981REVIEW ARTICLE (META-ANALYSIS)Carpal Tunnel Syndrome. Part I: Effectiveness of NonsurgicalTreatments–A Systematic Revie...
982                EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstedetreatments. The second rev...
EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstede                                            9...
Arch Phys Med Rehabil Vol 91, July 2010                                                                                   ...
EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstede                                             ...
986                   EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstede                       ...
EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstede                                             ...
988               EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstede   The low-quality RCT of P...
EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstede                                 989therapy a...
990              EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstedeterm. In the midterm, there ...
EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstede                                   991plus in...
Non surgical tto for cts
Non surgical tto for cts
Non surgical tto for cts
Non surgical tto for cts
Non surgical tto for cts
Non surgical tto for cts
Non surgical tto for cts
Non surgical tto for cts
Non surgical tto for cts
Non surgical tto for cts
Non surgical tto for cts
Non surgical tto for cts
Non surgical tto for cts
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Non surgical tto for cts

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Non surgical tto for cts

  1. 1. 981REVIEW ARTICLE (META-ANALYSIS)Carpal Tunnel Syndrome. Part I: Effectiveness of NonsurgicalTreatments–A Systematic ReviewBionka M. Huisstede, PhD, Peter Hoogvliet, MD, PhD, Manon S. Randsdorp, MD, Suzanne Glerum, MD,Marienke van Middelkoop, PhD, Bart W. Koes, PhD ABSTRACT. Huisstede BM, Hoogvliet P, Randsdorp MS,Glerum S, van Middelkoop M, Koes BW. Carpal tunnel syn-drome. Part I: effectiveness of nonsurgical treatments–a sys- C nervecompression ofSYNDROME, 1upperthepasses through ARPAL TUNNEL caused by entrapments located in the of the median nerve as it 6 peripheral extremity, is1tematic review. Arch Phys Med Rehabil 2010;91:981-1004. the carpal tunnel. Twenty-nine percent of those with chronic complaints of the Objective: To review literature systematically concerning upper extremity reported complaints in the wrist/hand area.2effectiveness of nonsurgical interventions for treating carpal The prevalence of possible or probable CTS in the generaltunnel syndrome (CTS). population depends on nuances of the definition used, but it is Data Sources: The Cochrane Library, PubMed, EMBASE, cited as being 5.3% in women and 2.1% in men.3 Among thoseCINAHL, and PEDro were searched for relevant systematic with work-related upper-extremity disorders, work-relatedreviews and randomized controlled trials (RCTs). CTS is one of the most disabling and costly, representing a Study Selection: Two reviewers independently applied the major cause of lost work days and workers’ compensation costsinclusion criteria to select potential studies. in the United States (U.S. Department of Health and Human Data Extraction: Two reviewers independently extracted Services, 1996). In the United States, 400,000 operations tothe data and assessed the methodologic quality. treat CTS are performed each year, costing a total of $2 Data Synthesis: A best-evidence synthesis was performed billion.4to summarize the results of the included studies. Two reviews Characteristic complaints of CTS are pain, paresthesia, andand 20 RCTs were included. Strong and moderate evidence numbness in the fingers and hand (in the area innervated by thewas found for the effectiveness of oral steroids, steroid injec- median nerve), often exacerbated at night.5 The exact patho- physiology of how the pressure in the carpal tunnel increasestions, ultrasound, electromagnetic field therapy, nocturnal over time is unclear,6 although it is known that the occurrencesplinting, and the use of ergonomic keyboards compared with of CTS is associated with an average hand force requirement ofa standard keyboard, and traditional cupping versus heat pads greater than 4kg, repetitiveness at work (cycle time 10s, orin the short term. Also, moderate evidence was found for 50% of cycle time performing the same movements), and aultrasound in the midterm. With the exception of oral and daily 8-hour energy-equivalent frequency-weighted accelera-steroid injections, no long-term results were reported for any of tion of 3.9m/s2.7these treatments. No evidence was found for the effectiveness Many interventions, both nonsurgical and surgical, haveof oral steroids in long term. Moreover, although higher doses been suggested to treat CTS. No therapy for CTS is universallyof steroid injections seem to be more effective in the midterm, accepted,8 although monodisciplinary as well as multidisci-the benefits of steroids injections were not maintained in the plinary clinical guidelines have been developed.9,10long term. For all other nonsurgical interventions studied, only Nonsurgical treatment options vary from rest or activitylimited or no evidence was found. modification to splinting, or the use of oral medication such as Conclusions: The reviewed evidence supports that a number nonsteroidal anti-inflammatory drugs or oral steroids.11 In de-of nonsurgical interventions benefit CTS in the short term, but compression surgery, open as well as endoscopic techniquesthere is sparse evidence on the midterm and long-term effec- have been used. The most frequently reported treatments aretiveness of these interventions. Therefore, future studies should splinting (56.3%) and nonsteroidal anti-inflammatory agentsconcentrate not only on short-term but also on midterm and (50.8%).12 Two Cochrane reviews have been written concern-long-term results. ing nonsurgical treatment options to treat CTS. One of these Key Words: Carpal tunnel syndrome; Rehabilitation; Re- reviews13 concerned the effectiveness of all types of nonsur-view [publication type]; Treatment outcome. gical treatments other than steroid injections. This review © 2010 by the American Congress of Rehabilitation showed short-term benefit from treatment with ultrasound,Medicine splinting, oral steroids, yoga, and carpal bone mobilization. No significant results were found in favor of other nonsurgical From Department of General Practice (Huisstede, Randsdorp, Glerum, List of Abbreviationsvan Middelkoop, Koes) and Department of Rehabilitation Medicine (Huisstede,Hoogvliet, Randsdorp), Erasmus Medical Center, Rotterdam, The Netherlands. CI confidence interval No commercial party having a direct financial interest in the results of the research CTS carpal tunnel syndromesupporting this article has or will confer a benefit on the authors or on any organi- DASH Disability of the Arm, Shoulder and Handzation with which the authors are associated. MD mean difference Reprint requests to Bionka M. Huisstede, PhD, Erasmus Medical Center—University Medical Center Rotterdam, Dept of Rehabilitation Medicine, Room RCT randomized controlled trialH-016, PO Box 2040, 3000 CA Rotterdam, The Netherlands, e-mail: RR relative riskb.huisstede@erasmusmc.nl. VAS visual analog scale 0003-9993/10/9107-00941$36.00/0 WMD weighted mean difference doi:10.1016/j.apmr.2010.03.022 Arch Phys Med Rehabil Vol 91, July 2010
