About us

The “Carpal Tunnel Plus” Clinic was developed to reduce the number of steps and wait times involved in diagnosing and treating compression neuropathies. People with may go through multiple steps often with a wait in between each step. We aim to provide care for people with compression neuropathies that is coordinated between different specialists (family practice, neurology, surgery) and addresses the often lengthy time gaps between each step, such as consultations, EMG, ultrasound, and surgery.

This innovation is a joint initiative between Family Practice, and the Providence Health Care Departments of Medicine and Surgery. Development of the pathway was supported by the SPH Department of Medicine Innovation Platform and by Shared Care / Doctors of BC.

A Value Based Health Care framework is used to ensure patient and family centered care, that looks at the full cycle of care – from community through specialist and back.

‍The CTS+ clinic is affiliated with the BC Centre for Complex Nerve Injury.

What is Value Based Health Care?

Value Based Health Care (VBHC) emphasizes organizing and delivering care in a way that improves health outcomes that matter to patients. By improving outcomes that patients care about (the “3Cs”: calm, comfort, capability) we add value from the patients’ perspective.

Key components of VBHC include:

Team based care by an Integrated Practice Unit (IPU)
Measuring outcomes that matter to patients
Collaboration between family doctors and specialists over the full cycle of care – from initial recognition of the pinched nerve through diagnostic testing to successful treatment or surgery if needed.

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To learn more, visit the PHC Department of Medicine website on VBHC

Good paper about VBHC:

https://www.phcmedstaff.ca/strategic-plan-in-action/qsv-pillar/‍

These articles are a great introduction to Value Based Healthcare:

1. Porter ME. What is Value in Health Care?
https://www.phcmedstaff.ca/wp-content/uploads/2020/07/Porter-What-is-value-in-health-care-NEJM-2010-1.pdf

2 Teisberg E, Wallace S. Creating a High Value Delivery System for Health Care

https://www.phcmedstaff.ca/wp-content/uploads/2020/07/Creating-a-High-Value-Delivery-System-semtcvs-2009-Teisberg-and-Wallace4.pdf

3. Stowell C, Akerman C. Better Value in Health Care Requires Focusing on Outcomes: Harvard Business Review

https://www.phcmedstaff.ca/wp-content/uploads/2020/07/iCHOM-Outcomes-Viewpoint2-HBR-2015.pdf

4. Porter ME. Measuring Health Outcomes: The Outcome Heirarchy

https://www.phcmedstaff.ca/wp-content/uploads/2020/07/Porter-Measuring-Health-Outcomes-2010-NEJM.pdf

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What is an Integrated Practice Unit? (IPU)

A team that provides coordinated care to a group of patients with shared medical needs over the full cycle of care, from diagnosis to optimal treatment.

The CTS+ team is made of neurologists, surgeons, technologist, and rehab doctors. They work together with your family physician to provide seamless care for the condition of carpal tunnel syndrome.

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Measuring outcomes that matter most to patients enables a cycle of continuous improvement. By measuring comparable data points and comparing outcomes across providers, organizations can understand what works well and what doesn’t. This drives ever-improving patient outcomes and experiences, generating evidence which leads to payment and regulatory reform. We aim to deliver high-quality care efficiently. Outcomes data shines light on the results of procedures, processes, structures, and systems that allow us to design the best possible pathway for you.

The “3 C’s” of outcome measurement:
Capability, Comfort and Calm
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Capability

The ability to carry on with life while receiving care

Comfort

Minimizing physical and psychological pain

Calm

Improving the ability to function and do the things that let me be me

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ICHOM (International Consortium for Outcome Measures). Please visit ICHOM.org.
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Hand and Wrist Data Set

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Co-directors

Dr. Sean Bristol

Dr. Bristol is the co-founder and surgical lead of the BC Centre for Complex Nerve Injury. From a two-physician program based off the successful model developed in London, Ontario, Bristol has expanded the team to include nine physicians under three different sub-specialty areas. Outside of work, I enjoy a busy family life and travel and personally enjoy golf, tennis and reading.

