American Academy of Orthopaedic Surgeons
Assumptions of the Writing Panel/Voting Panel
Before these appropriate use criteria (AUC) are consulted, it is assumed that:
- For this carpal tunnel syndrome (CTS) AUC, all patients receive an in-office diagnostic evaluation including a completed 6-item carpal tunnel symptoms scale (CTS-6) or Katz Hand Diagram.
- This AUC addresses adult patients with suspected primary CTS and excludes failed treatment after surgery.
- If patients are diabetic and a steroid injection is rated appropriate, the clinician and patient should be aware that the steroid medication may cause a transient but substantial elevation of blood glucose level.
- If operative treatment by carpal tunnel release is appropriate, endoscopic or open may be performed at the practicing clinician's discretion.
- In the absence of reliable evidence, it is the opinion of the work group that CTS during pregnancy should be treated at the discretion of patients and their clinicians within the confines of the clinical practice guideline.
- Duration of symptoms as an indication can be difficult to accurately quantify and therefore is not addressed in this AUC.
- The electrodiagnostic studies (EDSs) are ordered based on clinical judgement and are of sufficient quality to investigate the diagnosis of CTS and/or alternative diagnoses when appropriate.
- For the indication group "response to previous treatment," non-operative treatment assumes no prior steroid injection.
- When surgery is the most appropriate treatment but the patient is unwilling or there is a medical contraindication to surgery, clinicians may select non-operative treatment options.
Results of Appropriateness Rating
The AUC tables (see pages 19-86 in the original guideline document) contain the final appropriateness ratings assigned by the eight members of the voting panel. Patient characteristics are found under the column titled "Scenario". The AUC for each patient scenario can be found within each of the treatment rows. These criteria are formatted by appropriateness labels (i.e. "R"=Rarely Appropriate, "M"=May Be Appropriate, and "A"=Appropriate), median rating, and + or - indicating agreement or disagreement amongst the voting panel, respectively.
Evidence Supporting the Recommendations
The type of evidence supporting the recommendations is not specifically stated.
This Appropriate Use Criteria (AUC) for Management of Carpal Tunnel Syndrome is based on a review of the available literature and a list of clinical scenarios (i.e., criteria) constructed and voted on by experts in orthopaedic surgery and other relevant medical fields.
Implementation of the Guideline
Disseminating Appropriate Use Criteria
All American Academy of Orthopaedic Surgeons (AAOS) Appropriate Use Criteria (AUCs) can be accessed via a user-friendly app that is available via the OrthoGuidelines Web site (www.orthoguidelines.org/auc) or as a native app via the Apple and Google Play stores.
Publication of the AUC document is on the AAOS Web site at http://www.aaos.org/auc. This document provides interested readers with full documentation about the development of AUC and further details of the criteria ratings.
AUCs are first announced by an Academy press release and then published on the AAOS Web site. AUC summaries are published in the AAOS Now and the Journal of the American Academy of Orthopaedic Surgeons (JAAOS). In addition, the Academy's Annual Meeting showcases the AUCs on Academy Row and at Scientific Exhibits.
The dissemination efforts of AUC include Web-based mobile applications, webinars, and online modules for the Orthopaedic Knowledge Online Web site, radio media tours, and media briefings. In addition AUCs are also promoted in relevant Continuing Medical Education (CME) courses and distributed at the AAOS Resource Center.
Other dissemination efforts outside of the AAOS include submitting AUCs to the National Guideline Clearinghouse and to other medical specialty societies' meetings.
Mobile Device Resources
Benefits/Harms of Implementing the Guideline Recommendations
- The main benefit of appropriate use criteria focused on diagnosis is the emphasis on standardized diagnostic criteria which reduce variability in the case definition for carpal tunnel syndrome (CTS). This could have an important impact on the care of CTS, by minimizing the risk of incorrect diagnosis, and also help in the design of studies seeking to identify associations with specific workplace exposures, an area of interest for workers.