  2. 2. 982 EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstedetreatments. The second review14 reported on the effectiveness summarized in a (Cochrane) review were included in theof local corticosteroid injections. Corticosteroid injections present study.were more effective than placebo after 1 month and also moreeffective than oral corticosteroids after 3 months. No signifi- Categorization of the Relevant Literaturecant clinical benefit was found for corticosteroid injections Relevant publications are categorized under 3 headers: Sys-compared with other treatments or in favor of multiple injec- tematic reviews, Recent RCTs, and Additional RCTs. Thetions compared with 1 injection. header “Systematic reviews” describes all Cochrane and Since the publication of these Cochrane reviews, several Cochrane-based systematic reviews. The header “RecentRCTs have been published, and we wondered whether the RCTs” contains all RCTs published from the final date of theconclusions made in the Cochrane reviews would remain search strategy that the systematic review covered. Finally, thethe same or would need modification. To optimize further the header “Additional RCTs” describes all RCTs concerning in-quality of care for patients with CTS given by clinicians and by terventions that have not yet been described in a systematicmedical and paramedical staff working in primary care, an review.overview of the current state of the art regarding evidence-based information is needed that can support developing and Data Extractionupdating evidence-based protocols and guidelines for interven- Two researchers (M.S.R./S.G., B.M.H.) independently ex-tions. Therefore, we systematically reviewed scientific litera- tracted the data. Information was collected on the study pop-ture to provide an up-to-date overview of the evidence for the ulation, interventions used, outcome measures, and outcome. Aeffectiveness of interventions to treat CTS. This article, part I, consensus procedure was used to solve any disagreement be-concentrates on nonsurgical interventions to treat CTS. tween the researchers. METHODS The follow-up period was categorized into the short term (0 –3mo), the midterm (4 – 6mo), and the long term ( 6mo).Search Strategy Methodologic Quality Assessment A search of relevant systematic reviews on CTS was per- To identify potential risks of bias of the included RCTs, 2formed in the Cochrane Library. In addition, relevant reviews reviewers (M.S.R., B.M.H.) independently assessed the meth-and RCTs in PubMed, EMBASE, CINAHL, and PEDro were odologic quality of each RCT. The 12 quality criteria (table 1)searched (1) for interventions included in the systematic re- and operationalization of these criteria (appendix 2) wereviews from the date of the search strategy of the review up to adapted from Furlan et al.15 Each item was scored as “yes,”January 2010 (ie, recent RCTs), and (2) from the beginning of “no,” or “don’t know.” High quality was defined as a score ofthe database to January 2010 (ie, additional RCTs). 50% or more (ie, a “yes” score on 50% or more of the criteria) Key words related to the disorder such as “carpal tunnel on the methodologic quality assessment. A consensus proce-syndrome,” “median nerve entrapment,” and “interventions” dure was used to solve any disagreement between the review-were included in the literature search. The complete search ers.strategy is described in appendix 1. Data SynthesisInclusion Criteria If quantitative analysis of the studies was not possible be- Systematic reviews and/or RCTs were considered eligible cause of diverse outcome measures and other clinical hetero-for inclusion if they fulfilled all of the following criteria: (1) the geneity, a meta-analysis was not performed. In that case, westudy included patients with CTS, (2) CTS was not caused by summarized the results using a rating system consisting of 5an acute trauma or any systemic disease (such as osteoarthritis, levels of scientific evidence, taking into account the method-rheumatoid arthritis, diabetes mellitus, or other connective ologic quality and the outcome of the original studies (best-tissue disease) as described in the definition of complaints of evidence synthesis).16 All RCTs together—that is, the numberthe arm, neck, and/or shoulder (CANS), (3) an intervention for of RCTs found in the reviews plus the number of recent RCTstreating the disorder was evaluated, and (4) results on pain, or the number of additional RCTs— determined the availablefunction or recovery were reported. There were no language number of RCTs for a certain intervention. The article wasrestrictions. included in the best-evidence synthesis only if a comparison If a subset of the total number of patients included in a study was made between the groups (treatment vs placebo, treatmentmet our inclusion criteria, the study was included only if the vs control, or treatment vs another treatment) and the level ofoutcomes of the subset were assessed and reported indepen- significance was reported. The results of the study were labeleddently. “significant” if 1 of the 3 outcome measures had significant Studies on the effectiveness of analgesics given presurgery, results.during surgery, or directly postsurgery and in which the effect The level of evidence was ranked and divided into theof these analgesics on pain as a result of the surgery was following levels:studied are excluded from this review. 1. Strong evidence for effectiveness: consistent ( 75% of the trials report consistent findings); positive (signifi-Study Selection cant) findings within multiple higher-quality RCTs Two reviewers (M.S.R./S.G., B.M.H.) independently ap- 2. Moderate evidence for effectiveness: consistent positiveplied the inclusion criteria to select potential relevant studies (significant) findings within multiple lower-qualityfrom the title and abstracts of the references retrieved by the RCTs and/or 1 high-quality RCTliterature search. A consensus method was used to solve any 3. Limited evidence for effectiveness: positive (significant)disagreements concerning inclusion of studies, and a third findings within 1 low-quality RCTreviewer (B.W.K.) was consulted if disagreement persisted. 4. Conflicting evidence for effectiveness: provided by con- RCTs published after the search data mentioned in the flicting (significant) findings in the RCTs ( 75% of the(Cochrane) review and RCTs investigating interventions not trials report consistent findings)Arch Phys Med Rehabil Vol 91, July 2010