Dr. Kristine Chapman

Director, Neuromuscular Disease Unit, Vancouver Hospital
Head, Division of Neurology, Providence Health Care
Physician Lead, Innovation and Quality, Dept. of Medicine, PHC
Clinical Professor, University of British Columbia

Dr. Chapman is a Clinical Professor of neurology at the University of British Columbia. She completed her undergraduate degree in Occupational Therapy, and Neurology training at UBC followed by a Neuromuscular and Neurophysiology Fellowship at Harvard. Her interests include autoimmune neuropathies and complex nerve injuries.

Support for the development of the CTS+ clinic from the PHC Dept. of Medicine Innovation Pathway, Doctors of BC Shared Care, and the UBC Dept of Plastic Surgery.

About CTS

Symptoms of carpal tunnel syndrome:

Symptoms can vary. Most commonly, patients will describe wrist pain, hand stiffness, numbness or tingling of the hand (especially the thumb, index and middle fingers). Many patients will have numbness that wakes them from sleep and they feel the need to shake out the hand to “wake it up.” Others recognize numbness in the hand upon waking and it may take several minutes to even hours for the hand to normalize. Over time (usually months to years), the affected nerve becomes more dysfunctional leading to numbness all of the time, clumsiness and even weakness that will manifest as dropping objects.

Anatomy of the carpal (wrist) tunnel:

The carpal tunnel is a box on the palm side of the wrist (where the hand and forearm join). Inside the box run the median nerve and 9 tendons. Three sides of the box are bone and the top of the box is the very thick and strong transverse carpal ligament (TCL). This makes the box hard and unyielding. When swelling of the tendons occurs, pressure builds up within the carpal tunnel and chokes the median nerve.

The nerve can recover from being choked in the short term. If function returns to normal when the nerve “wakes up,” then there is unlikely any long-term damage to the nerve. However, over time the nerve can sustain long-term damage as the electrical wires within the nerve called axons can die. When this happens, patients will have numbness that is present all of the time and start to develop weakness and, in late stages, atrophy (shrinking of the muscles at the base of the thumb).
Image obtained from https://www.o-health.com.au/carpal-tunnel-syndrome

Diagnosis of CTS

Diagnosis of CTS is made by combination of history, physical examination, and nerve conduction studies/electromyography. In borderline cases or patient with other neuropathies, neuromuscular ultrasound can be used to confirm diagnosis. At the CTS+ clinic, outcome measurements will be used to help diagnose and monitor treatment response to ensure optimal management of CTS and other compression neuropathies.

Outcome measures

For patients, health outcomes that matter most focus on being able to do the things that ‘let me be me’, relieving suffering and letting people live their best lives while getting care. We can think about this in 3 categories: capability, comfort and calm.

Outcomes measures are most useful when done over time for each individual patient during their care journey. This allows us to determine if the treatments are working.All of the members of the CTS+ team who care for patients with compression neuropathies over their full care journey will work together measuring the same outcomes. You will be completing lab tests (glucose and thyroid study) and nerve testing, as well as outcome measures linked directly blow.

CTS+ Outcome measurement

Treatment: Carpal Tunnel Splint

Resting splints should be worn on the symptomatic side(s) AT NIGHT, to keep the wrist in a neutral position. This is the most “open” position for the tunnel the nerve passes through, so it is not a compressed while you sleep.It should have a short metal bar that will keep the wrist straight.

Splints are available for purchase in the EMG lab. Your insurance company may cover the cost. They are also available at most medical supply companies and many drug stores.

Splints should be tried for 4-6 weeks. If symptoms are not improving after 4 weeks of regular night-time use of a well fitted splint, you should have a re-assessment and consider other treatments.

Treatment: Steroid injection

A steroid injection at the carpal tunnel can improve symptoms. This reduces inflammation This may be short term, lasting 4-6 months, or may provide long term relief. This injection is done using an ultrasound to make sure it is delivered to the right place. Side effects can include discomfort and bruising at the site of injection, depigmentation at the site of injection, and very rarely injection site infection or damage to nerve, tendon, or blood vessel. These complications are significantly mitigated by use of ultrasound.

