10 Clinical Practice Guidelines in Hand Therapy and Hand Surgery
In physiotherapy and occupational therapy, Clinical Practice Guidelines (CPG) have established themselves as fundamental tools for guiding evidence-based clinical decision making. These guidelines, developed by experts and supported by the latest scientific evidence, provide a systematic framework for addressing specific clinical situations, optimizing the quality and efficiency of medical care.
CPGs represent a careful synthesis of the best available evidence, together with clinical experience and patient preferences, providing a comprehensive and up-to-date approach to the management of musculo-skeletal health conditions. These guidelines are not only valuable to healthcare professionals, but also serve as essential resources for improving patient safety and continuity of care.
In the context of clinical practice, CPGs offer numerous benefits. First, they help to standardize clinical decisions, reducing variability and improving consistency in patient care. In addition, they facilitate the rapid incorporation of scientific advances, promoting the continuous updating of healthcare professionals. This translates into more informed and effective care, aligned with best practices and current scientific evidence.
10 Relevant Clinical Practice Guidelines (CPG) for wrist, hand and/or finger injuries
In our quest to provide valuable resources to colleagues dealing with wrist, hand and finger segment injuries, we have conducted a search of available CPGs in hand therapy and surgery, and have located 10 Clinical Practice Guidelines (CPGs) that stand out for their relevance and usefulness. These guidelines have been carefully selected based on their comprehensive approach, scientific rigor and applicability in a variety of clinical settings. Let’s see them! 🕵️♀️
1. Carpal Tunnel Syndrome: Hand Pain and Sensory Deficits (2019)
This Clinical Practice Guideline developed by the Academy of Orthopaedic Physical Therapy (AOPT) and the Academy of Hand and Upper Extremity Physical Therapy (AHUEPT) of the American Physical Therapy Association (APTA), aimed to provide an analysis of evidence-based clinical guidelines for treating and preventing pain-based diagnoses and sensory deficits of the hand, such as Carpal Tunnel Syndrome.
The use of tests such as the Semmes-Weinstein monofilament and Phalen’s test to evaluate patients with suspected CTS is suggested. Outcome measures are highlighted, including the use of the Boston Carpal Tunnel Questionnaire Symptom Severity Scale (CTQ-SSS), and the recommendation of wrist orthoses in the neutral position for short-term symptomatic relief and functional improvement in patients seeking nonsurgical treatment is advised.
In addition, guidelines are provided on strength measurements, sensory and provocative testing, and other interventions such as manual therapy and therapeutic exercise.
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2. Carpal Tunnel Syndrome: Results of the European HANDGUIDE Study (2014)
Carpal Tunnel Syndrome is a prevalent condition caused by damage to the median nerve as a result of pressure inside the carpal tunnel, resulting in nerve injury. The aim of this guide was to reach a consensus on a multidisciplinary treatment guideline for CTS.
After 3 Delphi rounds, a consensus was reached on the description, symptoms and diagnosis of CTS. The experts agreed that patients with should always receive instructions, and that instructions combined with splints, corticosteroid injections, corticosteroid injections plus splints, and surgery are appropriate treatments for CTS. Details relevant to the use of instructions, splints, corticosteroid injections, and surgery were described.
The main factors for selecting one of the aforementioned were identified: severity and duration of the disorder, and previous treatments administered. The experts indicated that there was a relationship between severity and duration of the disorder and the choice of treatment was indicated by the experts and reflected in the guideline.
3. Management of Osteoarthritis of the Hand: 2018 Update of the EULAR Recommendations (2018)
The study addressed the need to update the European League Against Rheumatism (EULAR) recommendations for the treatment of osteoarthritis of the hand (OA). Following standardized procedures, the update incorporates new evidence since the 2007 recommendations. Based on the evidence and the opinion of an international group of 19 physicians, health professionals and patients from 10 European countries, general principles and recommendations were formulated.
Five general principles and ten recommendations were established. These principles address treatment goals, information, treatment individualization, shared decision making, and consideration of multidisciplinary approaches (nonpharmacological, pharmacological, surgical). Recommendations 1-3 focus on nonpharmacologic treatment options, such as education, assistive devices, exercises, and orthoses. Recommendations 4-8 detail the role of various pharmacological treatments, giving preference to topical over systemic drugs, with topical NSAIDs as the first choice. They also address oral analgesics, chondroitin sulfate, intra-articular glucocorticoids and disease-modifying antirheumatic drugs. Recommendation 9 includes surgical considerations, and the last recommendation addresses follow-up. These EULAR recommendations provide up-to-date guidance based on expert experience and research evidence for the management of hand osteoarthritis.
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4. Management of Distal Radius Fractures Evidence-Based Clinical Practice Guidelines (2020)
This clinical practice guideline approved by The American Academy of Orthopaedic Surgeons Board and The American Society for Surgery of the Hand was intended to inform the management of acute distal radius fractures using the best current evidence.
The guideline provides recommendations based on a rigorous, standardized process. In addition, it recognizes the diversity of care settings and providers, and is not exhaustive, emphasizing the importance of considering patient-specific factors and contextual needs when determining particular procedures or treatments.
