Local corticosteroid injection for carpal tunnel syndrome

Ultrasound-guided hydrodissection decreases gliding resistance of the median nerve within the carpal tunnel

INTRODUCTION

The aim of this study was to assess alterations in median nerve (MN) biomechanics within the carpal tunnel resulting from ultrasound-guided hydrodissection in a cadaveric model.

METHODS

Twelve fresh frozen human cadaver hands were used. MN gliding resistance was measured at baseline and posthydrodissection, by pulling the nerve proximally and then returning it to the origin. Six specimens were treated with hydrodissection, and 6 were used as controls.

RESULTS

In the hydrodissection group there was a significant reduction in mean peak gliding resistance of 92.9 ± 34.8 mN between baseline and immediately posthydrodissection (21.4% ± 10.5%; P = 0.001). No significant reduction between baseline and the second cycle occurred in the control group: 9.6 ± 29.8 mN (0.4% ± 5.3%; P = 0.467).

DISCUSSION

Hydrodissection can decrease the gliding resistance of the MN within the carpal tunnel, at least in wrists unaffected by carpal tunnel syndrome. A clinical trial of hydrodissection seems justified. Muscle Nerve 57: 25-32, 2018.

Comparing the effectiveness of ultrasound-guided versus blind steroid injection in the treatment of severe carpal tunnel syndrome

Background/aim: This study aimed to compare the effectiveness of ultrasound (US)-guided injection versus blind injection of corticosteroids in the treatment of carpal tunnel syndrome (CTS). Materials and methods: This prospective, randomized clinical trial included patients with severe CTS based on clinical and electrophysiological criteria. The patients were evaluated for clinical and electrophysiological parameters at baseline and 4 weeks after treatment. Symptom severity and hand function were assessed by the Boston questionnaire. The patients underwent blind injection or US-guided injection. Results: When compared with baseline, both groups showed significant improvement in Boston questionnaire scores and all electrophysiological parameters. Significant differences were observed between the groups for clinical parameters (Boston Symptom Severity Scale: P = 0.007; Functional Status Scale: P < 0.001) in favor of the US-guided group. Conclusion: This study demonstrated that both US-guided and blind injections were effective in reducing symptoms and improving hand function. US-guided injections may yield more effective clinical results in the short-term than blind injections in the treatment of patients with severe CTS.

Comparison of the efficacy of lidocaine and betamethasone dipropionate in carpal tunnel syndrome injection

BACKGROUND

Carpal tunnel syndrome (CTS) is a commonly seen peripheral nerve mononeuropathy. Corticosteroid injection within the carpal tunnel is among the conservative treatment options. The exact mechanism of action of steroids is not fully clear; decreased inflammation surrounding nerves or tendons is thought to be the main effect. Lidocaine has been shown to have anti-inflammatory effects on certain cells (monocytes, macrophages, neutrophils etc.). The aim of this study is to evaulate the efficacy of lidocaine treatment as a alternative to corticosteroid treatment in carpal tunnel syndrome.

METHODS

A total of 67 carpal tunnel syndrome patients who were diagnosed with physical examination and EMG were evaluated. Twenty-nine patients received a mixture of normal saline solution and lidocaine (0.5 cc of normal saline solution and 0.5 cc of lidocaine) while 38 patients were administered betamethasone dipropionate (1 cc). Quick DASH (Disabilities of the Arm, Shoulder and Hand) and Visual Analog Scale (VAS) scores were noted in 1st, 3rd and 6th month follow-ups.

RESULTS

There were no significant difference between saline solution + Lidocaine group and betamethasone dipropionate groups; initial, 1st, 3rd and 6th month VAS scores and QDASH scores (p > 0.05).

CONCLUSION

Considering the potential side effects of corticosteroid, lidocaine injection is a good alternative treatment of carpal tunnel syndrome instead of corticosteroids.

Conservative therapeutic management of carpal tunnel syndrome

ABSTRACT Carpal tunnel syndrome is the most prevalent nerve compression and can be clinically or surgically treated. In most cases, the first therapeutic alternative is conservative treatment but there is still much controversy regarding the most effective modality of this treatment. In this study, we critically evaluated the options of conservative treatment for carpal tunnel syndrome, aiming to guide the reader through the conventional options used in this therapy.

Mechanical wrist traction as a non-invasive treatment for carpal tunnel syndrome: a randomized controlled trial

BACKGROUND

Carpal tunnel syndrome (CTS) is a common, compressive nerve-entrapment disorder with symptoms of numbness, paresthesia, and pain. Carpal tunnel release surgery is the only known long-term effective treatment. However, surgery is invasive and up to 30% of patients report recurrence or persistence of symptoms or suffer from post-surgical complications. A promising non-surgical treatment for CTS is mechanical wrist traction. The purpose of this study was to evaluate clinical outcomes following mechanical traction in patients with CTS compared to care as usual.

METHODS

Adult patients (N = 181, mean age 58.1 (13.0) years, 67% women) with electrodiagnostically confirmed CTS were recruited from an outpatient neurology clinic in the Netherlands between October 2013 and April 2015. After baseline assessments, patients were randomized to either the intervention group (12 treatments with mechanical traction, twice a week for a period of 6 weeks) or "care as usual". The main clinical outcome measure was surgery during 6 months' follow-up. In addition, symptom severity was measured using the Boston Carpal Tunnel Questionnaire (BCTQ) at baseline, 3, and 6 months' follow-up. Baseline characteristics and severity of CTS symptoms at follow-up were compared between the intervention and care-as-usual groups using a t test and χ 2 tests. Time to event (surgery) between the groups was analyzed using Kaplan-Meier survival analysis and Cox proportional hazards analysis.

RESULTS

The intervention group had fewer surgeries (28%) compared to the care-as-usual group (43%) during follow-up (χ21 = 4.40, p = .036). Analyses of the survival curves revealed a statistically significant difference between the groups over time (log-rank test χ 21 = 6.94, p = .008). At 6 months' follow-up, symptom severity and functional status scores had significantly decreased from baseline in both groups (p < .001) and the improvements did not differ between the two groups.

CONCLUSIONS

Mechanical traction is associated with fewer surgical interventions compared to care as usual in CTS patients. Reductions in patient-reported symptoms at 6 months' follow-up was similar in both groups. The long-term effects of mechanical traction require further evaluation.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NL44692.008.13 . Registered on 19 September 2013.