Treatment: Surgery

If your symptoms do not improve with splinting or steroid injection, you may need surgery to decompress the nerve and prevent it from getting worse and developing weakness in the hand. ‍We recommend surgery if you have:
1) Consistent night time wakening especially if wakening even when using a splint.
2) Numbness that occurs during activities that interferes with daily activities or enjoyment activities (e.g. sports, riding a bicycle, knitting).
3) Weakness in the hand muscles.
4) Experienced short-term relief from steroid injection.

For detail, see the surgery tab

Other Conditions

Radial Neuropathy

Learn more

Fibular Neuropathy

Learn more

Meralgia Paresthetica

Learn more

Ulnar Neuropathy

Learn more

Carpal Tunnel Syndrome

Learn more

Care pathways

All patients will be referred to the EMG lab at SPH or Vancouver hospital for initial assessment. Depending on the severity of
symptoms, findings on examination and the nerve testing, your doctor will determine if your nerve injury is MILD, MODERATE, or SEVERE.
It is also possible that your symptoms are not the result of a neurologic issue but rather another problem such as tendonitis, arthritis or a pinched nerve in the neck.

Electrophysiologic Criteria for Mild/Mod/Severe CTS and Ulnar Neuropathy for CTS+ Pathway:

Mild CTS: Prolonged (relative or absolute) sensory latencies with normal motor studies. No evidence for axon loss.
Moderate CTS: Abnormal median sensory latencies as noted for mild CTS, and prolongation of median motor distal latency. No evidence of axon loss.
Severe CTS: Any evidence of axon loss as defined by either: (1) an absent SNAP or mixed SNAP (assuming no other neuropathy); (2) a low-amplitude or absent thenar CMAP; or (3) a needle EMG with fibrillation potentials and motor unit potential changes (large amplitude, long-duration motor unit potentials, or excessive polyphasics).

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References:

Stevens JC. AAEM minimonograph #26: The electrodiagnosis of carpal tunnel syndrome. Muscle Nerve 1997;20:1477–1486.

Bland JD. Do nerve conduction studies predict the outcome of carpal tunnel decompression? Muscle Nerve 2001;24:935–940.

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There are three management pathways for compression neuropathy (mild, moderate and severe) based on symptoms. Please note that these pathways are just guidelines and the specific management will be determined at the discretion of you and your physician.

For more information on the pathway arms please see below:

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On your first visit to the CTS+ clinic, all patients will have a neurologic consultation, including a history and physical examination, as well as electrodiagnostic studies. If you are diagnosed with MILD CTS you will be offered the following:

MILD Severity Pathway:

Neurology consultation and Nerve Conduction Studies/EMG
Outcome measures
Complete the Boston Carpal Tunnel assessment (self reported)
10 point pain scale (self reported)
Sensory and motor measures (done by the doctor)
Nerve Conduction Studies
Bloodwork requisition for fasting glucose and TSH
You will receive information material about carpal tunnel syndrome
Treatment
Splint for night time is available for purchase in EMG lab
Possible referral for US and Steroid injection at discretion of physician
3 month telehealth follow up:
You will receive a telephone follow up, where you will review a symptom checklist.
If you still have symptoms, you will be offered a repeat assessment.
If you have recovered, your family doctor will be notified that you are doing well and discharged from the CTS+ clinic.

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MODERATE Severity Pathway

Neurology consultation and Nerve Conduction Studies/EMG
Outcome measures
Complete the Boston Carpal Tunnel assessment (self reported)
10 point pain scale (self reported)
Sensory and motor measures (done by the doctor)
Nerve Conduction Studies
Bloodwork requisition for fasting glucose and TSH
You will receive information material about carpal tunnel syndrome
Treatment
Splint for night time is available for purchase in EMG lab
US and Steroid injection – target: within 2 weeks
You will receive a phone call approximately 2 weeks after injection by physician doing procedure to see if its helping
A 3 month EMG follow up will be booked to make sure you are recovering
Repeat Boston Carpal Tunnel assessment (ADD LINK)
Depending on how you are doing, you will either be referred for surgical management or a further follow up will be arranged (phone if mild, book EMG in 3 months if moderate)
6 months
Phone follow up with Boston Carpal Tunnel assessment if the symptoms were mild
Follow up EMG if moderate at the 3 month mark. If persistent at 6 months, consider surgery.

