Patient Education for the Treatment of Ulnar Neuropathy at the Elbow

Article Outline

• Abstract
• Methods
  • Participants
  • Interventions
  • Follow-Up Examination
  • Data Analysis
• Results
  • Demographic and Clinical Data and Outcome
  • Correlation Between Outcome and Other Variables
  • Factors Associated With Outcome
  • Repeat Nerve Conduction Studies
  • Recurrence
• Discussion
• Conclusions
• References
• Copyright

Abstract 

Nakamichi K, Tachibana S, Ida M, Yamamoto S. Patient education for the treatment of ulnar neuropathy at the elbow.

Objective

To assess the effect of patient education, the simplest conservative treatment of ulnar neuropathy at the elbow, and establish its indication.

Design

Patients with ulnar neuropathy at the elbow were treated by education. Its effects and factors affecting outcome were investigated. The length of the treatment was at least 3 months. If the symptoms were improving, the follow-up was lengthened. All of the improved patients were followed up at least for 1 year after they reached a plateau of improvement to check recurrence.

Setting

Patients were selected from an outpatient clinic of a general hospital.

Participants

Patients (N=77; 80 nerves) with ulnar neuropathy at the elbow diagnosed clinically and electrophysiologically.

Interventions

Patient education on the pathophysiology and activity modification to unload the ulnar nerve from mechanical stress.

Main Outcome Measures

Outcomes were graded as excellent, good, fair, or poor with use of the modified Akahori's classification system. Patient satisfaction was graded as 1 (low) to 5 (high). Repeat nerve conduction studies were performed in those who gave consent, and results were graded as excellent, good, fair, or poor.

Results

Fifty-three nerves (66%) had excellent or good outcomes. Multivariate logistic regression analysis revealed that degenerative change (graded as normal, mild, moderate, or severe) was associated with the outcome, while age, sex, side, duration and severity of the disease, diabetes, dislocation of the nerve, and smoking were not. Excellent or good outcomes were obtained in 43 (80%) of 54 nerves with no or mild degeneration and 10 (38%) of 26 nerves with moderate or severe degeneration. Recurrence was less frequent in the former (2 of 43 nerves, 5%) than the latter (4 of 10, 40%). The outcomes strongly correlated with the satisfaction scores and repeat nerve conduction study results.

Conclusions

Patient education is effective for a considerable number of patients with ulnar neuropathy at the elbow. Whether this is indicated depends on the grade of elbow degeneration. Those who have no or mild degeneration respond better to this treatment with a lower rate of recurrence than those with more severe degeneration regardless of age, sex, side, duration and severity of the disease, presence or absence of diabetes and dislocation of the nerve, and smoking status.

Key Words: Cubital tunnel syndrome, Patient education, Treatment

ULNAR NEUROPATHY AT the elbow is the second most common entrapment neuropathy after carpal tunnel syndrome. It frequently occurs when the ulnar nerve undergoes compression or traction at the cubital tunnel, which is bounded by the medial epicondyle anteriorly, the medial humeral trochlea and ulnohumeral ligament laterally, and the fibrous arcade formed by the 2 heads of the flexor carpi ulnaris posteromedially. Degenerative change of the elbow is a major cause in older patients, and younger persons may have it as a result of repetitive elbow motion.¹ It also occurs secondary to posttraumatic cubitus valgus deformity, which is referred to as tardy ulnar palsy. Dislocation of the nerve on elbow flexion, if present, may further irritate it. Clinically, patients initially complain of numbness and paresthesias in the little and ulnar half of the ring fingers. Pain over the medial aspects of the elbow and forearm, and tenderness in the tunnel are also present. As it progresses, weakness develops in the ulnar nerve distribution, resulting in loss of grip and pinch strengths, and clumsiness. Nerve conduction studies show slowing of motor and sensory nerve conduction velocities across the tunnel.

The neuropathy is treated conservatively or surgically. Conservative treatment has been indicated for patients with only mild sensory symptoms, and surgery for those with more severe sensory and motor deficits.¹, ², ³, ⁴, ⁵ In our experience, however, some of such severely affected patients can be successfully managed by education, the simplest conservative treatment. This led us to reevaluate the effects of patient education and establish its indications. We included cubital tunnel syndrome and tardy ulnar palsy because these were often seen in our clinic.

