SPECIAL REPORT

Improving the Diagnosis of Carpal Tunnel Syndrome Electrodiagnostic Tests (EDX) in Carpal Tunnel Syndrome A Modern Condition: Carpel Tunnel Syndrome Assessing and Treating Carpal Tunnel Syndrome Can Handheld Devices Lead to Earlier Diagnosis? The Future of Carpal Tunnel Diagnostics

Published by Global Business Media

SPECIAL REPORT: IMPROVING THE DIAGNOSIS OF CARPAL TUNNEL SYNDROME

SPECIAL REPORT

Improving the Diagnosis of Carpal Tunnel Syndrome Electrodiagnostic Tests (EDX) in Carpal Tunnel Syndrome A Modern Condition: Carpel Tunnel Syndrome

Contents

Assessing and Treating Carpal Tunnel Syndrome Can Handheld Devices Lead to Earlier Diagnosis? The Future of Carpal Tunnel Diagnostics

Foreword

Tom Cropper, Editor

Electrodiagnostic Tests (EDX) 3 in Carpal Tunnel Syndrome Prof Michael Sedgwick, MD FRCP - Mike.sedgwick@doctors.org.uk

Published by Global Business Media

Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org Publisher Kevin Bell Business Development Director Marie-Anne Brooks

Why do the Tests? To Establish or Refute the Diagnosis To Check Whether One or Both Sides Are Affected To Establish Severity of the Condition To Establish the Effect of Treatment To Exclude Other Conditions What to Test Which Equipment? No EDX? Physiological Note

A Modern Condition: Carpel Tunnel Syndrome Tom Cropper, Editor

Editor Tom Cropper

Rapid Growth Health Issues The Cost of Carpal Tunnel Syndrome

Senior Project Manager Steve Banks

Assessing and Treating Carpal Tunnel Syndrome

Advertising Executives Michael McCarthy Abigail Coombes Production Manager Paul Davies For further information visit: www.globalbusinessmedia.org

Jo Roth, Staff Writer

Treatment and Assessment The Drive Towards Earlier Detection Educating Patients Improving Technologies

Can Handheld Devices Lead to Earlier Diagnosis?

James Butler, Staff Writer The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles. ÂŠ 2019. The entire contents of this publication are protected by copyright. Full details are available from the Publishers. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner.

Current Diagnosis Methods Electro Diagnostics Next Generation Tests

The Future of Carpal Tunnel Diagnostics

Tom Cropper, Editor

Managing Costs Prevention is Better Than Care Imaging Diagnostics Handheld Electro Diagnostics

References 15

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SPECIAL REPORT: IMPROVING THE DIAGNOSIS OF CARPAL TUNNEL SYNDROME

Foreword

ARPAL TUNNEL Syndrome is on the rise.

among patients and clinicians also means many

While it can be treated quickly in primary care,

patients progress to more advanced stages before

more than 5,000 people are treated in secondary

the condition is adequately diagnosed.

care in the UK every year. Reducing that number

A new approach is necessary to catch the condition

will help health services cope with the strain and

as early as possible and our final two articles focus

improve the wellbeing of patients.

on fresh developments in screening and treatment.

Our opening article comes from Professor Michael

James Butler looks at developments in electro

Sedgwick who talks about the importance of

diagnostics tests. These can be highly beneficial

performing electro diagnostics tests (EDX). Although

but they add time to the treatment process. A new

doctors routinely make Carpal tunnel Syndrome

generation of handheld devices is now on the market

assessments, based on their own observations,

which are faster, more accessible, affordable and just

he highlights guidance from the US, UK, Australia

as accurate as conventional devices.

and Japan which recommends the use of a test to

We then look to the future. Mobile apps, advanced

confirm a diagnosis and establish the effectiveness

technologies and new treatment techniques will all

of treatment.

help clinicians identify Carpal Tunnel Syndrome

Elsewhere in this report we examine the growing impact of Carpal Tunnel Syndrome on health

earlier. All these advances promise a world of earlier detection and more effective treatment plans.

services. The modern world appears to be tailor-

CARPAL TUNNEL SYNDROME isnâ€™t going away.

made for the spread of the condition, but health

Our modern lives put us all into higher risk categories,

services are already struggling to make ends

but it can be managed. A shift toward proactive

meet. To cope with rising demand the focus must

preventative measures can improve outcomes for

swing towards earlier diagnosis.

patients and reduce the strain on resources.

Jo Roth then reviews the existing treatment pathways. Treatments such as injections and surgery all have their risks. A lack of awareness

Tom Cropper Editor

Tom Cropper has produced articles and reports on various aspects of global business over the past 15 years. He has also worked as a copywriter for some of the largest corporations in the world, including ANZ Bank, ING and KPMG.

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SPECIAL REPORT: IMPROVING THE DIAGNOSIS OF CARPAL TUNNEL SYNDROME

Electrodiagnostic Tests (EDX) in Carpal Tunnel Syndrome Prof Michael Sedgwick, MD FRCP - Mike.sedgwick@doctors.org.uk Always perform electrodiagnostic tests (EDX) on patients with suspected carpal tunnel syndrome before invasive (injection or surgical) treatment.