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SEVERE Severity Pathway:

Neurology consultation and Nerve Conduction Studies/EMG
Outcome measures
Complete the Boston Carpal Tunnel assessment (self reported)
10 point pain scale (self reported)
Sensory and motor measures (done by the doctor)
Nerve Conduction Studies
Bloodwork requisition for fasting glucose and TSH
You will receive a handout about carpal tunnel syndrome
If your nerve compression is severe, you will be referred for a virtual or in person surgical consult, with an aim to be seen within 2 weeks.

In some cases you may be able to see the surgeon on the same day. If that is the case, the booking clerk will give you the “CTS+ IPU information sheet” with map of where to go. (link for VH and SPH)
The Neurologist will give you a copy of EMG data to take to clinic
You will be re-registered at the OPD desk at hand clinic/plastics office
While waiting for your surgery, continue to wear the splint at night - splints are available for purchase in the EMG lab.
Surgery (link to surgery page)
Follow up with the surgeon ***WHEN*** post op

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It is possible to have very mild median nerve compression, that does not show up on the testing. A resting splint may be recommended and if your symptoms worsen, you should request re-assessment by calling the EMG booking clerk at (604) 875-4405.

Other conditions can mimic carpal tunnel syndrome, including tendonitis and arthritis. You can follow up with your family doctor if no neurologic explanation for your symptoms is found.

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Surgery

If your symptoms do not improve with splinting or steroid injection, you may need surgery to decompress the nerve and prevent it from getting worse and developing weakness in the hand.

We recommend surgery if you have:

1) Consistent night time wakening especially if wakening even when using a splinting

2) Numbness that occurs during activities that interferes with daily activities or enjoyment activities (e.g. sports, riding a bicycle, knitting)

3) Weakness in the hand muscles

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Risks of surgery:

There are risks to this operation as with any operation, but they are all low. The risk of infection is 1-2% and almost always can be managed with antibiotics taken by pill. Significant bleeding is extremely rare. As it is a local anesthetic procedure and patients do not have to go to sleep for the operation, the risks of anesthetic are also extremely rare. There is a scar which is typically red and raised for several weeks, but usually becomes a thin faded line after 2-3 months and our surgeons try to hide the scar in the natural creases of the palm. Damage to the nerve itself is less than 1 in 1000.

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The surgery itself is considered a minor procedure in that it can be done under local anesthetic only (injection with a needle to place some freezing into the skin similar to what is used at a dentist for a filling). The freezing is placed at the surgical location and then the hand and wrist are “prepped” meaning cleaned with a sterilizing solution to reduce the risk of infection. The surgical area is then draped meaning that sterile towels are placed around the area again to reduce risk of infection. The surgery starts only after testing of the skin to make sure there is no sharp or pain sensation.

Dissection is performed down to the transverse carpal ligament (TCL) and the TCL is cut along its entire length. By cutting the TCL, the roof of the tight box is opened. Now when pressure develops inside the carpal tunnel it does not cause choking of the nerve and this improves symptoms.

The operation itself takes about 15 minutes. The wound is closed with dissolving sutures underneath the skin and several layers of dressing that can be taken off in layers. An instruction sheet is provided on the day of surgery, but briefly, all layers of dressing generally come off after 3-8 days from the surgery. The patient is then asked to apply a large band-aid over the wound until follow-up which is approximately 2 weeks after surgery. It is okay to get the dressing wet in a shower after the tensor bandage is removed. There are NO sutures to remove.

