Managed Physical Medicine

Physical Therapy Following Carpal Tunnel Release: Guidelines and Considerations

MedRisk Advisory Board Member Dr. Jane Fedorcyzk responds to new performance measures regarding post-operative PT for carpal tunnel patients.

In December 2017, the American Academy of Orthopaedic Surgeons (AAOS) approved new carpal tunnel syndrome performance measures to be submitted to the U.S. Centers for Medicare & Medicaid Services (CMS) for consideration. The measures, which are based on a previously published AAOS Clinical Practice Guideline (CPG), discourage the routine use of occupational therapy (OT) or physical therapy (PT) after carpal tunnel release (CTR) surgery. In other words, each patient is different. Some patients will recover quickly with a home exercise program and some do better with clinical supervision and direction.

We interviewed MedRisk International Scientific Advisory Board (ISAB) member and hand and upper quarter rehabilitation expert Dr. Jane Fedorcyck, who talked through which patients may benefit from post-operative OT or PT support and what they stand to gain in the process.

The new measure cautions against “routine” use of OT or PT after CTR surgery, but under what circumstances should PT referral be considered?

Often, patients who are experiencing wrist pain have a limited incision carpal tunnel release, where a tiny incision is made at the proximal edge of the palm. The purpose of the surgery is to release a ligament and change the pressure gradient in the carpal tunnel. The surgery isn’t intended to fix the nerve but rather open up the space to allow the blood to flow so it can heal.

But sometimes the incision can cause a new pain experience, or it can improve the pain but issues such as numbness or the inability to move the hand, wrist or arm persist. This is the point at which patients are sometimes referred to a PT and often the first time we see a carpal tunnel patient.

What are the benefits of seeing a physical therapist post-operatively?

If a patient is still experiencing pain after surgery, a PT is going to do a thorough exam to get to the root of the problem. A PT will examine the entire upper limb. A cervical injury could be contributing or occurring at the same time. When there is neurogenic pain in an upper extremity, a PT will clear the cervical spine and brachial plexus and look for associated conditions as well.

But it’s more than the physical exam. A large part of what we do is patient education. Even if it is just that one post-operative visit, we have the opportunity to teach the patient how to do exercises correctly and speed up their recovery. I also teach my patients how to incorporate breathing, so it can act as a distractor against the pain. There is a lot of fear and anxiety in the recovery process, and PTs can help guide patients through that. This kind of education works well in a traditional in-clinic setting and also via telerehab or video conferencing.

How do these new performance measures impact MedRisk’s network of providers?

The guidelines are meant to support clinical decision-making for orthopedic surgeons, which are a source of referrals for OTs and PTs. At MedRisk, we care for these patients after the point of referral.

MedRisk’s evidence-based guidelines are specific to PT and incorporate the latest research, including evidence and recommendations from the American Physical Therapy Association (new updates are expected in 2019), ODG [Official Disability Guidelines], ACOEM [American College of Occupational and Environmental Medicine] and more. We use MedRisk’s guidelines as well as state-mandated guidelines to manage treatment strategies for carpal tunnel patients after they have been referred by the physician for PT.

In our field, treatment strategies are based on available evidence as well as clinical wisdom and the patient’s individual needs. Oftentimes, guidelines are informed by evidence from clinical trials that exclude patients with comorbidities. But real-life patients aren’t like this; they have unique conditions and circumstances. Guidelines must always be considered in the context of the patient to ensure they receive the best care possible.

About Jane Fedorczyk, PT, PhD, CHT, ATC

Jane Fedorczyk is a professor of physical therapy and rehabilitation sciences at the University of South Florida in Tampa, Florida, where she is also the co-coordinator of professional education. A certified hand therapist, she is the Immediate Past President of American Society of Hand Therapists, and active in the American Hand Therapy Foundation and the American Physical Therapy Association.

Dr. Fedorczyk holds a PhD in Physical Therapy and has received several professional honors, including the R. L. Petzoldt Award for Innovation in Hand Therapy.