Cervical Spondylosis Arthritis Brachial Neuritis Thoracic Outlet Syndrome Vibration White Finger Neuropathy

To Check Whether One or Both Sides Are Affected In over half the patients, the other hand is affected also but less severely.

To Establish Severity of the Condition

WHY DO THE TESTS?

That is a dogmatic statement. Can it be defended? It is not the author’s statement though he wholeheartedly agrees with it, it is the considered opinion of experts from Australia, Japan, United Kingdom and the United States.

Why do the Tests? 1. To establish or refute the diagnosis 2. To check whether one or both sides are affected 3. To establish severity of the condition 4. To establish effect of treatment 5. To exclude other conditions

To Establish or Refute the Diagnosis Any experienced Doctor can make a clinical diagnosis of carpal tunnel syndrome, can’t they? Yes, if the presentation is the classical one but often the symptoms do not ‘fit.’ There may be pain radiating up or even down the arm, the patient may not be able to give a coherent description, there may be language problems. Many other conditions can give symptoms similar to those of carpal tunnel syndrome, here are six of them:

There are three effective treatments available: 1. Splints to hold the wrist at a neutral angle during the night. 2. S teroid injections into the carpal tunnel. 3. Surgical decompression.

Grading Carpal Tunnel Syndrome 0 Normal 1 A bnormality shown only on ‘inching’ across the palmar segment, IV double peak, or comparing Median vs Ulnar motor 2 C onduction velocity in median innervated digits <40 M/sec. Distal motor latency (DML) <4.5msec 3 D istal Motor Latency 4.5-6.5msec, Digit II <40M/sec 4 D ML 4.5-6.5msec, Digit II Sensory nerve action potential (SNAP) absent 5 DML >6.5msec SNAPs absent 6 A bsent Motor response and absent SNAPs

Surgical decompression carries the risks common to all surgery, wound infection, haematoma, painful scar. There is the risk of damage to the median nerve or its palmar branch. There is the possibility that the decompression is incomplete, and the patient derives no benefit

Grades 1 and 2 are considered mild, grades 5 and 5 severe and grades 3 and 4 moderate.

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TO ESTABLISH SEVERITY OF THE CONDITION

Which treatment should you choose, and which would the patient choose once informed about the pros and cons of each? Splinting certainly works in mild cases but the symptoms frequently break through and one of the other methods must be considered

Treatment with diuretics and non-steroidal antiinflammatory drugs is not effective. Should the treatment be decided according to the severity of the condition? There is a general feeling that the more severe compressions warrant surgical decompression; splints may work for the mild cases and steroid injections for the moderate cases. A grading system has been proposed according to the EDX findings. Which treatment should you choose, and which would the patient choose once informed about the pros and cons of each? Splinting certainly works in mild cases but the symptoms frequently break through and one of the other methods must be considered. Both invasive treatments carry the risk of median nerve damage. The risk is small but finite. Steroid injections relieve symptoms but not in every case and not for all time. The relapse rate is high but injections can be repeated. Steroids carry the risk of atrophy and depigmentation of the skin and weakening of the flexor tendons of the wrist. Surgical decompression carries the risks common to all surgery, wound infection, haematoma, painful scar. There is the risk of damage to the median nerve or its palmar branch. There is the possibility that the decompression is incomplete, and the patient derives no benefit.

To Establish the Effect of Treatment Repeat EDX are requested in patients who have not improved or who have got worse. The most common problem is that a decompression has been incomplete. The area of greatest compression is at the distal margin of the transverse carpal ligament and the surgical incision sometimes does not go far enough distally. There may have been damage to the median nerve by surgery or by injection. If the splints are no longer working, it is time to do EDX if they have not already been done. Perhaps the compression is more severe than first thought. If the symptoms return after steroid injection, EDX will inform you whether the compression is getting worse or not. If it is deteriorating, surgery 4 | WWW.PRIMARYCAREREPORTS.CO.UK

may be considered, if not, another injection may be the treatment of choice. When a patient fails to improve after surgery EDX will show whether the decompression has been effective or if the nerve has been damaged. After decompression it is best to wait up to 3 months for the nerve to recover before re-testing. Repeat EDX studies give the same results even years later in normal subjects. Any change noted on re-testing is not due to natural fluctuations but is a real change in the status of the nerve. In some patients, up to 20%, carpal tunnels will recover spontaneously. Carpal tunnel syndrome developing in pregnancy is often self-limiting only to recur at the menopause. For those patients whose EDX results are getting worse, decompression should be seriously considered. Once the APB muscle atrophies, it is unlikely to recover even after successful decompression.

