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Hello and thank you for joining our CME presentation today. I'm Doctor David Benoy V VP of Clinical Value Based Care for Health Care Outcomes Performance Company, uh also known as HCO. Our topic for today is initial management of carpal tunnel syndrome. Thanks for joining. Uh Before we get started um uh on the topic for the day as we do uh for all CM E events, I want to assure the audience that I have no financial or nonfinancial relationships to disclose as it relates to this topic and uh subsequent uh presentation as a reminder to those of you who have attended other CM E topics we present presented in this series. Uh Our objective is to improve the continuum of care uh and outcomes for musculoskeletal patients. Uh by defining the role of primary care uh providers in uh musculoskeletal value based care. Uh We also aim to provide diagnostic and management pearls to PCPs and other providers um referring um uh to M SK specialists so that providers who manage the initial presentation of many common M SK issues can better diagnose and provide treatment. In addition, we aim to help providers identify red flags and other clinical factors. Uh necessitating urgent uh imaging or specialist referral at the end of today's session. Uh We hope the audience will uh be able to better diagnose carpal tunnel syndrome and be able to classify the severity um of the condition to help determine the most appropriate clinical treatment path. Uh The audience should also be able to better determine which patients will be most likely to benefit from therapy and diagnostic testing. And for which patients, a surgical referral may be warranted. The audience, they will also be able to uh uh order the most appropriate DME for DM E for initial management of carpal tunnel uh syndrome uh in order to achieve these objectives. Uh As we do in uh all talks in this series, we're gonna briefly review the HCO Specialty care network tip sheet. Um uh then we'll do a brief a run through for multiple important topics in the initial management of carpal tunnel syndrome. Uh starting with a background and then moving to evaluation of carpal tunnel symptoms. Um and then moving on to tips for conservative treatment testing. And finally, we'll touch on when a specialist referral uh may be clinically warranted. Uh It's uh uh always important to recognize why HOP O and HCO Specialty Care Network abbreviated as HS CN believes this information is important to distribute to our referral network including pcps and all other upstream providers. Um uh uh uh If you've seen other uh talks in the series, you may be familiar uh with what uh what I'm um uh telling you on this slide here, but uh some of you may or may not be familiar with value based care and the direction of health care uh leading in that uh uh direction. Uh by definition, value based care programs, incentivized health care providers to provide improved quality of care while reducing unnecessary cost. HCO specialty care network is a clinically integrated network which is a type of value based care program uh in Arizona. Uh HSEN has a full population health program uh for a Medicare Advantage population. Um HSEN was recently recognized by, by a top national accreditation organization U A uh for which you see the seal here um for its commitment to clinical integration and high quality care. And HSEN is actually the first specialty network in the country um with uh for which clinical integration designation um was awarded. Um The HSEN network comprises uh almost all the orthopedic surgeons um uh throughout Arizona and uh most of the pain providers uh as well. Uh They have all joined forces to follow standardized evidence based clinical pathways. Um HS and also collaborates with uh other providers including yourselves who uh who, who encounter M SK conditions uh with the goal of improving patient outcomes and experience. Um And as you're probably well aware, a significant percentage of the initial management of M SK uh conditions occurs not at the specialist level. Um but upstream, including in the PCP uh clinic, uh Therefore, it's clear that um in a population health program, that we clear that we rely on pcps um uh and other upstream providers uh to help reduce unnecessary MSK cost. Um As they're the most common gatekeeper uh for M SK care. Before we dive into the topic of the day, I should mention uh that the information presented uh in this talk is evidence based and uh consent is driven uh with uh recommended practices uh designed to be implemented for patients with MSK conditions. Um But as should be said, for all clinical programs, clinical discretion uh should be used uh with this guideline with these guidelines for patients, especially if they're a concomitant uh clinical uh factors or comorbid