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Patients who only have episodic symptoms (e.g. night or activity related symptoms) with no consistent numbness or weakness will usually notice an improvement in these episodic symptoms even within a few days of the surgery. Most patients describe improved sleep early on after the surgical discomfort subsides. However, patients that have consistent numbness or weakness will take much longer to recover because recovery here requires the axons that have died to re-grown. Axons only re-grow at a rate of around 1 inch/month. And so, from the surgical site to the finger tips can take 6 months or more and usually recovery is incomplete due to the longstanding damage to the nerve before the operation.

It is recommended that patients keep the hand elevated (e.g. higher than the elbow and with a pillow under the hand during sleep) for the first 24-48 hours after surgery. This helps reduce swelling in the area just as it would if keeping the foot elevated after an ankle sprain. This is probably the most important activity to help with pain control. We do not recommend slings as these end up leading to shoulder and elbow stiffness unnecessarily.

Dressing:

When the surgical dressing all comes off, it may appear that the wound is pulling apart. This is very common and considered normal. The most superficial layers of the skin in the palm are very thick and do not have the ability to heal. This causes them to pull back from the wound edge slightly (2-3mm), but the deeper tissues are healing. The top layers of the skin are actually dead and will slowly lift away like the layers of skin from a blister.

What activity can I do after surgery?

Patients are encouraged to use the hand gently right away. Patients can eat, type, text and lift objects up to a full coffee cup on the day of the surgery and up until follow-up. Patients are asked not to perform heavy activities such as weigh-lifting or gardening as heavy activities risk pulling the sutures apart and the wound opening up. It is important to keep the fingers and hand moving otherwise though to prevent stiffness which is much easier to prevent than treat after it has occurred.

Pain management:

Discomfort/pain after surgery is normally well controlled by taking routine acetaminophen (Tylenol) as described on the bottle for 24 hours and then just as needed after that. The acetaminophen can be supplemented with an anti-inflammatory medication (e.g. ibuprofen) if pain not well controlled. As long as the patient does not have another contra-indication to taking an anti-inflammatory (i.e. stomach ulcers, kidney disease, already taking a blood thinner), then it is safe to take both medications as they work differently and clear the body differently. This combination does not cause an over-dose as long as both medications are taken as directed and not beyond.

1 week post surgery
- small gapping in wound superficially
- expect more gapping in coming week
- minimal redness around wound

2 weeks post surgery
- superficial looks like not healed and
pulling away but deep layers healed
- dry crust around wound
- moderate redness around wound

3 weeks post surgery
- superficial now near completely healed
- dry dead skin like a blister
- this can be trimmed away and moisturized with
aggressive massage of scar
- normal for scar to be quite tender but
not doing harm by massaging as helps to desensitize

4 week post surgery
- wound healed superficially and
no more dry crusted skin
- small thickness at either end of
scar from suture knot under skin

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At the follow-up visit, it is normal for the hand to be sore and feel weak. Administrative activities can resume right away but speed and stamina will be reduced for about 2-3 weeks after surgery. Strength of the hand can feel reduced for much longer and is highly variable. Most patients describe that most of their strength has returned by 6 weeks after surgery. It is normal to have some soreness at the base of the palm for longer than this when pressure is applied to the base of the palm such as with a push-up or yoga. In most cases, patients have forgotten about this discomfort by 3 months but are typically doing all activities well before then. Importantly, once the wound is healed, this soreness is normal in almost all situations. The patient is not doing harm to the area by continuing with activities even if somewhat sore.

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Note: *This information is provided as a guideline only. Each patient is individual and may not fall within expectations provided above.

1) Infection

Superficial infection can occur after any cut in the skin. The risk in carpal tunnel surgery is around 2% and almost always can be treated with antibiotics by mouth. Only rarely is another operation required. Many patients are diagnosed with infection when there is irritation from the dissolving sutures and not true infection. If the redness spreads from the incision beyond 5mm or the patient is feeling unwell (e.g. fever, chills, loss of appetite or energy), then seeking the assistance of your family doctor or surgeon is best.

2) Worse symptoms/numbness

Once the freezing wears off, on rare occasions, patients may recognize numbness or carpal tunnel pain that is worse after the operation than before. If this persists after 3-5 days, then please contact the surgeon for earlier assessment. This can be due to an incomplete release of the ligament which can cause a specific constriction site on the nerve.