- Reducing risks improves treatment efficacy and is accomplished through collaboration and communication between patient and physician.
Many forms of management are associated with some potential for adverse outcomes, especially if invasive or operative.
Rating Scheme for the Strength of the Recommendations
- Volunteer physicians from multiple medical specialties created and categorized these Appropriate Use Criteria (AUC). These AUC are not intended to be comprehensive or a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. These AUC represent patients and situations that clinicians treating or diagnosing musculoskeletal conditions are most likely to encounter. The clinician's independent medical judgment, given the individual patient's clinical circumstances, should always determine patient care and treatment.
- These criteria should not be construed as including all indications or excluding indications reasonably directed to obtaining the same results. The criteria intend to address the most common clinical scenarios facing all appropriately trained surgeons and all qualified physicians managing patients under consideration for diagnosis and management of carpal tunnel syndrome. The ultimate judgment regarding any specific criteria should address all circumstances presented by the patient and the needs and resources particular to the locality or institution. It is also important to state that these criteria were developed as guidelines and are not meant to supersede clinician expertise and experience or patient preference.
- Some drugs or medical devices referenced or described in this document may not have been cleared by the Food and Drug Administration (FDA) or may have been cleared for a specific use only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or device he or she wishes to use in clinical practice.
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
The 2016 Clinical Practice Guideline on the Management of Carpal Tunnel Syndrome was used as the evidence base for this appropriate use criteria (AUC). This guideline helped to inform the decisions of the writing panel and voting panel where available and necessary. The search strategy used for the 2016 clinical practice guideline can be found in Appendix V of that guideline (see the "Availability of Companion Documents" field). For the inclusion and exclusion criteria, see the American Academy of Orthopaedic Surgeons (AAOS) guideline on management of carpal tunnel syndrome (see the "Availability of Companion Documents" field).
230 articles were included after full text review and quality analysis in the clinical practice guideline.
Weighting According to a Rating Scheme (Scheme Given)
For information on how the quality of data was evaluated, see the American Academy of Orthopaedic Surgeons (AAOS) guideline on management of carpal tunnel syndrome (see the "Availability of Companion Documents" field).
Systematic Review with Evidence Tables
The purpose of this Appropriate Use Criteria (AUC) is to help determine the appropriateness of clinical practice guideline recommendations for the heterogeneous patient population routinely seen in practice. The best available scientific evidence is synthesized with collective expert opinion on topics where gold standard randomized clinical trials are not available or are inadequately detailed for identifying distinct patient types. When there is evidence corroborated by consensus that expected benefits substantially outweigh potential risks, exclusive of cost, a procedure is determined to be appropriate. The American Academy of Orthopaedic Surgeons (AAOS) uses the Research and Development/University of California, Los Angeles (RAND/UCLA) Appropriateness Method (RAM). The process includes these steps: reviewing the results of the evidence analysis, compiling a list of clinical vignettes, and having an expert panel comprised of representatives from multiple medical specialties to determine the appropriateness of each of the clinical indications for treatment as "Appropriate," "May Be Appropriate," or "Rarely Appropriate."
Expert Consensus (Delphi)
The American Academy of Orthopaedic Surgeons (AAOS) uses the Research and Development/University of California, Los Angeles (RAND/UCLA) Appropriateness Method (RAM).
Two panels participated in the development of the carpal tunnel syndrome (CTS) appropriate use criteria (AUC). Members of the writing panel developed a list of 135 patient scenarios, for which six treatments were evaluated for appropriateness. The voting panel participated in three rounds of voting. During the first round of voting, the voting panel was given approximately two months to independently rate the appropriateness of each the provided treatments for each of the relevant patient scenarios as 'Appropriate', 'May Be Appropriate', or 'Rarely Appropriate' via an electronic ballot. After the first round of appropriateness ratings were submitted, AAOS staff calculated the median ratings for each patient scenario and specific treatment. An in-person voting panel meeting was held in Rosemont, IL on Friday, August 12, 2016. During this meeting, voting panel members addressed the scenarios/treatments which resulted in disagreement (definition of disagreement can be found in Table 3 in the original guideline document). The voting panel members discussed the list of assumptions, patient indications, and treatments to identify areas that needed to be clarified/edited. After the discussion and subsequent changes, the group was asked to rerate their first round ratings during the voting panel meeting, only if they were persuaded to do so by the discussion and available evidence. After completion of the second round of voting, the voting panel opted to look again at scenarios which still contained disagreement and open the ballot for a third round of voting. The voting panel determined appropriateness by rating treatments for the various patient scenarios (i.e., criteria) as "Appropriate", "May Be Appropriate", or "Rarely Appropriate". There was no attempt to obtain consensus about appropriateness.