Treatment outcome in patients with clinically defined carpal tunnel syndrome but normal electrodiagnostic test results: a randomized controlled trial

Little is known about treatment effect of carpal tunnel release in patients with clinically defined carpal tunnel syndrome (CTS), but normal electrodiagnostic test results (EDX). The aim of this study was to determine whether this category of patients will benefit from surgical treatment. 57 patients with clinically defined CTS and normal EDX were randomized for surgical treatment (n = 39) or non-surgical treatment (n = 18). A six-point scale for perceived improvement as well as the Boston Carpal Tunnel Questionnaire was completed at baseline and at follow-up after 6 months. A significant improvement of complaints was reported by 70.0% of the surgically treated patients and 39.4% reported full recovery 6 months after surgery. Furthermore, both Functional Status Score and Symptom Severity Score improved significantly more in the surgically treated group (p = 0.036 and p < 0.001, respectively). This study demonstrates that most patients with clinically defined CTS and normal EDX results will benefit from carpal tunnel release. Therefore, this group of CTS patients must not a priori be refrained from surgery.

Corticosteroid Injections for Carpal Tunnel Syndrome: Long-Term Follow-Up in a Population-Based Cohort

BACKGROUND

Corticosteroid injection is a recommended treatment option for carpal tunnel syndrome, before considering surgery. Nevertheless, injections remain controversial because there is strong evidence of only short-term benefits. This study aimed to determine the reintervention rate and to identify prognostic indicators for subsequent treatment after corticosteroid injection for carpal tunnel syndrome.

METHODS

This study evaluated residents of Olmsted County treated with a corticosteroid injection for carpal tunnel syndrome between 2001 and 2010. Treatment failure was the primary outcome of interest. Two definitions for failure were examined: (1) the patient receiving subsequent procedural intervention and (2) the patient undergoing carpal tunnel release. Survival was estimated using Kaplan-Meier methods, and association of covariates with increased failure was modeled using Cox proportional hazards regression.

RESULTS

The study included 774 affected hands in 595 patients. The median follow-up period was 7.4 years. Reintervention was performed in 68 percent of cases, of which 63 percent resulted in eventual surgery. Injectate volume was significant for the outcome of any retreatment [hazard ratio, 0.879 (95 percent CI, 0.804 to 0.96)] and surgery [hazard ratio, 0.906 (95 percent CI, 0.827 to 0.99)]. Rheumatoid arthritis was also significant in both models, with a hazard ratio of 0.627 (95 percent CI, 0.404 to 0.97) for any retreatment and 0.493 (95 percent CI, 0.292 to 0.83) for surgery.

CONCLUSIONS

In this cohort, 32 percent of patients did not receive subsequent treatment after a single injection, which indicates that there is a therapeutic role for corticosteroid injections in treating carpal tunnel syndrome. Further research is necessary to identify those patients who will benefit from an injection, to provide more individually tailored treatment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Low-level laser therapy for carpal tunnel syndrome

BACKGROUND

The role of low-level laser therapy (LLLT) in the management of carpal tunnel syndrome (CTS) is controversial. While some trials have shown distinct advantages of LLLT over placebo and some other non-surgical treatments, other trials have not.

OBJECTIVES

To assess the benefits and harms of LLLT versus placebo and versus other non-surgical interventions in the management of CTS.

SEARCH METHODS

On 9 December 2016 we searched CENTRAL, MEDLINE, Embase, and Science Citation Index Expanded for randomised controlled trials (RCTs). We also searched clinical trial registries for ongoing studies. We checked the references of primary studies and review articles, and contacted trial authors for additional studies.

SELECTION CRITERIA

We considered for inclusion RCTs (irrespective of blinding, publication status or language) comparing LLLT versus placebo or non-surgical treatment for the management of CTS.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials for inclusion and extracted the data. For continuous outcomes, we calculated the mean difference (MD) or standardised mean difference (SMD) with a 95% confidence interval (CI) using the random-effects model, calculated using Review Manager. For dichotomous data, we reported risk ratio (RR) and 95% CI.

MAIN RESULTS

We identified 22 trials randomising 1153 participants that were eligible for inclusion; nine trials (525 participants, 256 randomised to LLLT) compared LLLT with placebo, two (150 participants, 75 randomised to LLLT) compared LLLT with ultrasound, one compared LLLT with placebo and LLLT with ultrasound, two compared LLLT with steroid injection, and one trial each compared LLLT with other non-surgical interventions: fascial manipulation, application of a pulsed magnetic field, transcutaneous electrical nerve stimulation (TENS), steroid injection, tendon gliding exercises, and applying a wrist splint combined with non-steroidal anti-inflammatory drugs. Three studies compared LLLT as part of multiple interventions. Risk of bias varied across the studies, but was high or unclear in most assessed domains in most studies. Most studies were small, with few events, and effect estimates were generally imprecise and inconsistent; the combination of these factors led us to categorise the quality of evidence for most outcomes as very low or, for a small number, low. At short-term follow-up (less than three months), there was very low-quality evidence for any effect over placebo of LLLT on CTS for the primary outcome of Symptom Severity Score (scale 1 to 5, higher score represents worsening; MD -0.36, 95% CI -0.78 to 0.06) or Functional Status Scale (scale 1 to 5, higher score represents worsened disability; MD -0.56, 95% CI -1.03 to -0.09). At short-term (less than three months) follow-up, we are uncertain whether LLLT results in a greater improvement than placebo in visual analogue score (VAS) pain (scale 0 to 10, higher score represents worsening; MD -1.47, 95% CI -2.36 to -0.58) and several aspects of nerve conduction studies (motor nerve latency: higher score represents worsening; MD -0.09 ms, 95% CI -0.16 to -0.03; range 3.1 ms to 4.99 ms; sensory nerve latency: MD -0.10 ms, 95% CI -0.15 to -0.06; range 1.8 ms to 3.9 ms), as the quality of the evidence was very low. When compared with placebo at short-term follow-up, LLLT may slightly improve grip strength (MD 2.58 kg, 95% CI 1.22 to 3.95; range 14.2 kg to 25.23 kg) and finger-pinch strength (MD 0.94 kg, 95% CI 0.43 to 1.44; range 4.35 kg to 5.7 kg); however, the quality of evidence was low. Only VAS pain and finger-pinch strength results reached the minimal clinically important difference (MCID) as previously published. We are uncertain about the effect of LLLT in comparison to ultrasound at short-term follow-up for improvement in VAS pain (MD 2.81, 95% CI 1.21 to 4.40) and motor nerve latency (MD 0.61 ms, 95% CI 0.27 to 0.95), as the quality of evidence was very low. When compared with ultrasound at short-term follow-up, LLLT may result in slightly less improvement in finger-pinch strength (MD -0.71 kg, 95% CI -0.94 to -0.49) and motor nerve amplitude (MD -1.90 mV, 95% CI -3.63 to -0.18; range 7.10 mV to 9.70 mV); however, the quality of evidence was low. There was insufficient evidence to assess the long-term benefits of LLLT versus placebo or ultrasound. There was insufficient evidence to show whether LLLT is better or worse in the management of CTS than other non-surgical interventions. For all outcomes reported within these other comparisons, the quality of evidence was very low. There was insufficient evidence to assess adverse events, as only one study reported this outcome.