👉 Do you have patients with Radial Wrist Fracture? Then learn all about Differential Diagnosis of Radial-Side Wrist Pain [+FREE EBOOK].
5. Guyon Canal Syndrome: Results of the European HANDGUIDE Study (2013)
Guyon’s Canal Syndrome is a clinical entity of the hand that is not very prevalent. For its correct treatment, a thorough knowledge of the anatomy of the hand and wrist is essential. Unfortunately, data on the efficacy of interventions for this disorder are lacking. For this reason, the aim of this CPG was to establish a consensus on a multidisciplinary treatment guideline based on expert opinions.
The guideline identified key factors in selecting the ideal treatment for each case, such as severity or duration of the syndrome, and previous treatments. Despite its rarity and diagnostic challenges, this guideline has the potential to improve the understanding and treatment of Guyon’s canal syndrome.
Did you know that this ulnar nerve involvement is quite common among cyclists 🤔?
6. Trigger Finger Management: Results from the European HANDGUIDE Study (2014)
Trigger finger or stenosing tenosynovitis, characterized by an occasionally painful clicking or locking during finger flexion, is a common phenomenon in clinical practice. Despite its prevalence, there is no established “best practice” treatment protocol. The aim of this work was to establish a consensus on a multidisciplinary treatment guideline for trigger finger.
After four Delphi rounds, consensus was reached on the description, symptoms and diagnosis of spring finger. The experts agreed that treatment options such as the use of orthoses (splints), corticosteroid injections, corticosteroid injections combined with the use of orthoses, and surgery are appropriate.
It is recognized that the results represent the opinion of the group of experts at a given time and that, as evidence on the effectiveness of the interventions increases, the opinions of the experts may change, which would require a reevaluation and adjustment of the guideline.
Does Trigger Finger Tendons present Tendinosis characteristics?💥
7. De Quervain’s disease: results of the European HANDGUIDE study (2014)
De Quervain’s tenosynovitis is a common and painful disorder affecting the tendons of the wrist. The aim of this work was to establish a consensus on a multidisciplinary treatment guideline for the disease.
A consensus was reached on the description, symptoms and diagnosis of De Quervain’s disease. The experts agreed that patients with this disorder should always receive instructions and recommendations about the disease, and that these should be combined with another form of treatment and should not be used as the sole treatment. Combined instructions with NSAIDs, splints, NSAIDs plus splints, corticosteroid injections, corticosteroid injections plus splints or surgery. Details of the use of instructions, NSAIDs, splints, corticosteroid injections and surgery were described.
The main factors for selecting one of the aforementioned were identified: severity and duration of the disorder, and previous treatments administered. The experts indicated that there was a relationship between severity and duration of the disorder and the choice of treatment was indicated by the experts and reflected in the guideline.
Do you know these 6 fun facts about DeQuervain’s tenosynovitis?
8. Dupuytren’s disease: Results of the European HANDGUIDE Study (2013)
Dupuytren’s disease is a condition that affects the hand and manifests as a deformity in the tissue located under the palm of the hand, which gradually develops into a contracture that blocks the fingers of the hand in flexion. This contracture specifically impacts the ring and little finger, being more common in older men with roots in Northern Europe. This clinical practice guideline attempted to reach a consensus for a multidisciplinary treatment of the disease.
After four Delphi rounds, consensus was reached on the description, symptoms and diagnosis of Dupuytren’s disease. Open and needle fasciotomy, as well as limited fasciectomy and dermofasciectomy, were considered appropriate surgical techniques. Factors relevant to the choice of one of these surgical techniques were identified and divided into patient-related (age, comorbidity), disease-related (palpable cord, previous surgery in the same area, skin involvement, recovery time, recurrences) and surgeon-related (years of experience) factors. Associations of these factors with the choice of a specific surgical technique were reported in the guideline. Details relevant to the use of surgical and post-surgical interventions were described.
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9. Lateral Elbow Pain and Alterations in Muscle Function (2022)
This Clinical Practice Guideline developed by the Academy of Orthopaedic Physical Therapy (AOPT) and the Academy of Hand and Upper Extremity Physical Therapy (AHUEPT) of the American Physical Therapy Association (APTA), aimed to provide a review of evidence-based clinical guidelines for treating and preventing diagnoses based on Lateral Elbow Pain and Muscle Function Disturbances. This clinical practice guideline addresses the epidemiology, functional anatomy and pathophysiology, risk factors, clinical course, prognosis, differential diagnosis, tests and measures, and interventions for the management of lateral elbow tendinopathy in the physical therapy clinic.
The authors highlighted that, although often described as a self-limiting condition that frequently resolves on its own, high recurrence rates and prolonged sick leave raise the need for effective nonsurgical treatment for people with lateral elbow tendinopathy.
Recommendations for lateral epicondylitis (LE) emphasize the use of the PRTEE or DASH questionnaires to assess pain and function. In addition, the inclusion of physical impairment measures, such as range of motion and strength, along with interventions such as therapeutic exercise, joint manipulations, and dry needling are suggested to treat LE. The use of orthoses and bandages for immediate relief is addressed, and cryotherapy with TENS is recommended for short-term pain reduction. In terms of ergonomics, the implementation of educational interventions and workplace adjustments is supported.