To Exclude Other Conditions What if the EDX are normal, can the patients still have carpal tunnel syndrome? It is possible. Careful examination of the results will usually show them not to be â€˜textbook normalâ€™ but still within the defined limits. A useful option is to retest these patients after a few months if they still have symptoms. If the EDX are abnormal and the patient has no symptoms he or she does not have carpal tunnel syndrome. Sometimes this is seen on the other hand on patients, but when directly questioned, they admit to minimal symptoms on that side also. Sometimes there are no symptoms despite median nerve abnormalities. When the pattern of abnormalities is unusual, for instance if both median and ulnar SNAPS are absent or show slow conduction, then the diagnosis must be re-considered. It may be necessary to have full neurophysiological testing in a clinic led by a consultant in Clinical Neurophysiology.

What to Test Compression affects the largest diameter nerve fibres first; they are those serving fine touch

SPECIAL REPORT: IMPROVING THE DIAGNOSIS OF CARPAL TUNNEL SYNDROME

WHAT TO TEST

and pressure. Motor fibres are affected later. The first EDX abnormalities are therefore in sensory nerve conduction. They are also the first to recover after decompression. EDX measures latencies but it is better to convert to conduction velocities by measuring the distance travelled by the impulses. The latencies and therefore the conduction velocities are temperature dependent so be sure the patientâ€™s hand are warm. The earliest sign of compression is usually detected by comparing sensory nerve conduction in the IVth or ring finger where the median conduction will be slower than the ulnar. Check another median finger, II or III and digit V.

All authorities insist that some nerve other than the median be tested and the ulnar is the one to check. Distal motor latencies of the median to abductor pollicis brevis and the ulnar to abductor digiti minimi must be checked. Some doctors like to see motor conduction in the forearm of both median and ulnar recorded. Some devices allow conduction from the palm of the hand to the finger as well as from the wrist. This gives a conduction velocity through the canal itself and is a useful measure in borderline cases.

Which Equipment? Some have a preference for small portable devices, operated from mains or battery and

Both invasive treatments carry the risk of median nerve damage. The risk is small but finite. Steroid injections relieve symptoms but not in every case and not for all time

WHICH EQUIPMENT?

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SPECIAL REPORT: IMPROVING THE DIAGNOSIS OF CARPAL TUNNEL SYNDROME

Some devices allow conduction from the palm of the hand to the finger as well as from the wrist. This gives a conduction velocity through the canal itself and is a useful measure in borderline cases

displaying on a computer screen. Choose software which can be â€˜customisedâ€™, for instance, comparing digit IV median and ulnar sensory nerves is important. Can they both be displayed on the same graph for comparison? What about the report, can you customise it? The doctor wants to know; Is it carpal tunnel and How bad is it? He does not need 10 pages of traces and figures. In these days of company mergers, you need to know whether the company can give a guarantee to support and service the device for 10 years. The costs of electrodes can be substantial. Can the device run with ordinary electrodes sourced from any company? A device should offer a reasonably comprehensive range of tests. It should be able to measure nerve conduction in the legs for instance. Someone may wish to use the device for testing polyneuropathies which require a longer time trace and stronger stimuli than for carpal tunnel testing.

No EDX? Clinics without neurophysiological testing are likely to have more dissatisfied patients for any of the following reasons: a) The diagnosis was wrong, and the patient did not have median nerve compression. b) The diagnosis was correct, but the treatment chosen was inappropriate. c) There will be no objective way of following up patients. d) There will be no way of determining whether treatment has failed or has caused addition damage.

Physiological Note Carpal tunnel syndrome is what the patient feels. They feel numbness because some of the sensory fibres are not conducting impulses. EDX measures the function of the remaining fibres that are conducting impulses and defines a focal compressive neuropathy. The severity of the clinical symptoms and the degree of EDX abnormality, the grading of the median nerve compression, correspond very closely.

References: Nerve conduction studies and EMG in Carpal Tunnel Syndrome: Do they add value? Masahiro Sonoo, Daniel L. Menkes, Jeremy D.P. Bland, David Burke. (2018) Clinical Neurophysiology Practice. https://doi.org/10.1016/j.cnp.2018.02.005 2467-981X/

In these days of company mergers, you need to know whether the company can give a guarantee to support and service the device for 10 years

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SPECIAL REPORT: IMPROVING THE DIAGNOSIS OF CARPAL TUNNEL SYNDROME

A Modern Condition: Carpel Tunnel Syndrome Tom Cropper, Editor Increased use of technology, higher work hours and higher rates of obesity all mean more people are presenting with Carpal tunnel Syndrome earlier in life.

E OFTEN hear about Carpal Tunnel Syndrome as a modern condition. Certainly, the world we live in seems to be well made for it. At work, people are using machinery and operating computers for hours at a time. At home they are using their computers and smartphones. A lack of exercise and poor diet are contributing to increases in obesity, diabetes and high blood pressure, all of which may increase the risk of Carpal Tunnel Syndrome. However, evidence suggests doctors have been battling it since the Middle Ages, with mentions in the Persian Medical Handbook written by Avicenna1. Todayâ€™s world, though, has created a perfect storm of health trends and lifestyle choices which have sparked a rapid rise in the rates of Carpal Tunnel Syndrome.