Panel members of the Carpal Tunnel Syndrome AUC, who are orthopaedic specialists in treating wrist-related injuries/diseases, developed clinical scenarios using the following guiding principles:
- Patient scenarios must include a broad spectrum of patients that may be eligible for diagnosis or treatment of CTS [comprehensive]
- Patient indications must classify patients into a unique scenario [mutually exclusive]
- Patient indications must consistently classify similar patients into the same scenario [reliable, valid indicators]
The writing panel developed the scenarios by categorizing patients in terms of indications evident during the clinical decision making process (see Figure 1 in the original guideline document). These scenarios relied upon definitions and general assumptions, mutually agreed upon by the writing panel during the development of the scenarios. These definitions and assumptions were necessary to provide consistency in the interpretation of the clinical scenarios among experts voting on the scenarios and readers using the final criteria.
Formulating Indications and Scenarios
The AUC writing panel began the development of the scenarios by identifying clinical indications typical of patients with suspected CTS in clinical practice. Indications are most often parameters observable by the clinician, including symptoms or results of diagnostic tests. Additionally, "human factor" (e.g., activity level) or demographic variables can be considered.
Indications identified in clinical trials (derived from patient selection criteria) included in AAOS Clinical Practice Guidelines (CPGs) served as a starting point for the writing panel and ensured that these Appropriate Use Criteria referred to the evidence base for the CTS CPG. The writing panel considered this initial list and other indications based on their clinical expertise and selected the most clinically relevant indications (see Table 4 in the original guideline document). They then defined distinct classes for each indication in order to stratify/categorize the indication (see Table 4 in the original guideline document).
The indications are then organized into a matrix of clinical scenarios that addressed all combinations of the classifications. The writing panel was given the opportunity to remove any scenarios that rarely occur in clinical practice, but agreed that all scenarios were clinically relevant. The major clinical decision making indications chosen by the writing panel divided the matrix of clinical scenarios into chapters, as follows: CTS diagnostic likelihood based on clinical examination, electrodiagnostic testing history, clinical severity, response to previous treatment.
Creating Definitions and Assumptions
The CTS AUC writing panel constructed concise and explicit definitions for the indications and classifications. This standardization helped ensure the way that the writing panel defined the patient indications was consistent among those reading the clinical scenario matrix or the final criteria. Definitions drew explicit boundaries when possible and were based on standard medical practice or existing literature.
Additionally, the writing panel formulated a list of general assumptions in order to provide more consistent interpretations of a scenario (see "Assumptions of the Writing Panel" in the "Major Recommendations" field). These assumptions differed from definitions in that they identified circumstances that exist outside of the control of the clinical decision making process.
Assumptions also addressed the use of existing published literature regarding the effectiveness of treatment and/or the procedural skill level of physicians. Additionally, assumptions highlighted intrinsic methods described in this document such as the role of cost considerations in rating appropriateness or the validity of the definition of appropriateness. The main goal of assumptions was to focus scenarios so that they apply to the average patient presenting to an average physician at an average facility.
The definitions and assumptions should provide readers with a common starting point in interpreting the clinical scenarios. This list of definitions and assumptions accompanied the matrix of clinical scenarios in all stages of the development of this AUC and appears in the "Assumptions of the Writing Panel" section of the "Major Recommendations" field.