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Methods 

Participants 

We included 80 nerves (cubital tunnel syndrome, 75; tardy ulnar palsy, 5) of 77 patients (56 men, 21 women). Patients consisted of 67 office workers (55 men, 12 women), 9 homemakers (women), and 1 retiree (man). Two men and 1 woman were bilaterally affected. We excluded those with an acute elbow injury or pressure palsy developed during unphysiologic (associated with alcohol, narcotics, or anesthesia) deep sleep, or who had been treated elsewhere. All the patients consented to the treatment protocol, which complied with the ethical standards of our institutional review board.

We established the diagnosis clinically and electrophysiologically. The clinical evaluation included checking for sensory involvement in the ulnar nerve distribution with the use of static 2-point discrimination and Semmes-Weinstein monofilament threshold tests in the little finger, and performing a motor assessment by examination for muscle atrophy, performance of manual muscle tests, and measurement of grip and key-pinch strengths. Nerve conduction studies were performed independently at the Department of Neurophysiology. The diagnosis was mainly based on the American Association of Electrodiagnostic Medicine guidelines.⁶ It was confirmed when at least 2 of the following criteria were met: (1) a motor nerve conduction velocity across a 10-cm cubital tunnel segment of less than 50m/s; (2) slowing in the velocity greater than 10m/s in the 10-cm segment than in the forearm; (3) a decrease in the negative peak amplitude of the compound muscle action potentials of the abductor digiti minimi across the tunnel of greater than 20%; and (4) a configuration change of the potential above the elbow compared with below the elbow. We always compared nerve conductions in the forearm, cubital tunnel, and arm, and confirmed that slowing occurred at the tunnel. Sensory nerve conduction was studied in an orthodromic fashion with the use of needle electrodes. Slowing in the conduction velocity across the tunnel (<50m/s) or polyphasic potentials above the elbow were considered abnormal even when the motor nerve results were normal.⁷, ⁸ When both motor (compound muscle action potentials of the abductor digiti minimi) and sensory responses were absent, we stimulated the nerve above the elbow and measured a motor nerve latency at the flexor carpi ulnaris (normal upper limit at our institute, 3.5ms) to confirm that the compression occurred at the tunnel. In addition, we always confirmed normal median nerve conduction.

Plain radiographs of the elbow (anteroposterior, lateral, and cubital tunnel projection) were made in all of the patients independently at the Department of Radiology.

Interventions 

Our intervention was education alone. It consisted of a thorough explanation of the pathophysiology and activity modification. For the former, we explained to the patients that the disease was due to ulnar nerve compression or traction at the cubital tunnel and that the purpose of the education was to unload the nerve from mechanical stress. For the latter we told them to avoid the following: pressure on the medial aspect of the elbow; activities aggravating symptoms; repetitive flexion and extension; and flexion greater than 90° except for essential daily activities such as toothbrushing, combing, or bathing. We also explained that elbow flexion combined with wrist extension, overhead shoulder elevation, and contralateral head tilt or turning would further stretch the nerve.³, ⁹, ¹⁰ We then recommended maintaining the elbow in 45° of flexion as long as possible to reduce the extraneural and intraneural pressures.¹¹ While the patient was sitting, the hand was placed on the thigh with the forearm in supination.¹², ¹³ For computer keyboard use, the console and seat were repositioned. We used a goniometer set at 45° for the education on these postures. Patients who tended to sleep with their elbows flexed and experienced paresthesias at night or on awakening in the morning were advised to use a towel or bandage to restrict flexion. They also served as a reminder. To help them understand the activity modification and improve their compliance, we used an educational handout (fig 1).

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• Fig 1. 

  Handout for patient education. (A) Page 1 provides advice in writing. (B) Page 2 depicts activities and postures to avoid: (1) crossing arms over the body or reaching the neck or chin, especially while attending a meeting; (2) use of a phone (using the opposite hand, a headset, or shoulder cradle recommended) or carrying a box or bag with its straps on the shoulder; (3) lying with the elbows flexed or leaning upon them; and (4) push-ups, sit-ups, weightlifting, or other elbow exercises. (C) Page 3 shows examples (sitting and computer keyboard use) to maintain the elbow in 45° of flexion. A goniometer set at this angle (*) was used for the education.