  3. 3. EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstede 983 Table 1: Methodologic Quality Criteria: Sources of Risk of Bias Item Judgment 1. Was the method of randomization adequate? Yes / No / Unsure 2. Was the treatment allocation concealed? Yes / No / Unsure Was knowledge of the allocated interventions adequately prevented during the study? 3. Was the patient blinded to the intervention? Yes / No / Unsure 4. Was the care provider blinded to the intervention? Yes / No / Unsure 5. Was the outcome assessor blinded to the intervention? Yes / No / Unsure Were incomplete outcome data adequately addressed? 6. Was the dropout rate described and acceptable? Yes / No / Unsure 7. Were all randomized participants analyzed in the group to which they were allocated? Yes / No / Unsure 8. Are reports of the study free of suggestion of selective outcome reporting? Yes / No / Unsure Other sources of potential bias: 9. Were the groups similar at baseline regarding the most important prognostic indicators? Yes / No / Unsure 10. Were co-interventions avoided or similar? Yes / No / Unsure 11. Was the compliance acceptable in all groups? Yes / No / Unsure 12. Was the timing of the outcome assessment similar in all groups? Yes / No / Unsure 5. No evidence found for effectiveness of the inventions: Effectiveness of Interventions RCTs available, but no (significant) differences between Strong and moderate evidence for the effectiveness of non- intervention and control groups were reported surgical interventions for the treatment of CTS is presented in 6. No systematic review or RCT found table 5. A complete overview of levels of evidence for the effectiveness of all the identified nonsurgical interventions is RESULTS presented in table 6.Characteristics of the Included Studies 1. Nonsurgical Treatment (other than steroid injections) The initial literature search resulted in the identification of 4 The Cochrane review of O’Connor13 (search up to Februarysystematic reviews from the Cochrane Library and 47 reviews 2001, PubMed; up to March 2002, EMBASE; up to December(7 from PubMed, 29 from EMBASE, 11 from CINAHL). We 2001, CINAHL and PEDro) included 21 trials (n 923) study-identified another 750 RCTs (241 from PubMed, 276 from ing the effectiveness of all types of nonsurgical treatmentsEMBASE, 177 from CINAHL, 56 from PEDro). Finally, after (other than steroid injections) for CTS. The trials presentedselection based on the content of the titles, abstracts, and full findings in 12 treatment areas: splinting, ultrasound, ergonomictext of the references, 2 Cochrane reviews and 26 recent RCTs keyboards, oral medication, vitamins, exercise, yoga, mobili-(25 from PubMed 1 from PEDro, none from EMBASE or zation, magnet therapy, chiropractic care, laser, and acupunc-CINAHL) met our inclusion criteria. No additional RCTs were ture. Furthermore, we found 18 recent RCTs (n 963) on thefound. Four RCTs (2 from PubMed,17 2 from EMBASE18,19) effectiveness of splinting, ultrasound, laser, oral medication,were initially included based on the content of their abstract. manual therapy, magnetic field stimulation, acupuncture, mas-Because the full texts were not available in national and inter- sage therapy, heat wrap therapy, cupping therapy, botulinum Bnational medical libraries, we contacted the authors by e-mail; toxin, iontophoresis, and exercise. No additional RCTs werehowever, no full-text articles were received, so these articles found.could not be included in the present review. The data extractionof the included studies is presented in appendix 3 (systematic 1.1. Splintingreviews) and appendix 4 (recent RCTs). In the systematic review of O’Connor,13 3 RCTs22-24 on splinting were included. Furthermore, 7 recent RCTs25-31 onMethodologic Quality of the Included Studies splinting were found. The results of the methodologic quality assessment of the 20included recent and additional RCTs are presented in table 2. Different Positions for a Wrist Splint ComparedThe Cochrane review of O’Connor et al13 (which reported on Systematic review. One low-quality RCT22 (n 90) in thenonsurgical treatment other than steroid injections) used the Cochrane review of O’Connor13 compared the short-term ef-methodologic quality criteria of the Cochrane Reviewers Hand- fects of a wrist splint in neutral position with a wrist splinted inbook 4.0.20 Eight quality items were described, and RCTs were 20° extension. After 2 weeks of treatment, significant overalldefined as high-quality (A), moderate-quality (B), or low- and nocturnal improvement (RR 2.43, 95% CI, 1.12–5.28;quality (C). Moderate RCTs had a score of 50% or more on the and RR 2.14, 95% CI, .99 – 4.65, respectively) was found inquality criteria. Therefore, we decided that A and B study favor of the splint in neutral position.scores would be defined as high-quality RCTs (table 3). The We concluded that there is limited evidence that the use ofmethodologic quality criteria of Jadad et al21 were used in the a wrist splint in neutral position is more effective than anCochrane review of Marshall et al14 reporting on corticosteroid extended wrist position of 20° in patients with CTS in the shortinjections. Five quality items were described, and they defined term (2 weeks).poor-quality and good-quality studies (table 4). A total of 53 RCTs are included in our systematic review. Of Nocturnal Hand Brace Versus No Treatmentthese, 29 RCTs (55%) were of high quality, and 8% of the Systematic review. O’Connor13 found 1 low-quality RCT23studies scored 40% to 50% of the total score. (n 80) that compared a nocturnal hand brace with no treatment. Arch Phys Med Rehabil Vol 91, July 2010
  4. 4. Arch Phys Med Rehabil Vol 91, July 2010 984 Table 2: Methodologic Quality Scores of the Included RCTs Incomplete Free of Timing of Outcome Incomplete Suggestions the Blinding? Data Outcome of Selective Similarity of Co-interventions Compliance Outcome Adequate Allocation Blinding? Blinding? Outcome Addressed? Data? ITT Outcome Baseline Avoided or Acceptable in Assessment Score Study Reference Randomization? Concealment? Patients? Caregiver? Assessors? Dropouts? Analysis? Reporting? Characteristics? Similar? All Groups? Similar? Maximum Score Percentage EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstede Dammers et al73 ? NA 11 10 90 Chang et al48 ? ? 12 10 83 Irvine et al39 ? ? 12 10 83 Bialosky et al97 ? 12 9 75 Amirjani et al64 ? ? ? 12 8 67 Bakhtiary and Rashidy- Pour38 ? ? 12 8 67 Brininger et al26 ? ? 12 8 67 Evcik et al40 ? ? ? ? 12 8 67 Hui et al69 ? ? – ? 12 8 67 Mishra et al33 ? ? 12 8 67 Burke et al50 ? ? ? 12 7 58 Yagci et al30 ? ? 12 7 58 Yang et al57 ? ? ? 12 7 58 De Angelis et al31 ? ? 12 6 50 Michalsen et al61 ? ? ? 12 6 50 Shooshtari et al41 ? ? ? ? ? ? 12 6 50 Weintraub and Cole55 ? ? ? ? ? 12 6 50 Baysal et al25 ? ? 12 5 42 Moghtaderi et al79 ? ? ? ? ? ? 12 5 42 Michlovitz et al60 ? ? – ? ? 12 5 42 Moraska et al58 ? ? – ? ? 12 5 42 Premoselli et al29 ? ? – ? 12 5 42 Breuer et al62 ? ? ? ? ? NA 11 4 36 Pinar et al28 ? ? ? ? ? ? 12 4 33 Heebner and Roddey27 ? ? ? ? ? 12 3 25 Field et al59 ? ? ? ? ? ? ? ? 12 2 17 Abbreviations: , Yes; , No; ?, unsure; ITT, intention to treat; NA, not applicable (in an intervention such as surgery, compliance is not an issue).