Voting Panel Modifications to Writing Panel Materials
At the start of the in-person voting panel meeting, the voting panel was reminded that they have the ability to amend the original writing panel materials if the amendments resulted in more clinically relevant and practical criteria. In order to amend the original materials, the voting panel members were instructed that a member must make a motion to amend and another member must "second" that motion, after which a vote is conducted. If a majority of voting panel members voted "yes" to amend the original materials, the amendments were accepted. See the "Methods" section in the original guideline document for amendments/additions to the original AUC materials.
A multidisciplinary panel of clinicians was assembled to determine the appropriateness of treatments for the CTS AUC. A non-voting moderator, who is an orthopaedic surgeon, but is not a specialist in the treatment of CTS, moderated the voting panel. The moderator was familiar with the methods and procedures of AAOS AUC and led the panel (as a non-voter) in discussions. Additionally, no member of the voting panel was involved in the development (writing panel) of the scenarios.
The voting panel used a modified Delphi procedure to determine appropriateness ratings. The voting panel participated in three rounds of voting while considering evidence-based information provided in the literature review. While cost is often a relevant consideration, panelists focused their appropriateness ratings on the effectiveness of diagnosis and treatment of CTS.
When rating the appropriateness of a scenario, the voting panel considered the following definition:
"An appropriate action for suspected CTS is one for which the action is generally acceptable, is a reasonable approach for the indication, and is likely to improve the patient's health outcomes or survival."
They then rated each scenario using their best clinical judgment, taking into consideration the available evidence, for an average patient presenting to an average physician at an average facility as follows:
Table. Interpreting the 9-Point Appropriateness Scale
Appropriate for the indication provided, meaning treatment is generally acceptable and is a reasonable approach for the indication and is likely to improve the patient's health outcomes or survival.
|4-6||May Be Appropriate: |
Uncertain for the indication provided, meaning treatment may be acceptable and may be a reasonable approach for the indication, but with uncertainty implying that more research and/or patient information is needed to further classify the indication.
|1-3||Rarely Appropriate: |
Rarely an appropriate option for management of patients in this population due to the lack of a clear benefit/risk advantage; rarely an effective option for individual care plans; exceptions should have documentation of the clinical reasons for proceeding with this care option (i.e., procedure is not generally acceptable and is not generally reasonable for the indication).
Each panelist uses the scale below to record their response for each scenario:
Appropriateness of [Topic]
Rarely Appropriate: 1, 2, 3
May Be Appropriate: 4, 5, 6
Appropriate: 7, 8, 9
Round One Voting
The first round of voting occurred after completion of the independent review of the scenarios by the review panel and approval of the final indications, scenarios, and assumptions by the writing panel. The voting panel rated the scenarios electronically using a personalized ballot created by AAOS staff using the AAOS AUC Electronic Ballot Tool. There was no interaction between panel members while completing the first round of voting. Panelists considered the following materials:
- The instructions for rating appropriateness
- The completed literature review, that is appropriately referenced when evidence is available for a scenario
- The list of indications, definitions, and assumptions, to ensure consistency in the interpretation of the clinical scenarios
Round Two and Three Voting
The second round of voting occurred during the in-person voting panel meeting on August 12, 2016. Before the in-person meeting started, each panelist received a personalized document that included their first round ratings along with summarized results of the first-round ratings that resulted in disagreement. These results indicated the frequency of ratings for a scenario for all panelists. The document contained no identifying information for other panelists' ratings. The moderator also used a document that summarized the results of the panelists' first round voting. These personalized documents served as the basis for discussions of scenarios which resulted in disagreement.
During the discussion, the voting panel members were allowed to add or edit the assumptions list, patient indications, and/or treatments if clarification was needed. They were also asked to record a new rating for any scenarios/treatments, only if they were persuaded to do so by the discussion and/or the evidence. There was no attempt to obtain consensus among the panel members.