Follow-Up Examination 

The length of the treatment was at least 3 months. We advised the patients to strictly follow our instructions during this period and to get accustomed to the modified lifestyle.

We examined them every 3 or 4 weeks. If improvement was occurring, the follow-up was lengthened. We discontinued the treatment if the patient was unable to tolerate it or the symptoms were worsened at any intervals, or they remained unchanged at 3 months.

We followed all of the improved patients at least for 1 year after they reached a plateau of improvement to check for recurrence.

Data Analysis 

At the initial examination we obtained the following data, considering their possible influences on outcome: age, sex, affected side (dominant or nondominant), duration of the disease, presence or absence of diabetes and dislocation of the nerve, and smoking status (smoker or nonsmoker; for the former, pack-years calculated by packs a day multiplied by years of smoking).

Degenerative change of the elbow was graded with the use of the radiographs as normal, mild, moderate, or severe, independently at the Department of Radiology (fig 2).

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• Fig 2. 

  Grading of degenerative change of the elbow (upper panel, anteroposterior view; lower panel, cubital tunnel projection profiling the ulnar nerve groove [*]). (A) Normal. (B) Mild; osteophytes present only on the medial olecranon (arrow), not deforming the nerve groove. (C) Moderate; osteophytes present also on the medial humeral trochlea (arrow), deforming the groove. (D) Severe; in addition to a deformed groove, valgus deformity present (increase in carrying angle, 20° or greater in comparison with the angle of the contralateral elbow) due to a fracture of the lateral humeral condyle in childhood.

Outcome was first assessed at 3 months. If the symptoms were improving, it was reassessed later when the patient reached a plateau of improvement. At these intervals as well as at the initial examination, an observer, who was blinded to the above data, independently examined all the patients to record clinical data. He then incorporated the results of the nerve conduction studies and graded the initial severity (5 stages) and the outcome (excellent, good, fair, or poor) by using modified Akahori's classification systems (Table 1, Table 2, respectively).¹⁴ The outcome of dropouts was graded as poor with the use of an intention-to-treat analysis. Table 1, Table 2 both focus on clinical evaluation. Although table 1 showed both electrophysiologic and clinical findings, final staging was done clinically when stages for these findings were different. Table 2 was designed to grade outcome by evaluating the completeness of clinical recovery. Nerve conduction was not included in this table because of the imperfect correlation between clinical and electrophysiologic recoveries.¹⁴

Table 1. Assessment of Severity

NOTE. −, absent; +, mild; ++, moderate; +++, severe.

Abbreviation: MMT, manual muscle tests.

Table 2. Assessment of Outcome

NOTE. −, absent; +, present.

Abbreviation: MMT, manual muscle tests.

Repeat nerve conduction studies were performed in patients who gave consent when outcome was graded. The results were compared with those at the initial examination and graded (table 3).

Table 3. Assessment of Repeat Nerve Conduction Studies

Abbreviations: CMAP, compound muscle action potentials of the abductor digiti minimi; SNAP, sensory nerve action potentials above the elbow.

Finally, we asked the patients to score their satisfaction with the outcome (5, very satisfied; 4, satisfied; 3, intermediate; 2, unsatisfied; or 1, very unsatisfied), and the usefulness of the handout (3, very helpful [enlightening and motivating]; 2, helpful; or 1, not helpful).