  5. 5. EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstede 985 Table 3: Methodologic Quality Scores of the Cochrane Review of O’Connor et al13 Quality Our Score Definition of Blinding No No No According to High or Low Allocation Blinding Blinding Outcome Selection Performance Attrition O’Connor Score Study Quality of 13 Reference Randomization? Concealment? Patients? Caregiver? Assessors? Bias? Bias? Bias? et al Maximum Score StudyEbenbichler et al35 A 8 8 HighHui et al44 A 8 8 HighSpooner et al46 A 8 8 HighCarter et al54 B 8 7 HighChang et al42 B 8 7 HighHerskovitz et al43 B 8 7 HighRempel et al52 B 8 6 HighAigner et al56 B 8 5 HighOzkul et al63 ? B 8 5 HighOztas et al36 ? B 8 3 HighPal et al45 ? B 8 4 HighDavis et al51 C 8 5 LowManente et al23 C 8 4 LowBurke et al22 ? C 8 3 LowGarfinkel et al34 C 8 3 LowKoyuncu et al37 ? C 8 3 LowStransky et al47 ? C 8 3 LowTal-Akabi and Rushton49 C 8 3 LowAkalin et al32 ? C 8 2 LowTittiranonda et al53 ? C 8 2 LowWalker et al24 ? C 8 2 Low 13NOTE. Definition of O’Connor et al: A, high quality: all criteria met; B, moderate quality: 1 or more criteria partly met; C, low quality: 1 or morecriteria not met.Abbreviations: , Yes; , No; ?, unsure; , partly met.Significant results were found in favor of a nocturnal hand brace .15 .43, P .0001; and splint, .75 .28, vs control, .04 .30,compared with no treatment on symptom improvement P .0004, respectively).(WMD 1.07; 95% CI, 1.29 to .85), hand function It was concluded that there is moderate evidence in the short(WMD .55; 95% CI, .82 to .28), and overall improvement term and limited evidence in the midterm that a nocturnal hand(RR 4.00; 95% CI, 2.34 – 6.84) at 4 weeks of follow-up. brace is more effective than no therapy in the treatment of Recent RCTs. In the low-quality RCT of Premoselli et patients with CTS.al,29 (n 50) the positive results found in the review ofO’Connor13 were confirmed at 3 and 6 months of follow-up: Full-time use of a Wrist Splint Versus Night-Only Usesignificantly better results in favor of a nocturnal neutral wristsplint were found on symptoms (mean differences SD, Systematic review. In the low-quality RCT of Walker etsplint, 1.07 .39, vs control, .02 .24, P .001; and splint, al24 (n 24) included in the review of O’Connor13 that com-1.22 .39, vs control, .17 .29, P .001, respectively) and pared the full-time use of a wrist splint with night-only use, nofunction (mean differences SD, splint, .53 .22, vs control, significant differences were found on symptom improvement Arch Phys Med Rehabil Vol 91, July 2010
  6. 6. 986 EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstede Table 4: Methodologic Quality Scores of the Cochrane Review of Marshall et al14 Allocation Withdrawal/ Method Method Score Study Quality of Reference Randomization? Concealment? Double-Blind? Dropouts? Randomizing? Blinding? Maximum Score Percentage Study*Armstrong et al66 6 6 100 GoodDammers et al65 6 6 100 GoodWong et al68 6 6 100 GoodCeliker et al70 6 4 67 GoodWong et al74 ? 6 4 67 GoodOzdogan and Yazici67 ? 6 3 50 GoodAygul et al77 ? 6 2 33 PoorHabib et al76 ? 6 2 33 PoorSevim et al75 ? 6 2 33 PoorGökoglu et al78 ˘ ? 6 1 17 PoorLucantoni et al71 ? 6 1 17 PoorO’Gradaigh and Merry72 ? 6 1 17 PoorAbbreviations: , Yes; , No; ?, unsure.*Good, high quality; Poor, low quality.(WMD .21; 95% CI, .83 to .41) or hand function Wrist Splint Versus Hand Brace(WMD .21; 95% CI, .87 to .45) at 6 weeks of follow-up. Recent RCTs. One recent high-quality RCT (n 120)31 In conclusion, there is no evidence for the effectiveness of a compared a wrist splint with a hand brace. Both groups worefull-time use of a wrist splint compared with night-only use in the orthotic devices for 3 months at night. No significantpatients with CTS in the short term. differences between the groups were found on the symptom severity score, on the function severity score of the Boston Carpal Tunnel Questionnaire, and on pain from baseline to 3 Table 5: Strong and Moderate Evidence for Effectiveness months of follow-up and to 9 months of follow-up. of Nonsurgical Interventions for CTS Therefore, there is no evidence for the effectiveness of a Nonsurgical Interventions to Treat Strong or Moderate night hand brace compared with night splinting of the wrist for CTS Evidence Found the treatment of CTS in the short term. ✓abc Physiotherapy ✓de Oral Tendon and Nerve Gliding Exercises as Additive to ✓fghij Injection Splinting ✓klmno Other nonsurgical interventions Systematic review. One low-quality trial32 (n 36) found✓ Strong or moderate evidence found. no significant differences on symptom improvement, hand function, grip strength, and pinch strength for nerve and tendonShort-term: gliding exercises as additive to a neutral wrist splint at 3a Moderate evidence: ultrasound* vs placebo at 7wk of follow-up.c Moderate evidence: ultrasound* vs laser. months of follow-up.d Strong evidence: oral steroids* vs placebo at 2wk of follow-up. Recent RCTs. The low-quality study of Baysal et al25e Moderate evidence: oral steroids* vs placebo at 4wk of follow-up. (n 56) reported on ultrasound, splinting, and nerve and tendonf Strong evidence: corticosteroid injections* vs placebo. gliding exercises. Patients were divided into 3 treatmentg Moderate evidence: local* vs systemic steroids injection.h Moderate evidence: local corticosteroid injection* vs oral steroids. groups. Group 1 was treated with a splint and nerve and tendoni Moderate evidence: insulin injections as additive to steroids gliding exercises, group 2 with a splint and ultrasound treat- injections in patients with noninsulin-dependent diabetes ment, and group 3 with a splint, nerve and tendon gliding mellitus. exercises, and ultrasound treatment. No results between thek Moderate evidence: nocturnal hand brace* vs no therapy.l Moderate evidence: wrist splinting vs prednisone.* groups were presented. However, within the 3 treatmentm Moderate evidence: ergonomic keyboard* vs standard keyboard. groups, significant differences were found on pain (VAS), gripn Moderate evidence: dynamic magnetic field therapy* vs placebo strength, pinch strength, the symptom severity scale, and the therapy. function status scale at 8 weeks of follow-up.o Moderate evidence: cupping therapy vs head† pads. One recent high-quality RCT26 (n 51) studied 2 types ofMidterm:b splints (a neutral wrist and metacarpophalangeal splint, group Moderate evidence: ultrasound* vs placebo. 1; and a wrist cock-up splint, group 2) with and without tendonj Moderate evidence: 60mg methylprednisone* vs 20 or 40mg methylprednisone in the midterm. and nerve gliding exercises (groups 3 and 4, respectively). Significant results within the groups (no P value given) onLong-term: symptoms (group 1, 38%, vs group 2, 17%; groups 3 and 4, no percentages given) at 8 weeks of follow-up and pinch strength– (no further data given) within the groups were found at 4 weeks *in favor of follow-up. No between-group results were given.Arch Phys Med Rehabil Vol 91, July 2010