Rapid Growth Data suggests that the number of cases of Carpal Tunnel Syndrome have doubled over the past five years. While Carpal Tunnel Syndrome used to affect mainly people over the age of 40, it is becoming more prevalent among younger people. The problem, according to the authors of the report, lies in societyâ€™s increasing obsession with technology2. Another study from the Hong Kong Polytechnic University backs this up. It contends that college students who sit for hours each day glued to their tablets are putting themselves in line for the painful onset of Carpal Tunnel Syndrome. The study found that those who spend nine hours a day using computers, gaming consoles, tablets or smartphones were much more likely to suffer from Carpal Tunnel Syndrome. They experienced changes in the size and shape of the median nerve as well as changes in a ligament called the traverse carpel ligament. The study analysed students based on their device use and classified anyone using technology for more than five hours a day as an intensive user. Worryingly, it found that half of all students could be called intensive users and, of

these, the average was nine hours a day3. Another study from Childwise found that children were spending on average six hours a day on their devices, double the number in 19954. The rise in computer-based occupations has also coincided with an increase in Carpal Tunnel Syndrome and other musculoskeletal disorders. However, there is contradictory evidence about whether the two are linked. One study from Z Mediouni et al, found that rates of Carpal Tunnel Syndrome were higher among workers with non-computer related jobs. The highest risks, this study found, were among occupations which involved repetitive and forced pressure on the wrist5. It is, then, a popular myth to link keyboard work to Carpal Tunnel Syndrome. Evidence is inconclusive, but it is possible to say it is associated with people who perform heavy and repetitive tasks with their wrists, adopt awkward hand positions, have to hold strong grips regularly, use vibrating equipment or place mechanical stress on their palm. This means that people who use industrial equipment or use keyboards particularly heavily could increase their risks of developing the condition.

A lack of exercise and poor diet are contributing to increases in obesity, diabetes and high blood pressure, all of which may increase the risk of Carpal Tunnel Syndrome

Health Issues Aside from our use of technology, the modern world is contributing to the rise of Carpal Tunnel Syndrome in many different ways. An aging population brings more people into the higher risk groups. These people may also be more likely to require ongoing treatment as the condition has often advanced to a more serious degree than with younger patients. Conditions such as obesity, high blood pressure and diabetes, which can increase the risk of Carpal Tunnel Syndrome, are also rising. Several studies have shown the prevalence of Carpal Tunnel Syndrome to be higher in patients with diabetes, although the overall clinical evidence is inconclusive6. Other studies suggest Carpal Tunnel Syndrome may predict the onset of diabetes7. WWW.PRIMARYCAREREPORTS.CO.UK | 7

SPECIAL REPORT: IMPROVING THE DIAGNOSIS OF CARPAL TUNNEL SYNDROME

Data suggests that the number of cases of Carpal Tunnel Syndrome have doubled over the past five years. While Carpal Tunnel Syndrome used to affect mainly people over the age of 40, it is becoming more prevalent among younger people

Obesity related hospital admissions, meanwhile, rose by 15% in 2017/18. Figures from NHS Digital show 700,000 cases, a rise of around 100,0008. Researchers from the Finnish Institute of Occupational Health in Helsinki found that the risks of Carpal Tunnel Syndrome grew by 7.4% with each one unit increase in the body mass index9. It is, then, a heady concoction of multiple contributing factors which push up the rate Of Carpal Tunnel Syndrome. Our work life, social life, diet and exercise routines are all having an impact on how likely it is that we will require treatment for Carpal Tunnel Syndrome.

The Cost of Carpal Tunnel Syndrome The cost of treatment is considerable. Data from the US finds that more than 500,000 Carpal Tunnel Syndrome surgeries are performed each year costing an average of $2bn10. This cost comes at a time when health services are struggling to make ends meet. The NHS experienced a deficit of ÂŁ1bn in 2017, double the estimated ÂŁ496 million, and faces tough choices when scheduling treatments11. Carpal Tunnel release surgery was recently named among a list of surgeries which the NHS will now only perform if certain criteria are met12.

The news suggests that patients who may not be considered to be in the most urgent need of Carpal Tunnel Syndrome could be denied treatment. If other remedies have failed, they may find themselves with little alternative but to live with the condition. Both their wellbeing and the finances of the health service could be considerably improved by reducing the need for Carpal Tunnel Syndrome surgery. If the condition can be diagnosed early, injections or splints may be sufficient to ease the symptoms. Testing procedures, such as Electromyograms and Nerve Conduction Studies, can make it easier to spot signs at an early stage. However, these can add delays and can be expensive. New models are coming to the market which are faster, more affordable and more sensitive. Carpal Tunnel Syndrome, then, is becoming a growing problem. Health services will have to understand the evolving nature of the technology available to them to adopt the best strategy. This should be one which provides as much actionable evidence as possible to design the optimum care pathway. Success here will reduce the burden on health services and make the lives of patients much easier.