AUTHORS' CONCLUSIONS

The evidence is of very low quality and we found no data to support any clinical effect of LLLT in treating CTS. Only VAS pain and finger-pinch strength met previously published MCIDs but these are likely to be overestimates of effect given the small studies and significant risk of bias. There is low or very low-quality evidence to suggest that LLLT is less effective than ultrasound in the management of CTS based on short-term, clinically significant improvements in pain and finger-pinch strength. There is insufficient evidence to support LLLT being better or worse than any other type of non-surgical treatment in the management of CTS. Any further research of LLLT should be definitive, blinded, and of high quality.

Corticosteroid Injections for Carpal Tunnel Syndrome: Long-Term Follow-Up in a Population-Based Cohort

BACKGROUND

Corticosteroid injection is a recommended treatment option for carpal tunnel syndrome, before considering surgery. Nevertheless, injections remain controversial because there is strong evidence of only short-term benefits. This study aimed to determine the reintervention rate and to identify prognostic indicators for subsequent treatment after corticosteroid injection for carpal tunnel syndrome.

METHODS

This study evaluated residents of Olmsted County treated with a corticosteroid injection for carpal tunnel syndrome between 2001 and 2010. Treatment failure was the primary outcome of interest. Two definitions for failure were examined: (1) the patient receiving subsequent procedural intervention and (2) the patient undergoing carpal tunnel release. Survival was estimated using Kaplan-Meier methods, and association of covariates with increased failure was modeled using Cox proportional hazards regression.

RESULTS

The study included 774 affected hands in 595 patients. The median follow-up period was 7.4 years. Reintervention was performed in 68 percent of cases, of which 63 percent resulted in eventual surgery. Injectate volume was significant for the outcome of any retreatment [hazard ratio, 0.879 (95 percent CI, 0.804 to 0.96)] and surgery [hazard ratio, 0.906 (95 percent CI, 0.827 to 0.99)]. Rheumatoid arthritis was also significant in both models, with a hazard ratio of 0.627 (95 percent CI, 0.404 to 0.97) for any retreatment and 0.493 (95 percent CI, 0.292 to 0.83) for surgery.

CONCLUSIONS

In this cohort, 32 percent of patients did not receive subsequent treatment after a single injection, which indicates that there is a therapeutic role for corticosteroid injections in treating carpal tunnel syndrome. Further research is necessary to identify those patients who will benefit from an injection, to provide more individually tailored treatment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Effectiveness of Ultrasound-Guided Compared to Blind Steroid Injections in the Treatment of Carpal Tunnel Syndrome

OBJECTIVE

To compare the effectiveness of ultrasound-guided injections to blind injections in the treatment of carpal tunnel syndrome (CTS) in a large community-based cohort.

METHODS

This study evaluated residents of Olmsted County, Minnesota, treated with a corticosteroid injection for CTS between 2001 and 2010. The proportion of patients receiving retreatment and the duration of retreatment-free survival between blind and ultrasound-guided injections were compared. Propensity score matching was used to control for confounding by indication.

RESULTS

In the matched data set consisting of 234 (of 600) hands treated with a blind injection and 87 (of 89) ultrasound-guided injection cases, ultrasound guidance was associated with a reduced hazard of retreatment (hazard ratio 0.59 [95% confidence interval (95% CI) 0.37-0.93]). In addition, ultrasound guidance was associated with 55% reduced odds of retreatment within 1 year compared to blind injections (adjusted odds ratio 0.45 [95% CI 0.24-0.83]).

CONCLUSION

This study indicates that ultrasound-guided injections are more effective in comparison to blind injections in the treatment of CTS.

Comparison of the Clinical Effectiveness of Ultrasound-Guided Corticosteroid Injection with and without Needle Release of the Transverse Carpal Ligament in Carpal Tunnel Syndrome

BACKGROUND

To compare the clinical effectiveness of ultrasound-guided corticosteroid injection with and without needle release of the transverse carpal ligament (TCL) in carpal tunnel syndrome (CTS).

METHODS

Between May 2014 and June 2016, 52 patients (56 wrists) with CTS were included in this study. Among these patients, 28 wrists were treated with ultrasound-guided corticosteroid injection plus needle release of the TCL (group A) and 28 wrists were treated with a single ultrasound-guided corticosteroids injection (group B). The following parameters were assessed and compared including postoperative results of procedure based on relief of symptoms, electrophysiological parameters (distal motor latency, sensory conduction velocity, and sensory nerve action potential of median nerve), and ultrasound parameters (anteroposterior diameter and cross-sectional area of the median nerve at the levels of pisiform and hamate bone, and the thicknesses of TCL on the cross-section at the level of hamate bone).

RESULTS

The overall excellent and good rate regarding the postoperative results of procedure based on the relief of symptoms at 1 month postoperatively was 82.1% in group A and 46.4% in group B (p = 0.004). There was significant difference in the above electrophysiological and ultrasound parameters between the preoperative and postoperative values in both groups (all p < 0.05). Furthermore, a significant difference was also observed in the postoperative values of the above-mentioned electrophysiological and ultrasound parameters in the 2 groups (all p < 0.05).

CONCLUSIONS

Both approaches had treatment benefit in CTS. Ultrasound-guided corticosteroid injection in combination with needle release of the TCL is superior to the single ultrasound-guided corticosteroids injection.

Injection versus Decompression for Carpal Tunnel Syndrome-Pilot trial (INDICATE-P)-protocol for a randomised feasibility study

Background

Carpal tunnel syndrome (CTS) is the commonest peripheral nerve disorder in the UK, with over 52,996 carpal tunnel decompressions performed in 2011. By 2030, this figure is estimated to double. Whilst evidence supports conservative measures for mild symptoms, and early surgery for severe symptoms, controversy remains over the most appropriate management for patients that present with moderate disease, with regard to early surgery or late surgery following steroid injection. Injection versus Decompression for Carpal Tunnel Syndrome-Pilot trial (INDICATE-P) is a feasibility study for a multicentre, randomised controlled trial (INDICATE) to determine whether patients over the age of 18 with moderate CTS should undergo early surgical decompression of the median nerve or a single steroid injection (followed by later surgery if required).

Methods/design

INDICATE-P is a feasibility study for an open (non-blinded) randomised controlled pilot trial. Eligible participants will be adults with a clinical diagnosis of moderate CTS. This is defined as symptoms disturbing sleep or restricting activities of daily living or work, despite a 2-week trial of night splints. Participants will be randomised to one of two possible interventions: surgical decompression or a single steroid injection (followed by surgery later if required). Clinical outcome measures will be captured by postal questionnaire at 1, 3, 6 and 12 months post-randomisation. In order to improve the study design for the main INDICATE trial, feasibility data will also be collected to identify difficulties in recruitment and retention, to gain patient feedback on questionnaires and to confirm the suitability of the proposed outcome measures.