  7. 7. EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstede 987 Table 6: Total Overview of Evidence for Effectiveness of Nonsurgical Interventions for CTS Nonsurgical Treatment Physiotherapy Oral Treatment Injection Other Nonsurgical Treatments Ultrasound –Steroids vs Corticosteroid injections Splinting –Ultrasound* vs Placebo –Corticosteroid injection vs –Splinting in neutral position* vs splinting in extended wrist placebo Short-term: placebo position of 20° Short-term: 2wk: Short-term: Short term (2wk): 2wk: NE 4wk: –Local* vs systemic –Nocturnal hand brace* vs no therapy 7wk: –Nonsteroidal Short-term: Short-term: Midterm: anti- –Corticosteroid injection* Midterm: –1.5W/cm2 vs inflammatory vs oral steroids: –Full-time use wrist splint vs night-only splint 0.8W/cm2 drugs vs Short-term: Short-term: NE Short-term: NE placebo Long-term: NE –Night wrist splint vs night hand brace –1 vs 3MHz Short-term: NE –Corticosteroid injection vs Short-term: NE Short-term: NE –Diuretica vs anti-inflammatory –6wk day-and-night splint followed by 4wk night-splint and –Ultrasound* vs placebo medication plus splint 4wk nerve gliding exercises* vs same treatment without laser Short-term: NE Short-term: NE nerve gliding exercises Short-term: –Vitamin B6 –Corticosteroid injection* Short-term: vs placebo vs Helium laser treatment –Active neurodynamic exercises* as additive to night splint Laser therapy Short-term: NE Short-term: during heavy activities plus tendon gliding exercises –Laser vs –Oral Midterm: NE Midterm: placebo Prednisone –25mg hydrocortisone vs –Neutral wrist plus MCP splint (NW) vs wrist cock-up splint Short-term: NE 4 wk vs oral 100mg hydrocortisone (WCP) vs NW plus tendon and nerve gliding exercises (E) prednisone Short-term: NE vs WCP plus E Mobilization and 2wk: –60mg* Methylprednisone Short-term: NE manual therapy Long-term: NE vs 20 or 40mg –Splint plus nerve and tendon gliding exercises (NTE) vs –Carpal bone Methylprednisone splint plus ultrasound vs splint plus NTE plus ultrasound mobilization* Midterm: Short-term: NE vs no treatment Long-term: NE –Wrist splint vs oral prednisone* Short-term: –Short vs long-acting Short-term: –Neurodynamic corticosteroid injection –Low-level laser as additive to splinting vs carpal bone Short-term: NE Short-term: NE mobilization –Single vs 2 local –Yoga vs wrist splinting Short-term: NE corticosteroid injections Short-term: NE –Neurodynamic (15mg methylprednisone) technique plus Short-term: NE Chiropractic treatment splinting vs Midterm: NE –Chiropractic treatment vs medical treatment sham therapy Long-term: NE Midterm: NE plus splinting –Novel approach vs classic Short-term: NE approach of injection Ergonomic keyboards –Graston Short-term: NE –Ergonomic keyboard* vsstandard keyboard instrument– –Proximal approach vs Short-term: assisted soft distal approach of –Apple keyboard* vs standard keyboard tissue injection Midterm: mobilization Long-term: NE –Microsoft keyboard* vs standard keyboard (GISTM) plus –Corticosteroid injection* Midterm: home exercises vs iontophoresis –Other ergonomic keyboards vs regular keyboard vs manual soft Short-term: Midterm: NE tissue –Corticosteroid injection vs mobilization by phonophoresis Magnet therapy a clinician plus Midterm: NE –Magnet therapy vs placebo home exercises –Corticosteroid injection vs Short-term: NE Midterm: NE EMLA cream Short-term: NE Magnetic field therapy Massage –Dynamic magnet field therapy vs placebo –Targeted Injections other than Short-term: massage steroid protocol* vs –Botulinum B toxin vs Acupuncture general placebo –Laser acupuncture vs placebo massage Midterm: NE Short-term: NE protocol –Acupuncture vs oral steroids Short-term: Insulin as additive to Short-term: NE –Massage steroid injection therapy for 15 –In noninsulin-dependent Heat wrap therapy min plus self- diabetes mellitus: steroid –Heat wrap therapy* vs oral placebo massage vs no injections followed by Short-term (3d): treatment NPH injection* vs steroid Short-term: injections followed by Cupping therapy placebo injections –Cupping therapy* vs heat pads Short-term: Short-term (7d): Iontophoresis –Dexamethasone iontophoresis vs Placebo Midterm: NE Long-term: NEAbbreviations: , limited evidence found; , moderate evidence found; , strong evidence found; d, days; EMLA, Eutectic mixture of Local Anesthetic; MCP, metacarpo-phalangeal; mo, month; NE, no evidence found for effectiveness of the treatment: RCTs available, but no differences between intervention and control groups were found; NPH,isophane insulin injection; vs, versus; wk, weeks.*In favor of. Arch Phys Med Rehabil Vol 91, July 2010
  8. 8. 988 EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstede The low-quality RCT of Pinar et al28 (n 35) compared 2 Therefore, there is no evidence for the effectiveness ofgroups of patients with CTS: a day-and-night splint and a splinting compared with splinting plus low-level laser therapynonsurgical training program (nerve and gliding exercises) in the short term.were applied for 6 weeks to both groups. Subsequently, a nightsplint only was used in both groups, and nerve and gliding Splinting Versus Yogaexercises were continued in the experimental group for the Systematic review. One low-quality RCT (n 51)34 in theremaining 4 weeks. Significant progress was detected on grip review of O’Connor13 compared yoga with wrist splinting andstrength between the experimental group and the control group found no significant differences on pain at 8 weeks of(mean SD, 4.2 4.1 vs 1.3 1.5, respectively) at 10 weeks of follow-up.follow-up in favor of the experimental group. Furthermore, In conclusion, there is no evidence for the effectiveness ofbetween-group analyses showed no significant differences on yoga compared with wrist splinting to treat CTS in the shortpain and pinch strength. term. The low-quality study of Heebner and Roddey27 (n 60) 1.2 Ultrasoundinvestigated active neurodynamic exercises as additive to stan- Ultrasound Versus Placebodard care (consisting of splinting at night during heavy activ-ities plus tendon gliding exercises). No significant differences Systematic review. An analysis of pooled data from 2on the DASH Questionnaire, symptom severity score, and trials35,36 (n 63) of ultrasound treatments compared with pla-neurodynamic irritability of the median nerve were found at 6 cebo of O’Connor13 showed no significant effects on pain,months of follow-up. Significant differences were found on the symptoms, or function at 2 weeks of follow-up. However, 1function severity scale in favor of standard care with active high-quality trial35 showed significant symptom improvement after 7 weeks in patients treated with ultrasoundneurodynamic exercises at 6 months of follow-up (standard (WMD .99; 95% CI, 1.77 to .21), which was main-care with active neurodynamic exercises, 2.2 [mean], com- tained at 6 months of follow-up (WMD 1.86; 95% CI,pared with standard care, 2.9; P .016). 2.67 to 1.05). In conclusion, there is limited evidence that 6 weeks of Thus, there is no evidence for the effectiveness of ultrasoundday-and-night splinting with a nonsurgical training program compared to placebo at 2 weeks of follow-up, but there isfollowed by 4 weeks of night splint with nerve gliding exer- moderate evidence that ultrasound is more effective than pla-cises is more effective than the same treatment without nerve cebo in the treatment of patients with CTS at 7 weeks ofgliding exercises in the short term, and that active neurody- follow-up and in the midterm.namic exercises as additive to standard care (ie, night splintduring heavy activities plus tendon gliding exercises) is more Ultrasound: Comparison of Intensitieseffective (limited evidence) than standard care alone in themidterm. There is no evidence for the effectiveness of a neutral Systematic review. One high-quality RCT36 (n 30) in-wrist and metacarpophalangeal splint compared with a wrist cluded in the review of O’Connor13 compared 2 intensities ofcock-up splint with and without tendon and nerve gliding ultrasound (1.5W/cm2 and 0.8W/cm2) but found no significantexercises. Furthermore, there is no evidence for the effective- differences regarding pain and symptom improvement betweenness of treatment with a splint plus nerve and