The cost of treatment is considerable. Data from the US finds that more than 500,000 Carpal Tunnel Syndrome surgeries are performed each year costing an average of $2bn . This cost comes at a time when health services are struggling to make ends meet 8 | WWW.PRIMARYCAREREPORTS.CO.UK

SPECIAL REPORT: IMPROVING THE DIAGNOSIS OF CARPAL TUNNEL SYNDROME

Assessing and Treating Carpal Tunnel Syndrome Jo Roth, Staff Writer The earlier carpel tunnel syndrome is detected the easier it will be to treat, but many health services are leaving gaps in their assessment strategies.

REVENTION IS better than cure and this is particularly true of Carpal Tunnel Syndrome. If spotted early it can be remedied with a few simple interventions. If not, patients may need surgery with all the associated costs they can bring. For the sake of patients and their own finances, health services need to identify the condition earlier.

Treatment and Assessment Doctors have a number of standard treatments for Carpal Tunnel Syndrome, but some may not be effective in certain conditions and delays in diagnosis can lead to more invasive interventions. Steroids, for example, alleviate symptoms but may not last long and can have a number of complications such as damage to the median nerve. Common signs would be a shooting pain up the arm at the time of the injection. They may also lead to other issues such as sensory distortion, motor weaknesses, atrophy and a depigmentation of the skin. Although the number of complications is low, it still represents a significant risk, says the report, and injections should be used sparingly. Patients should not be heavily sedated and should be encouraged to inform medical staff of any adverse reactions at the time. Positioning of the needle will also be crucial to avoiding any injury to the nerve13. Splints can be used on the wrist to reduce the risk of further aggravating the injury for a few nights a week. The splint holds the finger in position at night when many people tend to flex their fists. Some studies show that this can have beneficial effects within just a few weeks. However, the relief is temporary and does not address the underlying issues caused by the condition. Compression surgery can alleviate symptoms, but it is not always effective and has the usual risks of surgery including haematoma and wound infections. In addition, it can cause median nerve damage and other complications. Surgery may take two forms:

â€˘ Open carpel tunnel release: The surgeon makes a cut on the inside of the wrist and then cuts through the flexor retinaculum. â€˘ Endoscopic carpal tunnel release: This is less invasive and carries a lower risk. The surgeon makes a cut on the palm and wrist before inserting an endoscope through one cut to monitor the procedure and guide the instrument through the second cut through the flexor retinaculum. More advanced endoscopic procedures involve making just a single cut in the wrist. This method is just as effective as open carpel tunnel surgery but may have slightly shorter recovery times.

The Drive Towards Earlier Detection The problem is that surgery is invasive and carries risk. It should be considered only if splints or steroid injections have failed to relieve symptoms or if they continue to resurface. The trick is to reduce the number of people requiring more extreme interventions by picking up the condition earlier. This will help both the health services and patients. The latter will want to avoid invasive surgery with all the risks and recovery time that involves. Health services will benefit from avoiding the higher costs involved with surgical intervention and a stay in hospital. A retrospective study by Reuf Karabeg et al analysed 43 patients who had been treated at the clinic for plastic and reconstructive surgery between 2000 and 2008. All patients had verified diagnosis of median nerve compression in the wrist and had a history of long-term work at a computer keyboard. They found that the average recovery time depended on the time which had elapsed between original diagnosis and surgery14. Health services need to develop methods which can detect symptoms at an earlier stage. Typical symptoms tend to include itchiness, tingling or burning sensations. Patients may wake up feeling the need to shake out a hand or experience difficulty grasping certain objects. Unfortunately, many of these symptoms go unaddressed or untreated. We live hectic modern lives and many

Part of the problem is the education of patients, especially those who are in the highrisk categories. These days, that includes a high proportion of the population as we all spend a significant amount of our time in front of a keyboard, either at work or at home

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Doctors have a number of standard treatments for Carpal Tunnel Syndrome, but some may not be effective in certain conditions and delays in diagnosis can lead to more invasive interventions

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people will simply put off going to a doctor until issues become too serious to ignore.

Educating Patients Part of the problem is the education of patients, especially those who are in the high-risk categories. These days, that includes a high proportion of the population as we all spend a significant amount of our time in front of a keyboard, either at work or at home. Patients need to know that the mild symptoms that they might decide to ignore or to live with could be serious if left untreated. People can benefit from information about how they can reduce the risks of developing Carpal Tunnel Syndrome at work and in their day-to-day lives. Simple measures such as taking a break every five minutes to stretch fingers, using an ergonomic stylus or using a keyboard pad to rest your wrists can reduce the impact on the muscles. Many companies are also developing wrist supports which can be worn day and night to keep the wrist in a more neutral position. Making information accessible will be important. The National Institutes of Health and American Medical Association recommends a focus on the readability of patient-centred information about Carpel Tunnel Syndrome. It suggests content should be levelled at a sixth grade reading level. An analysis of the most popular reading materials found on the web discovered that it uniformly exceeded the recommended reading age level making it less accessible to the widest range of patients15.