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10. Elbow Disorders: ACOEM Practice Guidelines (2013)
The American College of Occupational and Environmental Medicine (ACOEM) updated its treatment guidelines in the chapter on Elbow Disorders such as Lateral Elbow Tendinopathy, initiating the revision process in 2006. This document provided an overview of the evidence and recommendations developed, offering guidance for 13 major diagnoses with a total of 270 specific recommendations.
Diagnoses such as contusions, epicondylalgia or lateral and medial epicondylitis, elbow fractures, elbow dislocations, elbow sprains, biceps brachii tendinosis or ruptures, triceps brachii tendinosis or ruptures, Neuropathies of the Ulnar Nerve at the Elbow, Entrapments of the Radial Nerve at the Elbow or Pronator Syndrome and Entrapment of the Median Nerve, were the ones analyzed in this document.
6 TESTS FOR LATERAL EPICONDILITIS YOU MUST KNOW🔥
REFERENCES
1) Erickson, M., Lawrence, M., Jansen, C. W. S., Coker, D., Amadio, P., & Cleary, C. (2019). Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome. The Journal of orthopaedic and sports physical therapy, 49(5), CPG1–CPG85. https://doi.org/10.2519/jospt.2019.0301
2) Huisstede, B. M., Fridén, J., Coert, J. H., Hoogvliet, P., & European HANDGUIDE Group (2014). Carpal tunnel syndrome: hand surgeons, hand therapists, and physical medicine and rehabilitation physicians agree on a multidisciplinary treatment guideline—results from the European HANDGUIDE Study. Archives of physical medicine and rehabilitation, 95(12), 2253–2263. https://doi.org/10.1016/j.apmr.2014.06.022
3) Kloppenburg, M., Kroon, F. P., Blanco, F. J., Doherty, M., Dziedzic, K. S., Greibrokk, E., Haugen, I. K., Herrero-Beaumont, G., Jonsson, H., Kjeken, I., Maheu, E., Ramonda, R., Ritt, M. J., Smeets, W., Smolen, J. S., Stamm, T. A., Szekanecz, Z., Wittoek, R., & Carmona, L. (2019). 2018 update of the EULAR recommendations for the management of hand osteoarthritis. Annals of the rheumatic diseases, 78(1), 16–24. https://doi.org/10.1136/annrheumdis-2018-213826
4) American Academy of Orthopaedic Surgeons. Management of Distal Radius Fractures Evidence-Based Clinical Practice Guideline. www.aaos.org/drfcpg. Published December 5, 2020.
5) Hoogvliet, P., Coert, J. H., Fridén, J., Huisstede, B. M., & European HANDGUIDE group (2013). How to treat Guyon’s canal syndrome? Results from the European HANDGUIDE study: a multidisciplinary treatment guideline. British journal of sports medicine, 47(17), 1063–1070. https://doi.org/10.1136/bjsports-2013-092280
6) Huisstede, B. M., Hoogvliet, P., Coert, J. H., Fridén, J., & European HANDGUIDE Group (2014). Multidisciplinary consensus guideline for managing trigger finger: results from the European HANDGUIDE Study. Physical therapy, 94(10), 1421–1433. https://doi.org/10.2522/ptj.20130135
7) Huisstede, B. M., Coert, J. H., Fridén, J., Hoogvliet, P., & European HANDGUIDE Group (2014). Consensus on a multidisciplinary treatment guideline for de Quervain disease: results from the European HANDGUIDE study. Physical therapy, 94(8), 1095–1110. https://doi.org/10.2522/ptj.20130069
8) Huisstede, B. M. A., Hoogvliet, P., Coert, J. H., Fridén, J., & European HANDGUIDE Group (2013). Dupuytren disease: European hand surgeons, hand therapists, and physical medicine and rehabilitation physicians agree on a multidisciplinary treatment guideline: results from the HANDGUIDE study. Plastic and reconstructive surgery, 132(6), 964e–976e. https://doi.org/10.1097/01.prs.0000434410.40217.23
9) Lucado, A. M., Day, J. M., Vincent, J. I., MacDermid, J. C., Fedorczyk, J., Grewal, R., & Martin, R. L. (2022). Lateral Elbow Pain and Muscle Function Impairments. The Journal of orthopaedic and sports physical therapy, 52(12), CPG1–CPG111. https://doi.org/10.2519/jospt.2022.0302
10) Hegmann, K. T., Hoffman, H. E., Belcourt, R. M., Byrne, K., Glass, L., Melhorn, J. M., Richman, J., Zinni, P., 3rd, Thiese, M. S., Ott, U., Tokita, K., Passey, D. G., Effiong, A. C., Robbins, R. B., Ording, J. A., & American College of Occupational and Environmental Medicine (2013). ACOEM practice guidelines: elbow disorders. Journal of occupational and environmental medicine, 55(11), 1365–1374. https://doi.org/10.1097/JOM.0b013e3182a0d7ec
Pablo Rodríguez Sánchez-Laulhé
PhD Candidate | PT, Hand Therapy & eHealth Researcher