tendon gliding these intensities after 2 weeks.exercises compared with treatment with a splint plus ultrasound Therefore, we conclude there is no evidence for the effec-or compared with treatment with a splint plus tendon gliding tiveness of an ultrasound intensity of 1.5W/cm2 compared withexercises plus ultrasound in the short term. 0.8W/cm2 in the short term. Ultrasound: Different Frequencies ComparedSplinting Versus Oral Prednisone Systematic review. At 4 weeks of follow-up in another Recent RCTs. One recent high-quality RCT33 (n 71) low-quality RCT37 (n 21) included in the review ofcompared splinting of the wrist in neutral position for 4 weeks O’Connor,13 2 different frequencies (1 and 3MHz) were com-with oral prednisolone 20mg/d for 2 weeks followed by pared, but no significant differences were found on pain and10mg/d for 2 weeks. Significant differences were reported on function. It was concluded that there is no evidence for thethe function status score in favor of oral steroids compared with effectiveness of 1 or 3MHz frequency of ultrasound in patientssplinting (mean SD, splint, .16 .17, vs oral steroids, with CTS in the short term..26 .21; P .03), but no significant differences were found onthe symptom severity scale at 3 months of follow-up. Ultrasound Versus Laser Therapy In conclusion, there is moderate evidence that oral steroids Recent RCTs. In a high-quality RCT38 (n 90), ultra-are more effective than splinting of the wrist to treat CTS in the sound was compared with laser therapy. Ultrasound ap-short term. peared to be significantly more effective than laser therapy on pain (MD between groups, 4.4; 95% CI, 4.9 to 3.1;Splinting Versus Splinting Plus Low-Level Laser Therapy P .001) and function (hand grip strength: MD between Recent RCTs. One recent high-quality RCT30 compared a groups, 12.1; 95% CI, 5.7–27.6; P .001) at 4 weeks offull-time hand splint in neutral position for 3 months with follow-up.splinting plus 10 sessions of low-level laser therapy. Only Therefore, there is moderate evidence that ultrasound issignificant within-group results were reported on the symptom more effective than laser therapy in the treatment of patientsseverity score of the Boston Carpal Tunnel Questionnaire and with CTS in the short term.for grip strength within the splinting group. No significantdifferences between the groups were found on the Boston 1.3 Laser TherapyCarpal Tunnel Questionnaire (function capacity and symptom Recent RCTs. Three recent RCTs on laser therapy wereseverity scores). At 3 months of follow-up, no comparison found. In the high-quality RCT of Irvine et al39 (n 15), nobetween the groups for grip strength was made. significant differences were found between low-level laserArch Phys Med Rehabil Vol 91, July 2010
  9. 9. EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstede 989therapy and placebo on a symptom severity scale and on hand up. Further, no significant results were found on any outcomeperformance score at 9 weeks of follow-up. regarding pain, function, or improvement comparing neurody- In the high-quality study of Evcik et al40 (n 81), no signif- namic with carpal bone mobilization after 3 weeks of follow-icant differences were found between the low-level laser ther- up. No significant results were found on any outcome regardingapy and placebo treatment on hand grip strength, pinch grip, function by comparing neurodynamic with carpal bone mobi-pain, and functional capacity at 12 weeks of follow-up. lization in the short term. The high-quality study of Shooshtari et al41 (n 80) com- Recent RCTs. The high-quality study of Bialosky et al97pared low-level laser therapy to placebo. No comparisons be- reported on a neurodynamic technique intended to providetween the 2 groups were made. Significant differences were anatomic stress across the median nerve and combined thisfound on pain and hand grip within the low-level laser therapy intervention with splinting for 3 weeks. This intervention wasgroup (mean SD, from 7.8 .42 before treatment to compared with sham therapy. Both groups were also treated4.98 .12 at 3 weeks of follow-up, P .001; and from with a splint for 3 weeks. After 3 weeks of treatment, no19.81 5.06kg before treatment to 22.86 5.13kg at 3 weeks of significant differences between the groups were found on pain,follow-up, P .001, respectively). Within the placebo group, the DASH Questionnaire, or grip strength.significant differences were found for pain (mean SD, from The high-quality study of Burke et al50 (n 22) compared 28.01 .36 before treatment to 7.62 0.4 at 3 weeks of follow- manual therapy interventions: the Graston instrument–assistedup; P .001), but no significant differences were found for soft tissue mobilization plus home exercises with manual softhand grip. tissue mobilization by a clinician plus home exercises. Im- In conclusion, there is no evidence for the effectiveness of proved results were found within groups, but there were nolaser therapy compared with placebo as an intervention to treat significant differences between the 2 groups on pain, range ofCTS in the short term. motion (flexion and extension), grip strength, and the Boston Carpal Tunnel Questionnaire (functional status scale and the1.4 Oral Medications and Vitamins symptom severity scale) at 6 months of follow-up. Systematic review. Six RCTs42-47 (n 243) in the Co- Therefore, there is limited evidence that carpal bone mobi-chrane review of O’Connor13 reported on oral medication or lization is more effective than no treatment in the short term.vitamins. Three high-quality RCTs compared oral steroids with No evidence was found for the effectiveness of neurodynamicplacebo. 42-44 Pooling of the data of these 3 trials demonstrated versus carpal bone mobilization in the short term, for thesignificant changes in favor of oral steroids on symptom im- effectiveness of a neurodynamic technique plus splinting com-provement (WMD 7.23; 95% CI, 10.31 to 4.14) at 2 pared with a sham therapy plus splinting group in the shortweeks of follow-up. One RCT42 found significant differences term, or for the effectiveness of Graston instrument–assistedon symptom improvement at 4 weeks of follow-up soft tissue mobilization plus home exercises compared with(WMD 10.8; 95% CI, 15.26 to 6.34). soft tissue mobilization plus home exercises to treat CTS in the Two other high-quality RCTs compared nonsteroidal anti- midterm.inflammatory drugs42 and diuretics45 with placebo. No signif- Chiropractic Treatmenticant benefit on symptom improvement was reported for non-steroidal anti-inflammatory drugs or diuretics versus placebo at Systematic review. No significant differences on hand4 weeks of follow-up. One high-quality study46 and 1 low- function between chiropractic treatment (ie, manual thrusts,quality study 47 found no significant differences between vita- myofascial massage and loading, ultrasound, and nocturnalmin B6 and placebo on overall symptoms at 10 to 12 weeks of wrist splint) and medical treatment (ie, ibuprofen and wristfollow-up. splint) were found in a low-quality trial of Davis et al51 (n 91) Recent RCTs. The long-term effects of the study of Chang at 13 weeks of follow-up.et al42 included in the Cochrane review of O’Connor13 were Therefore, there is no evidence for the effectiveness ofreported by the high-quality RCT of Chang et al48 (n 109). chiropractic therapy compared with medical treatment for CTSChang48 compared oral prednisolone given for 4 weeks (20mg in the midterm.daily for 2 weeks followed by 10mg daily for 2 weeks) with Ergonomic Keyboardsoral prednisolone given for 2 weeks (20mg daily for 2 