3) Ongoing numbness

Persistent numbness after surgery is expected and completely normal if the patient had consistent numbness before surgery. This is because the axons (small electrical wires in the nerve) have died. These can recover partially but do so slowly (approximately 1 inch/month). Therefore, sensory improvement will usually take many months (usually 6-8 months) and is unlikely to return to completely normal sensation. This lack of recovery is from the damage to the nerve before the operation and there is no operation or treatment at this time that can speed up or improve nerve growth.

4) Pain at surgical site

Discomfort at the base of the palm is completely normal for the first 6 weeks. In most patients, this will continue to be sore for up to 3 months. However in some patients there is ongoing discomfort that can last for several months (usually resolves by 6 months). This is called pillar pain. We cannot predict who this will happen to, but normalizing activities and massaging the scar firmly after the wound is healed (determined at time of follow-up) help to reduce this risk.

5) Increased hypersensitivity in fingers

In patients with severe disease before the operation, they may notice increased hypersensitivity in the fingers to the point of discomfort or even pain. This is usually a good sign as it an indication that the nerve is becoming “alive” again. In some patients, the feeling is uncomfortable enough they may benefit from prescribed nerve medications that can help calm down the nerve.

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Information for Providers

1. When to refer a patient to the Carpal Tunnel Plus pathway:

Refer your patient to the Carpal Tunnel Plus clinic if a focal compression neuropathy such as carpal tunnel syndrome of ulnar neuropathy is suspected. If there is a general referral to the EMG lab for “paresthesias” or another condition is suspected buyt turns out to be CTS, the patient will still be entered into the pathway.

The “ Carpal Tunnel Plus” clinic provides streamlined diagnosis and treatment pathway. This multidisciplinary “Integrated Practice Unit” (or IPU) simplifies the care pathway for patients. Patients will be assessed and place in one of three arms of the pathway, mild, moderate, or severe (see care pathway tab). Progression within the pathway, including surgical referral, will not require referrals from the family physician. Consultation notes will be sent to the family physician/referring provider at each stage.

If possible, please include with the referral TSH and fasting glucose OR HgA1c as these are common predisposing metabolic risk factors for entrapment neuropathies.

2. Patient handouts for common compression neuropathy:

Carpal Tunnel Syndrome
Ulnar Neuropathy
Fibular Neuropathy
Meralgia Paresthetica
Radial Neuropathy

3. How to perform outcome measure set:

Have patient fill in the 10 point pain rating scale
Have patient fill in the Boston Carpal Tunnel Assessment
Perform Sensory “ten point” test - median, ulnar and radial distribution
Using a clean single use pin, demonstrate the light poke on an unaffected area. Normal sharp feeling is rated 10, no feeling is rated 0
Ask the patient to rate the sensation from 0-10 in

distal finger pad of digit 2 (median nerve distribution)
distal finger pad of digit 5 (ulnar nerve distribution)
snuff box area on back of hand (radial nerve distribution)

4. Motor testing of three muscles:

Median innervated - Abductor Pollicus Brevis:

Ulnar innervated - Finger Spreaders (Abductor Digiti MinimiandFirst Dorsal Interosseous):

Radial innervated - Finger Extensors (Extensor Digitorum Communis):

4. Criteria for mild/mod/severe pathways.

See Criteria.

5. Process Map for patient flow / SOPs

Carpal Tunnel Plus Clinic

About us

What is Value Based Health Care?

What is an Integrated Practice Unit? (IPU)

The “3 C’s” of outcome measurement: Capability, Comfort and Calm‍

Capability

Comfort

Calm

About CTS

Other Conditions

Care pathways

References:

There are three management pathways for compression neuropathy (mild, moderate and severe) based on symptoms. Please note that these pathways are just guidelines and the specific management will be determined at the discretion of you and your physician.

MILD Severity Pathway:

MODERATE Severity Pathway

Surgery

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Information for Providers

The “3 C’s” of outcome measurement:
Capability, Comfort and Calm
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