Other conditions can also increase risks such as high blood pressure or diabetes. By understanding their patients and considering their medical histories, clinicians might be able to highlight the presence of Carpal Tunnel Syndrome earlier.

Improving Technologies Health services will look also at the technologies they use to test for Carpal Tunnel Syndrome to see how these can be improved. Here the need is to provide tests which are faster, more sensitive and affordable. The earliest signs of compression normally come by comparing nerve conduction in the fourth or ring finger where this might be slower. Conventional nerve conduction studies (NCS) may be less effective at identifying these early signs. But this can only form part of the picture and may need other approaches such as electromyography which uses a needle electrode to measure electrical activity within the muscle. Many testing approaches can take time to deliver accurate and reliable results. New techniques can make it easier to provide fast and accurate assessments of Carpal Tunnel Syndrome. They lead to a minimally invasive approach which reduces the impact on the lifestyles of patients, delivers a more reliable result and can help clinicians design the most effective treatment approach. This should result in an earlier and more accurate diagnosis, improved patient outcomes and a lower impact on health service finances.

SPECIAL REPORT: IMPROVING THE DIAGNOSIS OF CARPAL TUNNEL SYNDROME

Can Handheld Devices Lead to Earlier Diagnosis? James Butler, Staff Writer Handheld electrodiagnostic devices offer a faster and more effective way for clinicians to identify the presence of Carpal Tunnel Syndrome.

IME IS money when it comes to healthcare. Demand is booming and resources are limited, so anything that services can do to reduce waiting times will be invaluable. However, although early identification may be crucial, it can also be difficult. There is no gold standard to refer to and clinicians will rely on their observations and information they have about a patient’s medical history. Patients may present in various ways and respond differently to treatment regimes.

Current Diagnosis Methods Clinicians will adopt a number of methods when assessing the needs of patients based on a physical examination, medical histories and screening tests. These include: •P halen Test: This involves flexing the wrist for 60 seconds. If the patient experiences paraesthesia or pain in the median nerve it will be considered positive. •T inel Tests: A clinician will lightly tap over the median nerve. If Carpal Tunnel Syndrome is present this may result in a shooting pain. •D urkin Test: This relies on compression of the underlying median nerve. Thumbs are placed on the proximal edge of the nerve to recreate the symptoms of Carpal Tunnel Syndrome. Each of these is affordable and simple to perform but they are prone to misdiagnosis. The literature review puts the sensitivity of the Phalen test at between 67% to 83% and 40% and 98%. The Tinel test is rated at between 48% and 73%16. It’s a wide range which makes it difficult to make a clear diagnosis. Other conditions may present some or all of the symptoms without being Carpal Tunnel Syndrome. Equally it is possible not to have some of the symptoms and still have Carpal Tunnel Syndrome.

Electro Diagnostics When results are uncertain doctors will move on to electro diagnostics testing which uses nerve conduction studies (NCS) and electromyography (EMG) testing. However, to avoid misdiagnosis, clinicians should consider

using these tests to confirm or eliminate the presence of Carpal Tunnel Syndrome. NCS evaluates how fast electrical signals move through the median nerve in the carpal tunnel and into the muscles. It’s a bit like measuring the flow of water through a garden hose. If this is slowing for any reason it suggests there might be a block or a kink in the hose somewhere down the line. It is this reduction in the flow of electrical signals that leads to altered sensations and muscle weakness. However, this may not be enough on its own to confirm or eliminate the existence of Carpal Tunnel Syndrome. Clinicians will often use EMG tests alongside NCS. These monitor the muscle itself rather than the nerve by examining how it depolarises when activated. It can be used in two ways. The least invasive approach is to place electrodes on the skin to stimulate the muscle and record its response. Alternatively, some tests may use a small needle which is inserted into the muscle and is used to provide the stimulation. However, this process can be painful. The advantage of EMG is that it can identify a very subtle loss of muscle function long before the patient experiences any subjective loss of strength. Therefore, when other symptoms are not present, this can highlight a problem which might have gone undetected. It plays a very important role in identifying nerve damage in the earliest stages and enabling prompt and timely treatment.

A new generation of point of care (POC) handheld devices is now coming to market which offer a faster and more affordable alternative. For example, you can find a Mediracer Carpal Tunnel Syndrome Analyser for around £5,000 for sale

Next Generation Tests EMG and NCS tests play an important role in the diagnosis process. They can provide certainty when previous assessments have been inconclusive, and they can help clinicians determine which courses of treatment will be most effective for individual patients. However, they can be expensive with machines costing more than $10,000 and can take time. For health services looking to cut costs and improve turnaround times, that can be a big turn off. A new generation of point of care (POC) handheld devices is now coming to market which offer a faster and more affordable alternative. WWW.PRIMARYCAREREPORTS.CO.UK | 11

SPECIAL REPORT: IMPROVING THE DIAGNOSIS OF CARPAL TUNNEL SYNDROME

The advantage of EMG is that it can identify a very subtle loss of muscle function long before the patient experiences any subjective loss of strength. Therefore, when other symptoms are not present, this can highlight a problem which might have gone undetected

For example, you can find a Mediracer Carpal Tunnel Syndrome Analyser for around £5,000 for sale. This is billed as a cost effective and easy to use tool for measuring sensory and motor nerve conductions to deliver fast Carpal Tunnel Syndrome assessment and verification. In a clinical trial, the Mediracer device was tested against traditional NCS testing methodologies. The correct positive identification results were 91% suggesting, as the report’s authors stated, that it “demonstrates a high degree of concordance with currently available NCS17.” “The simplicity of the handheld system and the possibility of it being used by a non-specialist suggest the definite possibility of having a one stop clinic for the validated diagnosis of Carpal Tunnel Syndrome,” states the report.