To investigate correlations between outcome and other ordinal scales (severity, elbow degeneration, satisfaction score, and repeat nerve conduction study assessment) or continuous data (age, duration of the disease, and cigarette pack-years), we used Spearman correlation tests. To compare outcomes of 2 groups (sex, side, diabetes, nerve dislocation, and smoking), we used Mann-Whiney U tests. The usefulness score was compared from those with excellent or good outcomes and with fair or poor outcomes, with time for the improvement to start taken into account, also with the use of Mann-Whiney U tests. To find out factors associated with outcome, we performed multivariate logistic regression analysis. We used outcome (excellent or good defined as 1 vs fair or poor as 0) as the dependent variable. We selected independent variables that were associated with the outcome with P less than 0.2 from age, sex, side, duration and severity of the disease, diabetes, degeneration grade, nerve dislocation, and smoking. The level of significance was P less than .05 in other statistical analyses. We performed data analysis with the use of SPSS 13.0.^a

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Results 

Demographic and Clinical Data and Outcome 

Table 4 shows the demographic and clinical data. Seven patients (7 nerves) whose outcomes were graded as poor dropped out during the initial 3-month period and underwent surgery because they were unable to tolerate the activity modification. The remaining 70 patients (73 nerves) rated themselves as compliant with the treatment. All of the 80 nerves had positive electrophysiologic results, with 61 having both motor and sensory nerve conduction abnormalities and 19 having only the latter.

Table 4. Demographic and Clinical Data^⁎

Variables	Values	No. of Nerves	Outcome
			Excellent	Good	Fair	Poor†
Age (y)	19–77 (mean, 52)	80(total)	26	27	6	21(7)
Sex	Man	58	22	18	6	12(4)
	Woman	22	4	9	0	9(3)
Side	Dominant	40	12	15	3	10(4)
	Nondominant	40	14	12	3	11(3)
Disease duration (mo)	1–60 (mean, 7)	80(total)	26	27	6	21 (7)
Severity (stage)	I	13	9	2	1	1(1)
	II	29	7	11	2	9(2)
	III	21	7	7	2	5(3)
	IV	15	3	6	1	5(1)
	V	2	0	1	0	1(0)
Diabetes	Absent	69	25	22	6	16(6)
	Present	11	1	5	0	5(1)
Elbow degeneration (grade)	Normal	37	18	11	2	6(4)
	Mild	17	6	8	0	3(0)
	Moderate	21	2	6	4	9(3)
	Severe	5	0	2	0	3(0)
Nerve dislocation	Absent	73	25	25	6	17(7)
	Present	7	1	2	0	4(0)
Smoking	Smoker‡	12	6	2	0	4(3)
	Nonsmoker	68	20	25	6	17(4)

Outcomes were excellent in 26 nerves, good in 27, fair in 6, and poor in 21 (including 7 dropouts). Thus 53 (66%) had excellent or good outcomes. It took 3 to 20 (median, 11) months for them to reach a plateau of improvement. In all of the 14 nerves with a poor outcome (nondropouts), the symptoms were unchanged, not worsened, at 3 months.

All the patients were initially unaware of the cause of their symptoms. The usefulness score was higher in those with excellent or good outcomes (median, 2.7 for 53 nerves) than in those with fair or poor outcomes (1.1 for 27 nerves; P<.001). In 40 of the former (75%), the symptoms started improving in less than 1 month. When the 53 nerves were divided into those in which the symptoms had started improving in less than 1 month (40 nerves) and 1 to 3 months (13 nerves), the score was higher in the former (median, 2.8) than in the latter (2.4; P=.009). Patients with a score of 3 reported that they were motivated to go along with the modified lifestyle afterward. Their improvement occurred after the education, which made it unlikely that they had been improving spontaneously before the intervention.

Surgery was performed in 19 nerves (outcome of the education: fair in 2 and poor in 17 including 7 dropouts). Techniques depended on elbow degeneration: simple decompression (release of the fibrous band) in 10 with no or mild degeneration, release of the band and medial epicondylectomy in 7 with moderate degeneration, and anterior submuscular nerve transposition in 2 with severe degeneration. Surgical outcomes, graded with the use of table 2, were excellent in 6, good in 6, fair in 5, and poor in 2. Repeat nerve conduction studies were performed in the 7 nerves with fair or poor outcomes. Recovery, graded with the use of table 3, was fair in 3 and poor in 4.

Correlation Between Outcome and Other Variables 

The outcome correlated negatively with age (Spearman ρ=−.25; P=.027), severity (Spearman ρ=−.22; P=.046), and degeneration grade (Spearman ρ=−.41; P<.001), but not with the disease duration and cigarette pack-years. There were no significant differences in outcome for sex, side, diabetes, nerve dislocation, and smoking (between smokers and nonsmokers).