Discussion

The INDICATE-P feasibility study will contribute to the design and execution of the INDICATE trial, which will seek to assess the safety and effectiveness of two approaches to treatment for patients over 18 years of age with moderate CTS: early carpal tunnel decompression or a single steroid injection (followed by later surgery).

The clinical and cost effectiveness of steroid injection compared with night splints for carpal tunnel syndrome: the INSTINCTS randomised clinical trial study protocol

BACKGROUND

Patients diagnosed with idiopathic mild to moderate carpal tunnel syndrome (CTS) are usually managed in primary care and commonly treated with night splints and/or corticosteroid injection. The comparative effectiveness of these interventions has not been reliably established nor investigated in the medium and long term. The primary objective of this trial is to investigate whether corticosteroid injection is effective in reducing symptoms and improving hand function in mild to moderate CTS over 6 weeks when compared with night splints. Secondary objectives are to determine specified comparative clinical outcomes and cost effectiveness of corticosteroid injection over 6 and 24 months.

METHOD/DESIGN

A multicentre, randomised, parallel group, clinical pragmatic trial will recruit 240 adults aged ≥18 years with mild to moderate CTS from GP Practices and Primary-Secondary Care Musculoskeletal Interface Clinics. Diagnosis will be by standardised clinical assessment. Participants will be randomised on an equal basis to receive either one injection of 20 mg Depo-Medrone or a night splint to be worn for 6 weeks. The primary outcome is the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. Secondary outcomes are the BCTQ symptom severity and function status subscales, symptom intensity, interrupted sleep, adherence to splinting, perceived benefit and satisfaction with treatment, work absence and reduction in work performance, EQ-5D-5L, referral to surgery and health utilisation costs. Participants will be assessed at baseline and followed up at 6 weeks, 6, 12 and 24 months. The primary analysis will use an intention to treat (ITT) approach and multiple imputation for missing data. The sample size was calculated to detect a 15 % greater improvement in the BTCQ overall score in the injection group compared to night-splinting at approximately 90 % power, 5 % two-tailed significance and allows for 15 % loss to follow-up.

DISCUSSION

The trial makes an important contribution to the evidence base available to support effective conservative management of CTS in primary care. No previous trials have directly compared these treatments for CTS in primary care populations, reported on clinical effectiveness at more than 6 months nor compared cost effectiveness of the interventions.

TRIAL REGISTRATION

Trial registration: EudraCT 2013-001435-48 (registered 05/06/2013), ClinicalTrials.gov NCT02038452 (registered 16/1/2014), and Current Controlled Trials ISRCTN09392969 (retrospectively registered 01/05/2014).

Does Hypothyroidism Affect Post-Operative Outcome of Patients Undergoing Carpal Tunnel Release?

Introduction

Risk factors associated with Carpal Tunnel Syndrome include repetitive use of hand and wrist, advanced age, obesity, pregnancy, diabetes mellitus and thyroid disease. Decompression of the median nerve is the last treatment of choice usually indicated when negative results to conservative treatments remain for three months. In this study, we aimed to find out whether hypothyroid patients would respond to CTS surgical decompression differently in comparison to healthy individuals.

Methods

This case control study was conducted on patients with CTS in need of surgical release who were refered to Shahid Faghihi hospital, International Branch of Shiraz University of Medical Sciences, Shiraz, Iran from January 2013 to January 2015. Twenty-five hypothyroid and 22 euthyroid patients were recruited. Hypothyroidism was diagnosed based on clinical symptoms and serum TSH level. All patients were followed for three weeks after surgery and a Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) was completed for them pre and post operation. An electrophysiological study was performed during the same follow up period. Statistical analysis was performed using SPSS version 16.

Results

The CTS grade reported by electrophysiological study, decreased significantly 3 weeks after operation in comparison with preoperative grades (p<0.001). A significant decrease was observed in the immediate postoperative BCTQ scores compared to preoperative (p<0.001). Also a decrease was detected in the three weeks of postoperative follow up compared to immediate postoperative BCTQ scores (p<0.001) and preoperative BCTQ scores (p<0.001). Postoperative BCTQ scores of euthyroid patients decreased more in comparison to hypothyroid patients (p<0.001).

Conclusion

It seems that, hypothyroidism has an effect on postoperative outcome of carpal tunnel release.

Electroacupuncture and splinting versus splinting alone to treat carpal tunnel syndrome: a randomized controlled trial

BACKGROUND

The effectiveness of acupuncture for managing carpal tunnel syndrome is uncertain, particularly in patients already receiving conventional treatments (e.g., splinting). We aimed to assess the effects of electroacupuncture combined with splinting.

METHODS

We conducted a randomized parallel-group assessor-blinded 2-arm trial on patients with clinically diagnosed primary carpal tunnel syndrome. The treatment group was offered 13 sessions of electroacupuncture over 17 weeks. The treatment and control groups both received continuous nocturnal wrist splinting.

RESULTS

Of 181 participants randomly assigned to electroacupuncture combined with splinting (n = 90) or splinting alone (n = 91), 174 (96.1%) completed all follow-up. The electroacupuncture group showed greater improvements at 17 weeks in symptoms (primary outcome of Symptom Severity Scale score mean difference [MD] -0.20, 95% confidence interval [CI] -0.36 to -0.03), disability (Disability of Arm, Shoulder and Hand Questionnaire score MD -6.72, 95% CI -10.9 to -2.57), function (Functional Status Scale score MD -0.22, 95% CI -0.38 to -0.05), dexterity (time to complete blinded pick-up test MD -6.13 seconds, 95% CI -10.6 to -1.63) and maximal tip pinch strength (MD 1.17 lb, 95% CI 0.48 to 1.86). Differences between groups were small and clinically unimportant for reduction in pain (numerical rating scale -0.70, 95% CI -1.34 to -0.06), and not significant for sensation (first finger monofilament test -0.08 mm, 95% CI -0.22 to 0.06).

INTERPRETATION

For patients with primary carpal tunnel syndrome, chronic mild to moderate symptoms and no indication for surgery, electroacupuncture produces small changes in symptoms, disability, function, dexterity and pinch strength when added to nocturnal splinting.

TRIAL REGISTRATION

Chinese Clinical Trial Register no. ChiCTR-TRC-11001655 (www.chictr.org.cn/showprojen.aspx?proj=7890); subsequently deposited in the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR-TRC-11001655).

Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomised, double-blind, controlled trial

Objective

To compare the effect of corticosteroids combined with local anaesthetic versus local anaesthetic alone during infiltrations of the pudendal nerve for pudendal nerve entrapment.

Design

Randomised, double‐blind, controlled trial.

Setting

Multicentre study.

Population

201 patients were included in the study, with a subgroup of 122 women.

Methods

CT‐guided pudendal nerve infiltrations were performed in the sacrospinous ligament and Alcock's canal. There were three study arms: patients in Arm A (n = 68) had local anaesthetic alone, those in Arm B (n = 66) had local anaesthetic plus corticosteroid and those in Arm C (n = 67) local anaesthetic plus corticosteroid with a large volume of normal saline.

Main outcome measures

The primary end‐point was the pain intensity score at 3 months. Patients were regarded as responders (at least a 30‐point improvement on a 100‐point visual analogue scale of mean maximum pain over a 2‐week period) or nonresponders.

Results

Three months’ postinfiltration, 11.8% of patients in the local anaesthetic only arm (Arm A) were responders versus 14.3% in the local anaesthetic plus corticosteroid arms (Arms B and C). This difference was not statistically significant (P = 0.62). No statistically significant difference was observed in the female subgroup between Arm A and Arms B and C (P = 0.09). No significant difference was detected for the various pain assessment procedures, functional criteria or quality‐of‐life criteria.

Conclusions

Corticosteroids provide no additional therapeutic benefits compared with local anaesthetic and should therefore no longer be used.

Tweetable abstract

Steroid infiltrations do not improve the results of local anaesthetic infiltrations in pudendal neuralgia.

Steroid infiltrations do not improve the results of local anaesthetic infiltrations in pudendal neuralgia.

A double-blind randomized controlled trial comparing dexamethasone and clonidine as adjuvants to a ropivacaine sciatic popliteal block for foot surgery

Background and aims

A popliteal block is effective in managing postoperative pain for foot surgery, but since the duration of analgesia is limited following a single-shot popliteal fossa block technique, methods to prolong effective postoperative analgesia are mandatory. The aim of this study was to assess the effect of adjuvants to ropivacaine on the duration of sensory and motor block.

Methods

In this double-blind randomized placebo-controlled study, we evaluated the analgesic effect of clonidine or dexamethasone (DXM) when added to ropivacaine for hallux valgus surgery. After obtaining institutional ethics research board approval and written informed consent, a total of 72 patients were randomly allocated. Fifty-seven of these patients were statistically analyzed. All patients received an ultrasound-guided single-shot popliteal fossa block with 30 mL of ropivacaine 0.75%, supplemented with saline, clonidine 100 µg, or DXM 5 mg. The primary end point was time to first pain sensation. Secondary end points were time to complete sensory and motor block regression.

Results

Compared to saline, duration to first pain sensation was prolonged by 9 hours (mean ± standard deviation: 31±9 hours) (42%) in the DXM group (P=0.024) and by 6 hours (28±10 hours) (27%) in the clonidine group (P=0.024). Compared to saline, DXM prolonged both complete sensory and motor blockade by 12 hours (25±7 hours) (46%) and 13 hours (36±6 hours) (55%), respectively, while clonidine prolonged complete sensory and motor blockade by 7 hours (30±7 hours) (27%) and 2 hours (22±5 hours) (10%), respectively. DXM prolonged sensory block regression time by 6 hours (21±7 hours) (41%) and clonidine by 2 hours (17±6 hours) (13%) compared to the control group (P=0.006). Similarly, DXM prolonged motor block regression by 7 hours (25±7 hours) (46%) and clonidine by 4 hours (21±4 hours) (19%) (P<0.0001).

Conclusion

Addition of DXM and clonidine to ropivacaine significantly prolonged the duration of postoperative sensory and motor block.

Rehabilitation following carpal tunnel release

BACKGROUND

Various rehabilitation treatments may be offered following carpal tunnel syndrome (CTS) surgery. The effectiveness of these interventions remains unclear. This is the first update of a review first published in 2013.

OBJECTIVES

To review the effectiveness and safety of rehabilitation interventions following CTS surgery compared with no treatment, placebo, or another intervention.

SEARCH METHODS

On 29 September 2015, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL Plus, AMED, LILACS, and PsycINFO. We also searched PEDro (3 December 2015) and clinical trials registers (3 December 2015).

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials that compared any postoperative rehabilitation intervention with either no intervention, placebo, or another postoperative rehabilitation intervention in individuals who had undergone CTS surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, assessed risk of bias, and assessed the quality of the body of evidence for primary outcomes using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach according to standard Cochrane methodology.

MAIN RESULTS

In this review we included 22 trials with a total of 1521 participants. Two of the trials were newly identified at this update. We studied different rehabilitation treatments including immobilisation using a wrist orthosis, dressings, exercise, controlled cold therapy, ice therapy, multi-modal hand rehabilitation, laser therapy, electrical modalities, scar desensitisation, and arnica. Three trials compared a rehabilitation treatment to a placebo, four compared rehabilitation to a no treatment control, three compared rehabilitation to standard care, and 15 compared various rehabilitation treatments to one another.Overall, the included studies were very low in quality. Thirteen trials explicitly reported random sequence generation; of these, five adequately concealed the allocation sequence. Four trials achieved blinding of both participants and outcome assessors. Five were at high risk of bias from incompleteness of outcome data at one or more time intervals, and eight had high risk of selective reporting bias.These trials were heterogeneous in terms of treatments provided, duration of interventions, the nature and timing of outcomes measured, and setting. Therefore, we were not able to pool results across trials.Four trials reported our primary outcome, change in self reported functional ability at three months or more. Of these, three trials provided sufficient outcome data for inclusion in this review. One small high-quality trial studied a desensitisation programme compared with standard treatment and revealed no statistically significant functional benefit based on the Boston Carpal Tunnel Questionnaire (BCTQ) (mean difference (MD) -0.03, 95% confidence interval (CI) -0.39 to 0.33). One low-quality trial assessed participants six months post surgery using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and found no significant difference between a no formal therapy group and a group given a two-week course of multi-modal therapy commenced at five to seven days post surgery (MD 1.00, 95% CI -4.44 to 6.44). One very low-quality quasi-randomised trial found no statistically significant difference in function on the BCTQ at three months post surgery with early immobilisation (plaster wrist orthosis worn until suture removal) compared with a splint and late mobilisation (MD 0.39, 95% CI -0.45 to 1.23).Differences between treatments for secondary outcome measures (change in self reported functional ability measured at less than three months; change in CTS symptoms; change in CTS-related impairment measures; presence of iatrogenic symptoms from surgery; return to work or occupation; and change in neurophysiological parameters) were generally small and not statistically significant. Few studies reported adverse events.