The use of POC handheld devices can improve dramatically the turnaround times for treatment. As the report stated treatment times in the NHS for patients could be several weeks which can cause costly delays in a system which is looking to reduce waiting times. This new device can reduce those waiting times, improve early detection and reduce costs. The goal of health services is to identify symptoms early and to minimise delays in the process. NCS and EMG tests provide more certainty to clinicians, but they can also take time. The arrival of new testing devices which deliver a high level of accuracy and reliability, promise to speed up the process and ensure more people receive a prompt, accurate diagnosis that reduces their risks of needing invasive, risky and expensive surgical procedures.

The simplicity of the handheld system and the possibility of it being used by a non-specialist suggest the definite possibility of having a one stop clinic for the validated diagnosis of Carpal Tunnel Syndrome

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SPECIAL REPORT: IMPROVING THE DIAGNOSIS OF CARPAL TUNNEL SYNDROME

The Future of Carpal Tunnel Diagnostics Tom Cropper, Editor Mobile technologies, portable equipment and ultrasonic imaging can all add value to the diagnosis of Carpal Tunnel Syndrome.

EALTH SERVICES can be forgiven for looking to the future with a bit of trepidation. They will be asked to deliver high care standards, to a greater number of people presenting with more complicated conditions. At the same time, they must deliver these improvements without being given the financial resources they need. The phrase ‘doing more with less’ is much overused in business, but it sums up the challenge. To succeed, they need solutions which can save money while improving outcomes. In the treatment of Carpal Tunnel Syndrome, this means getting much better at identifying symptoms early.

Managing Costs One of the big challenges for the future is costs. Ageing populations and advances in treatments means the next few decades will see dramatic increases in the cost of care. According to a report sponsored by Janssen in the Economist Intelligence Unit, health services in Europe are already barely covering their costs. And the World Bank predicts that public spending on healthcare could jump from 8% of GDP in 2000 to 14% in 203018. Without a major injection of funding, healthcare will not be affordable spending at the current rate. A critical cost analysis of Carpal Tunnel surgery at East Kent University unlocked an annual saving of £15,000 to the department. The trust critiqued their practices and implemented simple changes based on evidence. The report states: “The changes instigated are simple, sustainable and safe to implement while providing improved patient satisfaction. They are also easily transferrable across institutions and to other minor hand surgical procedures to afford even greater ongoing savings to the NHS19.” The report’s authors encourage clinicians to regularly appraise their practices to identify methods in which they can be managed in a more sustainable and effective way. The goal will be to reduce the strain on resources while also improving patient satisfaction.

It can be a delicate balancing act. All too often in the past, cost saving measures have achieved the opposite and news that the NHS may restrict Carpal Tunnel surgery in some cases, raises the prospect of people being left without a remedy20.

Prevention is Better Than Care The best way to achieve both options is to shift attention towards prevention and to make it easier for patients to manage the condition themselves. One solution may be found in the burgeoning market for healthcare apps. With most people in developed countries now owning a smartphone, the mobile health app market is booming. According to Grandview Research, it is growing at almost 45% year on year21. By 2026, it could reach USD $236.0bn as health services find new ways to help patients manage their health remotely. However, there has been relatively little research into their effectiveness. With so many apps entering the market, it is difficult to know which ones should be trusted. A report by M Grant into the use of apps found that an app which uses EMDR bilateral stimulation, could help to reduce pain. EMDR works by stimulating changes in the way negative memories are stored. It is thought to be helpful for patients experiencing PTSD and pain. In a case study, a patient with chronic pain including Carpal Tunnel Syndrome used the app to manage her issues. She had an aversion to surgery and medication and agreed to take part in the trial after a chance encounter with Grant in a corridor. She was advised to use the app whenever she felt pain or stress. After a period of three months, she reported a significant reduction in her levels of pain22. Medical apps can also be a good way to educate customers, especially those who might be considered to be high risk. For example, if someone works with heavy machinery which involves continuous repetitive wrist movements and had a history of diabetes, they would be at a particularly elevated risk of Carpal Tunnel

With most people in developed countries now owning a smartphone, the mobile health app market is booming. According to Grandview Research, it is growing at almost 45% year on year

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A critical cost analysis of Carpal Tunnel surgery at East Kent University unlocked an annual saving of ÂŁ15,000 to the department

Syndrome. Mobile apps can help to identify symptoms early, and they could also help to make adjustments by giving advice such as taking breaks, flexing wrists or wearing support. There is now an enormous amount of information available online about Carpal Tunnel Syndrome and its management. Making sure this is accessible and gets to the people who need to read it will be an important part of managing exposure to health risks.