The outcome strongly correlated with the satisfaction score (Spearman ρ=.96; P<.001) (table 5).

Table 5. Correlation Between Outcome and Satisfaction Score^⁎

Outcome	Satisfaction Score
	5	4	3	2	1
Excellent	26
Good	2	19	5	1
Fair			2	3	1
Poor				4	17(7†)

Factors Associated With Outcome 

The following variables were associated with the outcome (P<0.2) and used as independent variables in a logistic regression model: age, sex, severity, diabetes, degeneration grade, and nerve dislocation. The model revealed that only the degeneration grade was significantly associated with the outcome (table 6).

Table 6. Results of Logistic Regression Analysis

Independent Variables	Odds (95% CI)⁎	P
Age	1.00(0.96–1.05)	.973
Sex
Man	1
Woman	1.46(0.48–4.48)	.507
Severity	0.95(0.56–1.60)	.839
Diabetes
Absent	1
Present	0.69(0.17–2.75)	.598
Elbow degeneration	0.50(0.27–0.91)	.024
Nerve dislocation
Absent	1
Present	0.40(0.07–2.30)	.305

Abbreviation: CI, confidence interval.

When the nerves were divided into those with no or mild degeneration (54 nerves) and those with moderate or severe degeneration (26 nerves), excellent or good outcomes were obtained in 43 (80%) of the former and in 10 (38%) of the latter. Comparison of these groups (no or mild degeneration defined as 0 vs moderate or severe degeneration defined as 1) in the logistic regression model revealed an odds ratio of .20 (95% confidence interval, .06–.64; P=.007).

Repeat Nerve Conduction Studies 

Repeat nerve conduction studies were performed in 53 nerves (table 7). The results strongly correlated with the outcomes (Spearman ρ=.82; P<.001).

Table 7. Correlation Between Outcome and Repeat Nerve Conduction Study Results^⁎

Recurrence 

We followed up all of the 53 nerves with excellent or good outcomes for 1 to 6 (median, 2.1) years after they reached a plateau of improvement. The disease recurred in 2 nerves with mild elbow degeneration and 4 with moderate degeneration. Mann-Whiney U tests revealed that the recurrence rate was significantly lower (P<.001) in nerves with no or mild degeneration (2 of 43 nerves, 5%) than in those with moderate or severe degeneration (4 of 10 nerves, 40%). Four of the nerves required surgery (simple decompression in 1 with mild degeneration, and release of the fibrous band and medial epicondylectomy in 3 with moderate degeneration). Surgical outcomes, graded with the use of table 2, were excellent in 1 nerve and good in 3 nerves. None of them had repeat nerve conduction studies.

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Discussion 

Our data indicate that patient education is effective in a wider spectrum of patients with ulnar neuropathy at the elbow than previously considered and suggest its indications need to be reviewed. The decision whether to use conservative treatment has been mainly based on severity, and it has been indicated for patients with mild sensory symptoms without muscle weakness or atrophy.¹, ², ³, ⁴, ⁵ The methods include education and splinting, and the former has been used for those with infrequent, or intermittent, cause-effect type of sensory symptoms, and the latter for those with more severe, constant symptoms.³ Although these have proven helpful, most of the patients studied had a mild disease,¹², ¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹ and thus overall effects, especially on severely affected ones, have not been well investigated. Age, diabetes, duration of the disease, and smoking, a risk factor for the neuropathy,²⁰, ²¹ need to be taken into account because these factors negatively affect surgical outcome.⁴, ²², ²³ However, our data indicated that degenerative change of the elbow should first be considered. Many of the patients even with advanced disease benefited from the education as long as they had no or mild degeneration. Although the severity and age were inversely proportional to the outcome, they were not significant in the logistic regression model. After all, those with no or mild degeneration responded better (excellent or good outcomes in 80%) and had a lower rate of recurrence (5%) than those with moderate or severe degeneration (38% and 40%, respectively). The outcomes strongly correlated with the satisfaction scores and repeat nerve conduction study results, indicating that the assessment system (table 2) well reflected patient satisfaction and neurophysiologic status. Degenerative change of the elbow has not been highlighted. We recommend that this should be evaluated at the initial examination.