AUTHORS' CONCLUSIONS

There is limited and, in general, low quality evidence for the benefit of the reviewed interventions. People who have undergone CTS surgery should be informed about the limited evidence of effectiveness of postoperative rehabilitation interventions. Until researchers provide results of more high-quality trials that assess the effectiveness and safety of various rehabilitation treatments, the decision to provide rehabilitation following CTS surgery should be based on the clinician's expertise, the patient's preferences and the context of the rehabilitation environment. It is important for researchers to identify patients who respond to a particular treatment and those who do not, and to undertake high-quality studies that evaluate the severity of iatrogenic symptoms from surgery, measure function and return-to-work rates, and control for confounding variables.

Antioxidant activity of linalool in patients with carpal tunnel syndrome

Background

Carpal tunnel syndrome (CTS) is a common peripheral neuropathy and ischemic-reperfusion injury. Oxidative stress is considered a major cause of CTS. Linalool, a component of essential oils, has antioxidant activity. This study was designed to determine the effects of linalool inhalation on oxidative stress in patients with CTS.

Methods

This double-blind, placebo-controlled study assessed the effects of linalool inhalation on oxidative stress in patients with CTS. Thirty-seven subjects, with and without CTS, were randomized to inhalation of 1 % linalool or carrier oil. 1,1-Diphenyl-2-picrylhydrazyl (DPPH) radical scavenging activity, systolic blood pressure (sBP), diastolic blood pressure (dBP) and pulse rate were analyzed.

Results

DPPH inhibition was significantly higher in both experimental groups than in their respective controls. Moreover inhalation of linalool reduced sBP, dBP and pulse rate in the CTS group, and pulse rate in the non-CTS group. However, there were no significant differences among the study groups in nitrite levels, sBP, dBP and pulse rate.

Conclusions

Inhalation of linalool increases antioxidative activity and reduces blood pressure and pulse rate in patients with CTS.

Local anesthetic injections with or without steroid for chronic non-cancer pain: a protocol for a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Steroids are often combined with local anesthetic (LA) and injected to reduce pain associated with various chronic non-cancer pain (CNCP) complaints. The biological rationale behind injection of a steroid solution is unclear, and it is uncertain whether the addition of steroids offers any additional benefits over injection of LA alone. We propose to conduct a systematic review and meta-analysis to summarize the evidence for using steroids and LA vs. LA alone in the treatment of CNCP.

METHODS

An experienced librarian will perform a comprehensive search of EMBASE, MEDLINE, and the Cochrane Central Registry of Controlled Trials (CENTRAL) databases with search terms for clinical indications, LA, and steroid agents. We will review bibliographies of all relevant published reviews in the last 5 years for additional studies. Eligible trials will be published in English and randomly allocate patients with CNCP to treatment with steroid and LA injection therapy or injection with LA alone. We will use the guidelines published by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) to inform the outcomes that we collect and present. Teams of reviewers will independently and in duplicate assess trial eligibility, abstract data, and assess risk of bias among eligible trials. We will prioritize intention to treat analysis and, when possible, pool outcomes across trials using random effects models. We will report our findings as risk differences, weighted mean differences, or standardized mean differences for individual outcomes. Further, to ensure interpretability of our results, we will present risk differences and measures of relative effect for pain reduction based on anchor-based minimally important clinical differences. We will conduct a priori defined subgroup analyses and use the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to evaluate the certainty of the evidence on an outcome-by-outcome basis.

DISCUSSION

Our review will evaluate both the effectiveness and the adverse events associated with steroid plus LA vs. LA alone for CNCP, evaluate the quality of the evidence using the GRADE approach, and prioritize patient-important outcomes guided by IMMPACT recommendations. Our results will facilitate evidence-based management of patients with chronic non-cancer pain and identify key areas for future research.

TRIAL REGISTRATION

PROSPERO CRD42015020614.

Peripheral neuropathies

Peripheral neuropathies are diseases of the peripheral nervous system that can be divided into mononeuropathies, multifocal neuropathies, and polyneuropathies. Symptoms usually include numbness and paresthesia. These symptoms are often accompanied by weakness and can be painful. Polyneuropathies can be divided into axonal and demyelinating forms, which is important for diagnostic reasons. Most peripheral neuropathies develop over months or years, but some are rapidly progressive. Some patients only suffer from mild, unilateral, slowly progressive tingling in the fingers due to median nerve compression in the wrist (carpal tunnel syndrome), while other patients can be tetraplegic, with respiratory insufficiency within 1-2 days due to Guillain-Barré syndrome. Carpal tunnel syndrome, with a prevalence of 5% and incidence of 1-2 per 1000 person-years, is the most common mononeuropathy. Population-based data for chronic polyneuropathy are relatively scarce. Prevalence is estimated at 1% and increases to 7% in persons over 65 years of age. Incidence is approximately 1 per 1000 person-years. Immune-mediated polyneuropathies like Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy are rare diseases, with an annual incidence of approximately 1-2 and 0.2-0.5 per 100 000 persons respectively. Most peripheral neuropathies are more prevalent in older adults and in men, except for carpal tunnel syndrome, which is more common in women. Diabetes is a common cause of peripheral neuropathy and is associated with both mono- and polyneuropathies. Among the group of chronic polyneuropathies, in about 20-25% no direct cause can be found. These are slowly progressive axonal polyneuropathies.

A Bayesian network meta-analysis: Comparing the clinical effectiveness of local corticosteroid injections using different treatment strategies for carpal tunnel syndrome

BACKGROUND

Local corticosteroid injections are commonly used to improve the short-term symptomatic severity and the functional status of the hands affected by carpal tunnel syndrome. We conducted a systematic review and Bayesian network-meta-analysis to compare the clinical effectiveness of local corticosteroid injections using different injection approaches.

METHODS

Electronic literature in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science, and other sources were searched to identify clinical studies comparing different injection approaches with each other or placebo for carpal tunnel syndrome. Two review authors conducted selection of studies, data extraction, and assessment of risk of bias independently. Random-effects models were used to conduct the pairwise meta-analysis and the Bayesian network meta-analysis.