Upon completion of the second round of voting, AAOS staff and moderators used the AAOS AUC Electronic Ballot Tool to again identify any statistical disagreements. After discussing these again, and at the request of the voting panel, the ballots were opened for a third round of voting. No voter was forced to participate in this round of voting and there was no attempt to obtain consensus among the panel members. After the final ratings were submitted, AAOS staff used the AAOS AUC Electronic Ballot Tool to export the median values and level of agreement for all voting items.
Using the median value of the third round ratings, AAOS staff determined the final levels of appropriateness. Disagreement among raters can affect the final rating. Agreement and disagreement were determined using the BIOMED definitions of Agreement and Disagreement, as reported in the RAND/UCLA Appropriate Method User's Manual, for a panel of 8 to 10 voting members (see Table 2 in the original guideline document). The 8-to-10 panel member disagreement cutoff was used for this voting panel. For this panel size, disagreement is defined as when ≥3 members' appropriateness ratings fell within the appropriate (7-9) and rarely appropriate (1-3) ranges for any scenario (i.e., ≥3 members' ratings fell between 1-3 and ≥5 members' ratings fell between 7-9 on any given scenario and its treatment). If there is still disagreement in the voting panel ratings after the second round of voting, that voting item is labeled as "5" regardless of median score. Agreement is defined as ≤2 panelists rated outside of the 3-point range containing the median.
See Table 3 in the original guideline document for additional information on final ratings.
A formal cost analysis was not performed and published cost analyses were not reviewed. While cost is often a relevant consideration, panelists focused their appropriateness ratings on the effectiveness of diagnosis and treatment of carpal tunnel syndrome.
Internal Peer Review
The American Academy of Orthopaedic Surgeons (AAOS) Appropriate Use Criteria (AUC) Section, the AAOS Council on Research and Quality, and the AAOS Board of Directors sequentially approved the Appropriate Use Criteria for Management of carpal tunnel syndrome. See Appendix B in the original guideline document for additional information on documentation of approval.
Identifying Information and Availability
American Academy of Orthopaedic Surgeons (AAOS). American Academy of Orthopaedic Surgeons appropriate use criteria for the management of carpal tunnel syndrome. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2016 Dec 9. 94 p. [7 references]
Not applicable: The guideline was not adapted from another source.
The American Academy of Orthopaedic Surgeons exclusively funded development of these Appropriate Use Criteria. The American Academy of Orthopaedic Surgeons received no funding from outside commercial sources to support the development of these Appropriate Use Criteria.
Appropriate Use Criteria for the Management of Carpal Tunnel Syndrome Writing Panel
Writing Panel Members: Noah Raizman, MD, American Academy of Orthopaedic Surgeons; Gary Frykman, MD, American Academy of Orthopaedic Surgeons; Min Jung Park, MD, American Academy of Orthopaedic Surgeons; Charles T Resnick, MD, American Academy of Orthopaedic Surgeons; Murray J Goodman, MD, American Academy of Orthopaedic Surgeons; Robert A. Werner, MD, American Academy of Physical Medicine and Rehabilitation; Warren C. Hammert, MD, American Association for Hand Surgery; Joy MacDermid, MD, American Society of Hand Therapists; Diana Carr, MD, American Academy of Orthopaedic Surgeons; Michael Cartwright, MD, American Academy of Neurology; Brent Graham, MD, American Society for Surgery of the Hand
Voting Panel Members: Philip E. Blazar, MD, American Academy of Orthopaedic Surgeons; Shafic A. Sraj, MD, American Academy of Orthopaedic Surgeons; Theresa O. Wyrick, MD, American Academy of Orthopaedic Surgeons; John Kincaid, MD, American Academy of Neurology; Atul T. Patel, MD, American Academy of Physical Medicine & Rehabilitation; Gary Mlady, MD, American College of Radiology; Kathryn L. Mueller, MD, American College of Occupational & Environmental Medicine; Caroline W. Stegink Jansen, PT, PhD, American Society of Hand Therapists; Charles A. Goldfarb, MD, American Society for Surgery of the Hand