Our patient education consisted of 2 components: explanation of the pathophysiology and education on activity modification. Both were important because all of the patients were initially unaware of the cause of their symptoms, and success of the treatment required their excellent compliance. Our handout, depicting frequently seen activities and postures to avoid and recommending 45° of elbow flexion, helped tailor the education to each of them. Although 7 patients dropped out, the remaining 70 were compliant. Although the minimal treatment length was 3 months, the symptoms started improving in less than 1 month in 75% of the nerves with excellent or good outcomes. Once the patients noted improvement, they felt the handout was useful and were motivated to go along with the modified lifestyle for a long time. This was particularly the case for those having early improvement.

It may be argued that part of the improvement had occurred spontaneously. Because it is difficult to distinguish between the effect of the education and the natural course of the disease, our study does not rule out this possibility. However, no reports on natural history have clearly shown that interventions had not been used, and thus it is unclear whether the disease is self-limiting. In our study, the improvement occurred after, not before, the intervention. This suggests that our education played a major role.

Our activity modification aimed at reducing the extraneural and intraneural pressures. As the elbow is flexed, the nerve is stretched and kinked, and the cubital tunnel becomes narrower and flatter. The former increases the intraneural pressure and the latter the extraneural pressure, especially when flexion exceeds 90°.⁹, ¹¹, ²⁴, ²⁵, ²⁶, ²⁷, ²⁸ Gelberman et al¹¹ measured these pressures at the tunnel in 10° increments in cadavers. The extraneural pressure was lowest with the elbow flexed 40°, and the intraneural pressure was lowest with the elbow flexed 50°. They recommended approximately 45° of flexion as the optimum position for immobilization. The intraneural pressure also increases with wrist extension, forearm pronation, overhead shoulder elevation, and contralateral head tilt or turning.³, ⁹, ¹⁰, ¹², ¹³ These findings formed the basis of our education.

The less satisfactory outcomes in those with moderate or severe degeneration are conceivable because in such elbows, the cubital tunnel is narrowed where the extraneural pressure is elevated.²⁹ We think this offset the treatment effect.

There are several limitations to our study. First, our patients were nonlaborers, and the effects of the education on those having other types of occupations, especially labor-intensive jobs, remain to be investigated. Second, the above recommendation, maintaining 45° of elbow flexion, was from a study on normal elbows.¹¹ Further studies are necessary to determine whether this can be applied to degenerative or valgus elbows. We recommended this position to all of the patients because in such elbows, the extraneural pressure is also lower in extension than flexion,²⁹ and we attempted to make the treatment protocol uniform. Third, although 70 patients reported that they followed the instructions well, their compliances were not objectively quantified, which could have influenced the outcome.

Based on our data and above considerations, we think the contraindications and indications of patient education are as follows: (1) Because no nerves were worsened during the 3-month period, patient education has no contraindications as long as the patient is compliant. During this period, the decision is made whether to continue patient education, keeping in mind that symptoms will start improving in less than 1 month in many patients (in this study, 75% of those with excellent or good outcomes). (2) Patient education is best indicated for those who have no or mild elbow degeneration. Such patients have a good chance of recovery with a low recurrence rate regardless of age, sex, side, duration and severity of the disease, presence or absence of diabetes and nerve dislocation, and smoking status. (3) Patient education may be used for those with advanced degeneration because they may sometimes respond well. However, a low rate of success and possible recurrence should be explained.

When obtaining an informed consent, physicians should inform patients of all treatment options. We believe that patient education should be reappraised in this process. This treatment is simple, noninvasive, inexpensive, and, unlike scheduled treatments such as surgery, can be started immediately after the diagnosis is made.

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Conclusions 

Patient education is effective in a wider spectrum of patients with ulnar neuropathy at the elbow than previously considered. Whether patient education is indicated depends on the grade of elbow degeneration. Those who have no or mild degeneration respond well to this treatment with a low rate of recurrence regardless of age, sex, affected side, duration and severity of the disease, presence or absence of diabetes and dislocation of the nerve, and smoking status.

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