conditions that may alter um the clinical clinically appropriate treatment path as we do for all uh talks in this series. Uh Let's start with a review of the HSC N uh tip sheet. Uh We sent this out um to all of you uh that would be in attendance uh today. But if you don't have a copy, uh please feel free to email us uh at HSC N at ho dot com and we'll, we'll be happy to send you a copy. So you have one for your clinic. Um As a reminder, this tips sheet is uh more specific to the older Medicare Medicare advantage population, but many uh tips here are also relevant to a younger population as well. Uh Today, we're focusing on wrist and hand pain due to carpal tunnel syndrome. That's the fourth uh row on this uh tip sheet. Um We'll go through each column in a little bit more detail uh and, and more specifics there. But uh it's a good way of seeing the overall suggestions of the specialists for initial management. Uh as you can see on a tip sheet here, um for wrist pain, including for symptoms of carpal tunnel syndrome, advanced imaging and IMA and therapy are not components of the initial management plan. Uh notated with a um uh a red uh emblem there uh but other form um but other forms of conservative therapy including activity modification and DME may be part of a plan uh which is signified in uh we'll discuss all these sub subtopics more uh within this talk. As a review, carpal tunnel syndrome is caused by median nerve uh entrapment uh and should come no surprise uh that this uh the most common nerve entrapment uh syndrome affecting approximately uh three or more than 3% of the general population. Uh Most cases of carpal tunnel syndrome are caused by a combination of factors uh which we'll discuss in this talk. Um And issues with carpal tunnel pathology are common in uh men in uh uh in um in more common in women and in uh older patients especially but can happen uh for sure. In uh men and younger patients as well. Also as a reminder uh of the nerve distribution of the median nerve, as you can see on this graphic here, uh the median nerve uh provides sensation to the uh first um uh first through uh fourth uh digits with half of the fourth digit being uh innervated by the median nerve of the medial. Um uh have um carpal Syndros, uh car carpal tunnel syndrome usually presents as a, a gradual or progressive atraumatic uh wrist pain, uh hand pain weakness, uh numbness and tingling in the median distribution. And um and usually it's in the setting of overuse, but it could come on with no obvious reason. Uh in some patients, uh the area that has pain as well as numbness should be um elucidated um uh from a history as it helps differentiate this condition from other nerve or, or tendon really related issues in the hands and the wrist, including ulnar nerve uh related pain or, or neuropathy, uh which can be, which can present as a medial uh side pain in the hand, including a part of the fourth digit and the whole fifth digit. In addition to the risk factors already mentioned, there are additional risk factors considered for carpal tunnel uh syndrome. Uh These include heredity, um uh uh sometimes uh carpal tunnel syndrome. Um uh I is uh more common um uh in some people that have uh anatomical differences, uh which changes the amount of space uh for the nerve uh to get to the carpal tunnel. Um repetitive hand use um is a risk factor, repeating the same hand and wrist motions or activities over a prolonged period of time can aggravate the tendons in the wrist, um causing swelling and inflammation that puts pressure on the nerve. Um and hand and wrist position itself doing activities that involve extreme flexion or extension of the hand and wrist for a prolonged period of time can impre increase that pressure on the nerve uh as well. There are uh also additional risk factors of pregnancy. Uh uh Pregnancy can bring on symptoms due to hormonal changes, uh which cause swelling that results in pressure uh on the nerve. Um and in those cases, uh where pregnancy is the cause of symptoms gradually resolve over a period of weeks after delivery. And then other health conditions can also increase the risk. Uh diabetes, rheumatoid arthritis, uh thyroid uh pathology uh can increase um the chances of having carpal tunnel uh syndrome after uh history elucidates, symptoms of carpal tunnel syndrome. It's important to um to uh support the suspicions condition with a thorough uh examination. Um This will help also help to determine the severity of the condition further uh on inspection. It's important to look at the hands for signs of arthritis, symmetry, muscle atrophy. Um late stages of carpal tunnel syndrome can be found um can can lead to profound thenar atrophy. Uh For those who don't remember the thenar prominence or eminence is the muscle belly just medial and proximal to the thumb