RESULTS

Overall, 10 studies with 633 patients were included in the systematic review. Among the injection approaches, local corticosteroid injections using the ultrasound-guided in-plane injection (Ulnar-I) approach was the best treatment strategy for clinical response (median OR versus placebo 128.30, 95% CrI 9.76 to 2299.00), change in symptom severity scale (median MD versus placebo -1.16, 95% CrI -1.95 to -0.38) , and change in functional status scale (median MD versus placebo -0.74, 95% CrI -2.00 to 0.52) at short-term follow-up period in the network meta-analysis. Local corticosteroid injections using other injection approaches were better than placebo for clinical response (for the PI approach, median OR versus placebo 8.85, 95% CrI 3.00 to 33.15; for the DI approach, median OR versus placebo 7.00, 95% CrI 0.53 to 118.80) , change in symptom severity scale (for the Ulnar-O approach, median MD versus placebo -0.78, 95% CrI -1.43 to -0.16; for the PI approach, median MD versus placebo -0.58, 95% CrI -0.95 to -0.22), and change in functional status scale (for the Ulnar-O approach, median MD versus placebo -0.63, 95% CrI -1.67 to 0.43; for the PI approach, median MD versus placebo -0.46, 95% CrI -1.11 to 0.21) at short-term follow-up period. The quality of studies is good.

CONCLUSIONS

According to our analyses, the ultrasound-guided in-plane injection (Ulnar-I) approach was the most effective treatment among the injection approaches for carpal tunnel syndrome.

Comparison between the effects of progesterone versus corticosteroid local injections in mild and moderate carpal tunnel syndrome: a randomized clinical trial

Background

The objective of this study was to compare the short-term effects of progesterone and corticosteroid local injections in the treatment of female patients with carpal tunnel syndrome.

Methods

A randomized clinical trial was used for this study, 60 hands with mild and moderate Carpal Tunnel Syndrome categorized in two groups were used for this study. Patients were treated with a single local injection of triamcinolone acetonide in one group and single local injection of 17-alpha hydroxy progesterone in the other group. Variables such as pain (based on Visual Analogue Scale), symptom severity and functional status (based on Bostone/Levine symptom severity and functional status scale) and nerve conduction study were evaluated before and 10 weeks after the treatments.

Results

Ten weeks after treatment, pain severity and median nerve sensory and motor latencies decreased while patients’ functional status increased meaningfully in both groups. However, there were no meaningful differences between two groups regarding mentioned variables. Pain severity was milder and duration of post-injection pain was shorter in the corticosteroid group. The rates of patient satisfaction were also meaningfully higher in the corticosteroid group.

Conclusions

Both treatments were effective in the short-term management of mild and moderate disease, clinically and electrophysiologically. There were no significant differences in therapeutic effects between two groups.

Trial registration

Current controlled trials IRCT2013101313442N4

Carpal tunnel syndrome and work

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome, and it frequently presents in working-aged adults. Its mild form causes 'nuisance' symptoms including dysaesthesia and nocturnal waking. At its most severe, CTS can significantly impair motor function and weaken pinch grip. This review discusses the anatomy of the carpal tunnel and the clinical presentation of the syndrome as well as the classification and diagnosis of the condition. CTS has a profile of well-established risk factors including individual factors and predisposing co-morbidities, which are briefly discussed. There is a growing body of evidence for an association between CTS and various occupational factors, which is also explored. Management of CTS, conservative and surgical, is described. Finally, the issue of safe return to work post carpal tunnel release surgery and the lack of evidence-based guidelines are discussed.

Clinical implications of real-time visualized ultrasound-guided injection for the treatment of ulnar neuropathy at the elbow: a pilot study

OBJECTIVE

To investigate the feasibility of ultrasound (US)-guided steroid injection by in-plane approach for cubital tunnel syndrome (CuTS), based on symptomatic, morphologic and electrophysiological outcomes.

METHODS

A total of 10 patients, who were clinically diagnosed as CuTS and confirmed by an electrodiagnostic study, participated in this study. US-guided injection into the cubital tunnel was performed with 40 mg triamcinolone and 2 mL of 1% lidocaine. Outcomes of the injections were evaluated at pre-injection, 1st week and 4th week after injection. Visual analog scale, self-administered questionnaire of the ulnar neuropathy at the elbow (SQUNE), and McGowan classification were used for clinical evaluation. Cross-sectional area of the ulnar nerve by US and the electrophysiological severity scale through a nerve conduction study were utilized in the evaluation of morphologic and electrophysiological changes. The cross-sectional area of the ulnar nerve was measured at 3 points of condylar, proximal, and distal level of the cubital tunnel.

RESULTS

No side effects were reported during the study period. The visual analog scale and cross-sectional area showed a significant decrease at 1st week and 4th week, as compared to baseline (p<0.05). The electrophysiological severity scale was significantly decreased at the 4th week, as compared with baseline and 1st week (p<0.05). Among the quantitative components of the scale, there were statistically significant improvements with respect to the conduction velocity and block.

CONCLUSION

The new approach of US-guided injection may be a safe tool for the treatment of CuTS. Symptomatic and morphologic recoveries preceded the electrophysiological improvement.

Carpal and cubital tunnel and other, rarer nerve compression syndromes

BACKGROUND

Carpal tunnel syndrome is by far the most common peripheral nerve compression syndrome, affecting approximately one in every six adults to a greater or lesser extent. Splitting the flexor retinaculum to treat carpal tunnel syndrome is the second most common specialized surgical procedure in Germany. Cubital tunnel syndrome is rarer by a factor of 13, and the other compression syndromes are rarer still.

METHODS

This review is based on publications retrieved by a selective literature search of PubMed and the Cochrane Library, along with current guidelines and the authors' clinical and scientific experience.

RESULTS

Randomized controlled trials have shown, with a high level of evidence, that the surgical treatment of carpal tunnel syndrome yields very good results regardless of the particular technique used, as long as the diagnosis and the indication for surgery are well established by the electrophysiologic and radiological findings and the operation is properly performed. The success rates of open surgery, and the single-portal and dual-portal endoscopic methods are 91.6%, 93.4% and 92.5%, respectively. When performed by experienced hands, all these procedures have complication rates below 1%. The surgical treatment of cubital tunnel syndrome has a comparably low complication rate, but worse results overall. Neuro-ultrasonography and magnetic resonance imaging (neuro-MRI) are increasingly being used to complement the diagnostic findings of electrophysiologic studies.

CONCLUSION

Evidence-based diagnostic methods and treatment recommendations are now available for the two most common peripheral nerve compression syndromes. Further controlled trials are needed for most of the rarer syndromes, especially the controversial ones.

Two novel nonsurgical treatments of carpal tunnel syndrome

This article describes 2 nonsurgical approaches to the treatment of carpal tunnel syndrome that are not routinely offered, probably due to a lack of awareness. Osteopathic manipulative treatment (OMT) is commonly used for many medical problems, including musculoskeletal issues. OMT of the carpal tunnel is well described and researched, and can be clinically used by a skilled practitioner. The second treatment strategy is a more recent development. The use of ultrasound for guidance of injection is established, but a newer technique using sonographically guided percutaneous needle release of the transverse carpal ligament has shown promising results.