Additional Contributor: Marc J. Richard, MD, American Academy of Orthopaedic Surgeons
Voting Panel Round Two Discussion Moderator: Pekka Mooar, MD & William J. Doherty, MD (moderator-in-training)
Appropriate Use Criteria (AUC) Section Leader, American Academy of Orthopaedic Surgeons (AAOS) Committee on Evidence-Based Quality and Value: Robert H. Quinn, MD
Chair, AAOS Committee on Evidence-Based Quality and Value: Kevin Shea, MD
Chair, AAOS Council on Research and Quality: David S. Jevsevar, MD, MBA
AAOS Staff: William O. Shaffer, MD, Medical Director; Deborah S. Cummins, PhD, Director, Department of Research and Scientific Affairs; Jayson Murray, MA, Manager, Evidence-Based Medicine Unit; Ryan Pezold, MA, Lead Research Analyst, Evidence-Based Medicine Unit; Peter Shores, MPH, Statistician, Evidence-Based Medicine; Anne Woznica, MLS, Medical Librarian; Kaitlyn Sevarino, MBA, Evidence-Based Quality and Value (EBQV) Specialist; Erica Linskey, Administrative Assistant, Evidence-Based Medicine Unit
In accordance with American Academy of Orthopaedic Surgeons policy, all individuals whose names appear as authors or contributors to this document filed a disclosure statement as part of the submission process. All authors provided full disclosure of potential conflicts of interest prior to participation in the development of these Appropriate Use Criteria. Disclosure information for all panel members can be found in Appendix C in the original guideline document.
This is the current release of the guideline.
This guideline meets NGC's 2013 (revised) inclusion criteria.
Available from the American Academy of Orthopaedic Surgeons (AAOS) Web site and the OrthoGuidelines Web site.
The following are available:
- American Academy of Orthopaedic Surgeons (AAOS). Management of carpal tunnel syndrome evidence-based clinical practice guideline. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2016 Feb 29. 983 p. Available from the American Academy of Orthopaedic Surgeons (AAOS) Web site.
- AAOS Appropriate Use Criteria Methodology. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS). 11 p. Available from the AAOS Web site.
A mobile app for the appropriate use criteria for the management of carpal tunnel syndrome is available on the AAOS Web site.
Samples of the 6-item carpal tunnel symptoms scale (CTS-6) and Katz Hand Diagram are available in the Appendix A of the original guideline document.
This NGC summary was completed by ECRI Institute on June 29, 2017. The information was verified by the guideline developer on July 18, 2017.
This NEATS assessment was completed by ECRI Institute on July 13, 2017. The information was verified by the guideline developer on July 18, 2017.
This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. For more information, please contact AAOS Department of Research and Scientific Affairs, 9400 West Higgins Road, Rosemont, IL 60018; Phone: (847) 823-7186; Fax: (847) 823-8125.
Carpal tunnel syndrome
Note: This appropriate use criteria (AUC) does not apply to:
- Acute carpal tunnel syndrome
- Untreated inflammatory arthritis
- Untreated diabetes
- Thyroid disease
- Pernicious anemia
Physical Medicine and Rehabilitation
Advanced Practice Nurses
Health Care Providers
To help determine the appropriateness of clinical practice guideline recommendations for the heterogeneous patient with carpal tunnel syndrome (CTS) routinely seen in practice
Adult patients with suspected primary carpal tunnel syndrome
Note: This appropriate use criteria (AUC) does not include:
- Patients with a known space-occupying lesion in the carpal tunnel
- Patients who have failed treatment after surgery
- Pediatric and adolescent patients
- Investigating alternative diagnosis
- Investigating further: electrodiagnostic study
- Non-operative treatment
- Oral steroids or ketoprofen phonophoresis
- Steroid injection
- Operative treatment: carpal tunnel release
- Change in symptoms
- Functional status
- Patient satisfaction
- Quality of life
Contraindications vary widely based on the treatment administered.
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