on the palmar side of the hand, thenar atrophy uh can also um can be seen visually or it could be palpated uh in comparison to the unaffected uh hand. The next part of the examination is a motor examination. Uh You can check the strength of the muscles of the hand that have been impacted by carpal tunnel uh syndrome by placing the patient's um hand palm side up on the exam table. Um and putting the thumb into flexion uh or coming off the table. Um in, you can instruct the patient to resist uh movement while you try to extend the thumb flat against the table or back towards the table. It's also helpful uh to do um a quick sensory examination. As mentioned earlier, the nerve uh provides sensation uh to the first or third digits uh as well as part of the uh fourth digit um assessing for abnormal sensation um consistent with distribution um is an important part of the diagnosis. There are also uh several um provocative maneuvers. Um uh These are designed to replicate symptoms of paresthesia that can aid in the clinical evaluation of carpal tunnel syndrome. Um And you can see on the graphic here. The first one that we uh all learned early in our training is the Phalen's test. This test is not uh perfect and neither is any test. Uh for carpal tunnel uh sensitivity, 68% specificity, 73% but it can be helpful in the context uh of other tests. Uh and symptoms uh for this test, a positive test involves uh a reduced sensation after prolonged wrist flexion um for up to one minute uh to increase the pressure in uh going through the carpal tunnel and pain uh may be elicited. Uh but that's not the primary endpoint for this test to be positive. It's actually reduced uh sensation similar to the Phalen test is a reverse uh Phalen test also known as uh uh worms's test. Uh Again, it's not the most sensitive uh test uh was sensitivity to 57%. But the speci specificity is not awful. It's 78%. As you can see here on the right, the tests per uh performed by placing the hands together uh to cause bilateral wrist extension which also increases pressure in the carpal tunnel. There's also the carpal uh compression test. Uh Durkin's test again, no test is perfect. Uh This one is a slightly better specificity at 83% to do this test. Uh you hold the patient's risk in slight flexion um and directly compress the median nerve by applying pressure to the proximal wrist crease for about 30 seconds. Um A positive result occurs if the patient develops pain or paresthesias uh or numbness in the median nerve distribution and, uh, one more, uh known by many of you, uh, the Tennell test, uh, similar specificity as the others. But, um, not catching as many cases with the sensitivity of 50% Tennell test. Uh, for carpal tunnel symptoms involve you tapping over the volar carpal ligament, the lumen that stretches across the wrist along the area of the median, uh, whe where the median nerve uh comes through at the carpal tunnel, uh for 60 seconds and a positive test, um, res results. Um, and a positive 10 sign occurs when a patient reports tingling or electric shocks. Um, along the distribution of the median nerve. Uh, if you do wanna get a little bit more fancy, the sensitivity of that Tennell test can be increased by using a, um, a reflex hammer, uh, instead of fingers to tap over the carpal tunnel. So, what is a history and all the tests to tell you, um, it tells you how to categorize carpal tunnel, uh, symptoms into mild, moderate or severe. Uh, and that will help dictate, uh, the treatment pathway. Uh, mild symptoms are present when there's a sensory impairment in the median nerve distribution but no persistent numbness or weakness. Um, symptoms, uh, do not disrupt, disturb sleep impair hand function or interfere with activities of daily living. And, and this is the vast majority of, of patients with carpal tunnel. Um, symptoms will, will have mild symptoms. There may be some with some moderate symptoms uh, where there's persistent numbness in the median distribution or mild, uh, nightly or nocturnal symptoms, uh, which may disrupt sleep. Um, and it may interfere, interfere somewhat with hand function. Um, but the patient is still able to perform their ADLs uh, without a problem. And then there's severe carpal tunnel uh syndrome, uh, where there's weakness present in the median distribution, uh, or symptoms that are disabling, uh, routinely disrupt sleep, uh, or prevent the patient from carrying out. Uh, one or more of their, uh, ADL S like getting dressed or bathing et cetera. Now that you have your history and physical, which helps to point you toward how severe the condition is. Uh, we can now, uh, talk treatment, uh, for those are the mild symptoms. The initial treatment consists of antiinflammatory medications and, uh, an over the counter velcro uh wrist brace, I am say over the counter, uh, custom