weeksand placebo for 2 weeks). No significant differences on overall Systematic review. Two RCTs52,53 included in the reviewimprovement were found at 12 months of follow-up. of O’Connor13 studied ergonomic keyboards compared with In conclusion, there is strong evidence after 2 weeks and control. The high-quality study of Rempel et al52 (n 18)moderate evidence after 4 weeks that oral steroids are more compared an ergonomic keyboard with a standard keyboardeffective than placebo. There is no evidence for the effective- and found significant changes on pain and hand function inness of 20mg daily of prednisolone for 2 weeks followed by favor of the ergonomic keyboard (WMD 2.40, 95% CI,10mg daily of the same drug for 2 weeks versus 20mg pred- 4.45 to 0.35; WMD 2.20, 95% CI, 12.08 to 7.68,nisolone daily for 2 weeks followed by placebo in the long respectively) at 3 months of follow-up. The low-quality studyterm. Furthermore, there is no evidence for the effectiveness of of Tittiranonda et al53 (n 80) found no significant differencesanti-inflammatory drugs or diuretica in the short term. In ad- on pain among 3 ergonomic keyboards (ie, comfort keyboarddition, there is no evidence for the effectiveness of vitamin B6 system, Apple adjusTable keyboard, and Microsoft naturalto treat CTS in the short term. keyboard) and a regular keyboard at 6 months of follow-up. At 6 months of follow-up, significant changes on hand function1.5 Other Nonsurgical Treatments were found in favor of the Apple keyboard and the Microsoft keyboard compared with a regular keyboard (WMD .93, 95%Mobilization and Manual Therapy CI, .26 –1.60; WMD 1.92, 95% CI, .84 –3.00, respectively), Systematic review. The low-quality RCT of Tal-Akabi and but no significant differences were found on hand function inRushton49 (n 21) on carpal bone mobilization demonstrated a the ergonomic keyboard group.significant benefit on symptoms compared with no treatment Thus, there is moderate evidence that an ergonomic key-(WMD 1.43; 95% CI, 2.19 to .67) at 3 weeks of follow- board is more effective than a standard keyboard in the short Arch Phys Med Rehabil Vol 91, July 2010
  10. 10. 990 EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstedeterm. In the midterm, there is limited evidence that an Apple 3.00 at the last day; P .05), pain (massage group, from 4.11 atkeyboard and a Microsoft keyboard are more effective than a baseline to 2.59 at 4 weeks of follow-up compared with con-regular keyboard, but no evidence for the effectiveness of other trols, from 6.17 at baseline to 4.83 at 4 weeks of follow-up;ergonomic keyboards compared with a regular keyboard. P .05), and grip strength (massage group, from 6.61 at base- line to 7.8 at 4 weeks of follow-up compared with controls,Magnet Therapy from 5.58 at baseline to 6.25 at 4 weeks of follow-up; P .05) Systematic review. One high-quality RCT (n 30)54 com- after 3 treatment sessions at 4 weeks of follow-up.pared magnet therapy with placebo and found no significant Therefore, there is limited evidence that a targeted massagebenefit on pain between these groups at 2 weeks of follow-up. protocol is more effective than a general massage protocol, and Therefore, we found no evidence for the effectiveness of that massage therapy for 15 minutes once a week with self-magnet therapy. massage daily is more effective than no treatment in the short term.Magnetic Field Therapy Recent RCTs. Significant differences were found in a Heat Wrap Therapyhigh-quality study of Weintraub and Cole55 (n 36) on the Recent RCTs. One recent low-quality RCT60 (n 22) stud-Neuropathy Pain Scale (total composite; reduction: treatment ied low-level heat wrap therapy (104°F; 40°C) for 3 days (withgroup, 42%, compared with controls, 24%; P .04) between a total of 26 time points) compared with oral placebo with asimultaneous and time-varying dynamic magnetic field stimu- follow-up of 2 days. Significant differences in favor of low-lation on the wrist and sham therapy from baseline to 2 months level heat wrap therapy were found on pain at 20 of the 26 timeof follow-up. In contrast, no significant differences were found points (P .05), joint stiffness reduction at 19 of the 26 timeon pain and Patients Clinical Global Impression of Change at points (P .05), grip strength (mean SD, heat wrap,2 months of follow-up. 6.1 1.6kg, vs oral placebo, 0.8 1.4kg; P .012) and symptom Therefore, we found moderate evidence for the effectiveness severity scale (mean SD, heat wrap, .97 .16, vs oral pla-of dynamic magnetic field therapy in the short term to treat cebo, .14 .14; P .001). After 3 days, significant differencespatients with CTS. in favor of heat wrap therapy were found on function status scale, but not at 5 days of follow-up (mean SD, heat wrap,Acupuncture .65 .16, vs oral placebo, .00 .16, P .006, and heat wrap, Systematic review. A high-quality RCT (n 26)56 demon- .57 .22, vs oral placebo, .12 .20, P .07, respectively).strated no significant differences between laser acupuncture There is limited evidence that heat wrap therapy is moreand placebo on night pain at 3 weeks of follow-up. effective than oral placebo in the short term (3 days of Recent RCTs. The high-quality study of Yang et al57 com- follow-up).pared 4 weeks of acupuncture (8 sessions) with oral steroids(first 2 weeks, 20mg prednisolone daily, followed by 2 weeks Cupping Therapyof 10mg prednisolone daily). Both interventions resulted in Recent RCTs. The high-quality study of Michalsen et al61better but no significant differences on the Global Symptom compared traditional cupping therapy with heat pads (controlScore at 4 weeks of follow-up (mean percent change SD group). At day 7, significant differences were found on pain at restfrom baseline to 4 weeks, acupuncture group, 70 24.6, vs (MD 22.9; 95% CI, 35.3 to 10.5), the Levine CTS scoresteroid group, 64.7 27.6). (symptom severity, mean difference, 22.9, 95% CI, 35.3 to It was concluded that there is no evidence for the effective- 10.5; functional status, MD 0.6, 95% CI, 0.8 to 0.3), andness of laser acupuncture for the treatment of CTS in the short the DASH score (MD 11.1; 95% CI, 17.1 to 5.1).term, or for the effectiveness of acupuncture compared with Therefore, we concluded that cupping therapy is moreoral steroid drugs to treat CTS in the short term. effective (moderate evidence) than heat pads at 7 days of follow-up.Massage Therapy Recent RCTs. The low-quality study RCT of Moraska et Injections Other Than Steroidsal58 (n 27) compared a targeted massage protocol (focused on Recent RCTs. An injection with botulinum B toxin intothe affected upper extremity and addressing areas of constric- each of the 3 hypothenar muscles was compared with placebotion, ischemia, and nerve entrapment) with a general massage in the low-quality study of Breuer et al62 (n 20). The studyprotocol (relaxing massage to reduce tension of the back, neck, reported no significant differences on Clinical Global Impres-and upper extremities) for 6 weeks. Significant effects were sion of Severity at 13 weeks of follow-up.found on grip strength at 10 weeks of follow-up in favor of the Thus, there is no evidence for the effectiveness of botulinumtargeted massage group (targeted massage group, mean from B toxin compared with ibuprofen and wrist splint to treat25.1kg to 29.5kg; 95% CI, 27.7–31.3kg; vs the general mas- patients with CTS in the midterm.sage group, mean from 25.1kg to 26.3kg; P .04). No signif-icant differences were found on pinch strength (at 6wk), symp-tom severity score (at 10wk), function status scale (at 6wk), Insulin as Additive to a Steroid Injectionand the Grooved Pegboard Test (at 6wk). The low-quality Systematic review. The high-quality study of Ozkul et al63study of Field et al59 (n 16) also examined massage therapy as investigated insulin as additive to steroid injection (methyl-treatment for CTS, but they compared a 15-minute massage prednisolone 20mg in 1mL) for 7 weeks in patients withonce a week for a 4-week period plus self-massage daily with noninsulin-dependent diabetes mellitus and found significanta control group without treatment. Significant differences were differences on the Global Symptom scale in favor of steroidfound in favor of the massage group on CTS (ie, loss of injection plus insulin injections at 8 weeks of follow-up (nostrength, tingling, numbness, burning, or pain to the affected exact data and P value given).region; massage group, from 3.00 at the first day to 2.22 at the In conclusion, there is moderate evidence that in patientslast day compared with controls, from 3.00 at the first day to with noninsulin-dependent diabetes mellitus, steroid injectionArch Phys Med Rehabil Vol 91, July 2010
