pain Syndrome.  

NHS GGC Physiotherapy Service - Wrist and Hand

National Carpal Tunnel Patient Information Leaflet

Carpal Tunnel Syndrome Patient Information BSSH

NHS Inform - Wrist, Hand and Finger Problems

GG&C Carpal Tunnel Post Operative Patient Information Leaflet