braces are not necessary and will not change the overall outcome but may push more, um, push a significant amount of cost onto the patient. Um, an example of a wrist brace, you could, uh find a drug stores on this slide here. Um, a wrist brace in this situation maintains the risk of a neutral position pre, uh preventing prolonged flexion and extension of the wrist and limiting activities that raise pressure within the carpal tunnel. Uh, splints can be worn continuously. Uh, most people, uh, uh, don't wear them uh continuously and they take them off, uh, during the day. Um, if they do perform activities that create increased pressure through the carpal tunnel, though this may, um, delay some resolution of the symptoms and they may need to wear their wrist brace a little bit longer, uh, throughout the day. Um, but it's always a balance to what's, uh, uh, tolerable, uh, for the patient, uh, as well as, uh, continuous wearing can be, uh, difficult for many, uh, with splints, a trial of 1 to 2 months is reasonable to assess the response of splinting. It's not something that happens overnight. Um, it, it takes a little while for the inflammation and uh the area to calm down enough to see if it's actually had uh a successful uh treatment uh through splinting, uh or bracing. And again, splints can be found in most drug stores. It's often cheaper than prescribing them. Um, and you should avoid custom splinting and bracing unless over the counter splinting and bracing has failed. And in that case, um, generally the, any kind of custom bracing should be ordered by a specialist. Um, I did make a note here um about the initial treatment as it relates to therapy. Uh, well, it might be tempting to order therapy for carpal tunnel syndrome. Um, it's not clinically indicated there's, uh, it's not been shown to alter the long term outcome um, of the patient's condition. It's best to avoid therapy unless in certain refractory uh cases um, home exercises, uh, may be an option during recovery and these and generic exercises for carpal tunnel symptoms, uh can be uh found online easily. You can direct your patients. Uh, there. Now let's touch on a diagnostic testing. Um, like therapy, prescriptions, diagnostic tests and ancillary. Um, treatments are not indicated for most patients with carpal tunnel symptoms as necessary treatment. Uh I mean, testing could be ordered by a specialist, um, like in a patient with persistent symptoms despite trial of splinting and other medications and other conservative care. Um, and for patients with a clear diagnosis of carpal tunnel syndrome, I mean, the symptoms are consistent with carpal tunnel clearly on history and physical um e electrodiagnostic testing. Uh uh uh electromyography and nerve conduction study are not recommended. Um It, it's not necessary to confirm the diagnosis with an EMG, it's, it's clear clinically and it's also not necessary to order an EMG if the symptoms are, are really unclear. Um, but if the patient has severe enough condition to get an EMG at some point, that that'd probably be the point where the patient is also seeing a hand specialist and they should be the ones ordering the EMG, especially since there are ways to order the, the test that may be very specific to the treatment the specialist is considering. And um speaking of um specialist referrals, uh a patient with moderate or severe uh carpal tunnel or those with mild carpal tunnel that has not responded to a full trial uh of conservative treatment at least a few weeks. Um Two or three months usually should be referred to a hand specialist for consideration of a, of an injection um versus surgical intervention. Um I add, I add this in although it's rare, um patients without a clear diagnosis of carpal syndrome, uh but with severe enough symptoms that need further attention could also be referred to a specialist for further workup. I like to end each uh talk in a series of common M SK conditions with some take home points uh for carpal tunnel uh syndrome, uh conservative treatment prior to specialist referral and diagnostic testing is typically the most um appropriate initial treatment, uh physical and occupational therapy uh are not indicated. Um Conservative trials should last 1 to 2 months uh to avoid unnecessary referrals and testing. And patients who require DM E should be trialed first on non custom um and DM E if they need to go past that, which is rare. Um without a specialist directing this, the patient should have custom DM E ordered by the specialist. Um an E MG should not be typically ordered by a PCP. Uh They can be done by a hand specialist if uh if needed. Thank you for uh joining us today for this presentation. Uh We hope you enjoy the talk and hope uh you join us again soon as we explore other topics in M SK Care. Thank you. Have a good day.