Imaging Diagnostics In recent years, high resolution ultrasonography has emerged as a valuable tool. It is less invasive, has a lower cost and deliver results in a shorter time. The most widely used approach measures a cross sectional image of the median nerve at the wrist. A report by Tengfei Fu et al sought to assess the value of ultrasonography as a diagnostics tool. It examined 46 patients with clinical and electrodiagnostic evidence of Carpal Tunnel Syndrome. The electrodiagnostic and clinical examinations were accepted as the gold standard and showed a strong positive correlation with results from the ultrasonographic test. The reportâ€™s authors acknowledged that the study had limitations due to the small sample size, but the results, they

said, were enough to show that it had significant promise for use in a clinical setting23. MRI scans can also be used for those cases in which an electrodiagnosis has been equivocal. As with US imagining it can show a bowing of the flexor retinaculum and an enlargement of the median nerve or symptoms such as a loss of fat.

Handheld Electro Diagnostics As for electrodiagnosis methods? These are also evolving rapidly. The rise of accurate and highly sensitive handheld devices is making it easier to collect results quickly while reducing the impact on financial resources. Taken alongside other emerging methods, these have a clear potential to increase the speed and confidence with which a diagnosis can be made. Technology is improving the ability of health services to treat people with Carpal Tunnel Syndrome at every stage, but it is in diagnosis that there are real gains to be made. This can avoid patients going on to develop this painful and chronic condition while reducing the need for hospital treatment. So, while more and more people will be developing Carpal Tunnel Syndrome, the adoption of technology means that their condition can be spotted and resolved more quickly.

The rise of accurate and highly sensitive handheld devices is making it easier to collect results quickly while reducing the impact on financial resources

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SPECIAL REPORT: IMPROVING THE DIAGNOSIS OF CARPAL TUNNEL SYNDROME

References: 1

New Candidates for Treatment and Management of Carpel Tunnel Syndrome Based on the Persian Canon of Medicine: https://www.sciencedirect.com/science/article/pii/S2213422017302196

Cases of Carpel Tunnel Syndrome are on the Rise: http://bit.ly/2JmxlDn

Too Much Tech Tied to Carpel Tunnel Syndrome: https://www.livescience.com/59637-tech-use-tied-to-carpal-tunnel-syndrome.html

Children Spend Six Hours a Day or More on Screens: https://www.bbc.co.uk/news/technology-32067158

Carpal Tunnel Syndrome and Computer Use at Work: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4567686/

Does Diabetes Mellitus Influence Carpal Tunnel Syndrome: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5532320/

Carpal Tunnel May Predict Diabetes: https://www.webmd.com/pain-management/carpal-tunnel/news/20060822/carpal-tunnel-predict-diabetes

Obesity Related Hospital Admissions Rise by 15%: https://www.theguardian.com/society/2019/may/08/obesity-related-hospital-admissions-in-england-rise-by-15 8

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Obesity Linked to Increased: https://www.clinicaladvisor.com/home/web-exclusives/obesity-associated-with-increased-carpal-tunnel-syndrome-risk/ Analysis of Predicted Costs of Carpal Tunnel Syndrome: https://www.ncbi.nlm.nih.gov/pubmed/29166787

NHS Deficit Last Year Double Estimates: https://www.theguardian.com/society/2018/may/28/nhs-deficit-last-year-twice-as-high-as-expected-say-sources 11

NHS to Stop Ineffective Treatments: https://www.bbc.co.uk/news/health-44665560

Median Nerve Injuries Caused by Carpel Tunnel Injection: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3990818/

The Important of Early Diagnosis of Carpel Tunnel Syndrome: https://www.scopemed.org/?mno=4362

Patient Education for Carpel Tunnel Syndrome: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4551621/

Importance of Recognising Carpal Tunnel Syndrome: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5409271/

Carpal Tunnel Syndrome Diagnosis. Validation of a Clinic based Nerve Conduction Measurement Device: http://bit.ly/2xE738E

The Future of Healthcare in Europe: https://www.janssen.com/croatia/sites/www_janssen_com_crotia/files/the_future_of_healthcare_in_europe_0.pdf

How Critical Cost Analysis Can Save Money in Todayâ€™s NHS: https://bmjopenquality.bmj.com/content/7/2/e000115

NHS Proposes to Stop Funding 17 unnecessary Surgeries: https://www.bmj.com/content/362/bmj.k2903/rr-3

M Health Apps Market Size Worth $236bn by 2026: https://www.grandviewresearch.com/press-release/global-mhealth-app-market

The Use of an App to Manage Carpal Tunnel Syndrome: http://www.oapublishinglondon.com/article/1465

Carpal Tunnel Assessment with Ultrasonography: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4305299/

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Notes:

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