  11. 11. EFFECTIVENESS OF NONSURGICAL TREATMENTS FOR CARPAL TUNNEL SYNDROME, Huisstede 991plus insulin injections are more effective than steroid injections provement compared with baseline, vs oral prednisolone,alone for the treatment of CTS in the short term. 51.9% improvement compared with baseline; P .05). Thus, there is moderate evidence that corticosteroid injec-Ionthophoresis tions are more effective than oral steroids in the short term. Recent RCTs. One recent RCT of high quality64 found no Furthermore, there is no evidence for the effectiveness ofsignificant differences on the Levine Questionnaire between corticosteroid injections compared with oral steroids in thedexamethasone iontophoresis and a control group (iontophore- treatment of patients with CTS in the long term.sis with distilled water) at 3 and 6 months of follow-up. We concluded there is no evidence for the effectiveness of Corticosteroid Injection Versus Anti-inflammatorydexamethasone iontophoresis compared with a placebo con- Medication Plus Splintingtrolled group in midterm and long term. Systematic review. In one high-quality trial70 (n 23) in- cluded in the Cochrane review of Marshall,14 there was no2. Corticosteroid injections significant improvement in symptoms between the injection Marshall14 conducted a Cochrane review (search up to group (40mg methylprednisolone) and the anti-inflammatoryMay 2006) on local corticosteroid injection versus placebo medication (120mg acemetacin) plus splinting group at 2 and 8injection or other nonsurgical interventions in improving weeks after treatment. Also, on pain (VAS), no significantclinical outcome and also to determine how long symptom improvement was found at 2 and 8 weeks of follow-up.relief lasted. Twelve RCTs were included (n 671) in this We concluded that there is no evidence for the effectiveness ofreview. Furthermore, 3 recent RCTs were found. corticosteroid injection compared with anti-inflammatory medica- tion plus splinting as intervention for CTS in the short term.Corticosteroid Injections Versus Placebo Corticosteroid Injection Versus Helium-Neon Laser Systematic review. One high-quality study65 (n 60) in-cluded in the review of Marshall14 demonstrated significant Treatmentclinical improvement in favor of local corticosteroid (40mg Systematic review. In the low-quality study of Lucantoni etmethylprednisolone) compared with placebo injection al71 (n 40), at 20 days of follow-up, significant differences(RR 3.83; 95% CI, 1.82– 8.05) 1 month after treatment. were found in favor of corticosteroid injections with 20mg Another high-quality study66 (n 81) compared 1.5mg beta- methylprednisolone compared with helium-neon laser onmethasone with placebo and found significant clinical improve- symptom improvement (RR 1.89; 95% CI, 1.12–3.17). How-ment in favor of corticosteroid injections 2 weeks after treat- ever, significant effects were no longer reported at 6 months ofment (RR 2.04; 95% CI, 1.26 –3.31). Pooling of the data of follow-up.the 2 RCTs demonstrated significant clinical improvement in Therefore, there is limited evidence that corticosteroid in-favor of corticosteroid injection in the short term (RR 2.58; jections are more effective than helium-neon laser in the short95% CI, 1.72–3.87). term, but no evidence was found for the effectiveness in the In conclusion, we found strong evidence that a corticosteroid midterm.injection is more effective than placebo in the treatment ofpatients with CTS in the short term. Different Doses of Local Corticosteroid Injections Systematic review. The low-quality study of O’GradaighLocal Versus Systemic Corticosteroid Injection and Merry72 (n 64) found no significant differences on clin- Systematic review. One high-quality trial67 (n 37) ical symptoms between the 25-mg hydrocortisone local injec-showed a better rate of improvement with a local corticosteroid tion group and the 100-mg hydrocortisone group at 6 weeks ofinjection (betamethasone 1.5mg) than with a systemic cortico- follow-up.steroid injection (betamethasone 1.5mg) (RR 3.17; 95% CI, Recent RCTs. One high-quality RCT73 (n 172) reporting1.02–9.87) at 1 month of follow-up. on corticosteroid injections to treat CTS was found. At 1 year Therefore, there is moderate evidence that local corticoste- of follow-up, better but nonsignificant differences in treatmentroid injections are more effective than systemic corticosteroid response were found for an injection with 60mg methylpred-injections to treat CTS in the short term. nisone compared with injections with 20mg or 40mg of the same medication. At 6 months of follow-up, significantly betterCorticosteroid Injection Versus Oral Steroid results were found in favor of the 60-mg doses compared with Systematic review. One high-quality trial68 (n 60) in- the other 2 doses (60-mg group, 73% [32/44] vs 40-mg group,cluded in the Cochrane review14 found no significant differ- 53% [23/43]) and 40mg (60-mg group, 73% [32/44] vs 20-mgences on symptom improvement on the Global Symptom Score group, 56% [25/45]) of the same medication.at 2 weeks of follow-up and significant differences on symptom In conclusion, there is no evidence for the effectiveness ofimprovement on the Global Symptom Score in favor of corti- 25-mg hydrocortisone local injections compared with 100-mgcosteroid injections (15mg methylprednisolone) compared with hydrocortisone injections in the short term. There is moderateoral steroids (25mg methylprednisolone) at 8 weeks and 12 evidence that 60mg methylprednisone is more effective than 20weeks of follow-up (WMD 7.16, 95% CI, 11.46 to or 40mg methylprednisone in the midterm, but no evidence for 2.86; and WMD 7.10, 95% CI, 11.68 to 2.52, the effectiveness of 60mg methylprednisone compared with 20respectively). or 40mg methylprednisone to treat CTS in the long term. Recent RCTs. The long-term effects of the study of Wonget al68 were reported by the high-quality study of Hui et al.69 Of Short-Versus Long-Acting Corticosteroid Injectionthe 80 randomized participants, 35 did not require surgical Systematic review. The low-quality study of O’Gradaightreatment in 80 weeks of follow-up; no significant differences and Merry72 (n 39) also examined the effectiveness of short-between these groups were found on the Global Symptom acting local corticosteroid (100mg hydrocortisone) versusScore at 80 weeks of follow-up (steroid injection, 69.5% im- long-acting corticosteroid (20mg triamcinolone). No signifi- Arch Phys Med Rehabil Vol 91, July 2010

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