Screening for thyroid dysfunction and diabetes in patients with carpal tunnel syndrome

BACKGROUND

Current literature demonstrates that patients with carpal tunnel syndrome (CTS) have a higher prevalence of hypothyroidism and diabetes. The British Society for Surgery of the Hand (BSSH) advises screening CTS patients for thyroid and glucose dysfunction before surgery. This study aimed to analyze the current departmental practice for patients listed for carpal tunnel decompression (CTD) with respect to preoperative assessment of diabetic and thyroid status.

METHOD

A retrospective review of all patients who underwent surgery for CTS under one team over a 3 year period (2009-2011) in a UK teaching hospital was performed. Patients' medical records and pathology results were reviewed.

RESULTS

A total of 103 procedures were performed in 100 patients. Preoperative thyroid function was checked in 63/100 patients with an abnormal result in 3/63 patients. Two of these patients were subsequently diagnosed with hypothyroidism. Similarly blood glucose was checked in 67/100 patients. This resulted in the new diagnosis of three patients with diabetes.

CONCLUSION

The results are consistent with the view that CTS is associated with thyroid dysfunction and diabetes and screening helps in diagnosing new cases of these conditions in this select group. The cost of diagnosing new cases of hypothyroidism and diabetes can be considered as money well spent.

Anatomical and ultrasound correlation of the superficial branch of the radial nerve

INTRODUCTION

This anatomical study evaluates the role and correlation of ultrasound (US) with anatomy in depicting the superficial branch of the radial nerve (SBRN) and to evaluate the feasibility of US guided perineural infiltration as a potential therapeutic option in Wartenberg syndrome.

METHODS

Twenty-one arms from 11 non-embalmed cadavers were examined with US. Under US guidance perineural injection with ink was performed proximal to the site where the SBRN perforates the forearm fascia. The distribution of ink around the nerve was evaluated with dissection.

RESULTS

US allowed the distinction of the SBRN segments and their relation to the fascia. In all cases, the subfascial segment was stained. In only 57% the subfascially applied ink also reached the subcutaneous compartment.

CONCLUSIONS

With US it is possible to examine and differentiate all segments of the SBRN. US guidance can be used for perineural injection of all relevant segments.

Carpal tunnel syndrome pathophysiology: role of subsynovial connective tissue

Carpal tunnel syndrome (CTS) is a very common pathology. Its most common diagnosis is idiopathic. Although it is accepted that chronic increase in pressure within the carpal tunnel is responsible for median nerve neuropathy, the exact pathophysiology leading to this pressure increase remains unknown. All the histological studies of the carpal tunnel in the CTS find a noninflammatory thickening of the subsynovial connective tissue (SSCT), which seems to be a characteristic of this pathology. Numerous animal models have been developed to recreate CTS in vivo to develop and improve preventive strategies and effective conservative treatments by a better understanding of its pathophysiology. The creation of a shear injury of the SSCT in a rabbit model induced similar modifications to what is observed in CTS, suggesting that this could be a pathway leading to idiopathic CTS.

Carpal tunnel syndrome - Part II (treatment)

The treatments for non-deficit forms of carpal tunnel syndrome (CTS) are corticoid infiltration and/or a nighttime immobilization brace. Surgical treatment, which includes sectioning the retinaculum of the flexors (retinaculotomy), is indicated in cases of resistance to conservative treatment in deficit forms or, more frequently, in acute forms. In minimally invasive techniques (endoscopy and mini-open), and even though the learning curve is longer, it seems that functional recovery occurs earlier than in the classical surgery, but with identical long-term results. The choice depends on the surgeon, patient, severity, etiology and availability of material. The results are satisfactory in close to 90% of the cases. Recovery of strength requires four to six months after regression of the pain of pillar pain type. This surgery has the reputation of being benign and has a complication rate of 0.2-0.5%.

Conservative treatment of carpal tunnel syndrome: comparison between laser therapy and Fascial Manipulation(®)

The etiopathogenesis of Carpal Tunnel Syndrome (CTS) is multifactorial and most cases are classified as idiopathic (Thurston 2013). A randomized controlled trial was performed to compare the effectiveness of Fascial Manipulation(®) (FM) and Low-Level Laser Therapy (LLLT) for CTS. This prospective trial included 42 patients (70 hands with symptoms) with clinical and electroneuromyographic diagnosis of CTS. The patients were randomly assigned to receive multiple sessions of FM or multiple session of LLLT. The Visual Analogic Scale (VAS) and Boston Carpal Tunnel Questionnaire (BCTQ) were performed at baseline, end of treatment and after three months. The group that received FM showed a significant reduction in subjective pain perception and an increased function assessed by BCTQ at the end of the treatment and follow-up. The group that received LLLT showed an improvement in the BCTQ at the end of the treatment but the improvement level was not sustained at the three month follow-up. FM is a valid alternative treatment for CTS.

Effectiveness of mechanical traction as a non-surgical treatment for carpal tunnel syndrome compared to care as usual: study protocol for a randomized controlled trial

BACKGROUND

Carpal tunnel syndrome (CTS) is a common condition (prevalence of 4%) where the median nerve is compressed within the carpal tunnel resulting in numbness, tingling, and pain in the hand. Current non-surgical treatment options (oral medication, corticosteroid injections, splinting, exercise, and mobilization) show limited effects, especially in the long-term. Carpal tunnel release (CTR) surgery is effective in 70 to 75% of patients, but is relatively invasive and can be accompanied by complications. In an observational study, mechanical traction proved to be effective in up to 70% of patients directly after treatment and in 60% after two years follow-up. This randomized controlled trial (RCT) will examine the effectiveness of mechanical traction compared to care as usual in CTS.

METHODS/DESIGN

Patients diagnosed with CTS will be recruited from an outpatient neurology clinic and randomly assigned to the intervention group (mechanical traction) or the control group (care as usual). Participants in the intervention group will receive 12 treatments with mechanical traction during six consecutive weeks. Primary outcome is symptom severity and functional status, which are measured with the Boston Carpel Tunnel Questionnaire (BCTQ). Secondary outcomes are quality of life (WHOQOL-BREF), health related resource utilization, and absenteeism from work. Outcomes will be assessed at baseline, and at 3, 6, and 12 months after inclusion. Linear mixed effect models will be used to determine the change from baseline at 12 months on the BCTQ, WHOQOL-BREF, absenteeism from work and health related resource utilization. The baseline measurement, change from baseline at three and six months, as well as duration of symptoms until inclusion, age, gender, and co-morbidity will be included as covariates The Pearson's correlation coefficient will be generated to assess the correlation between depression and anxiety and treatment outcome.

DISCUSSION

Since current non-surgical treatment options are not effective long-term and CTR is relatively invasive, there is a need for an effective and non-invasive treatment option. Mechanical traction is a safe treatment option that may provide a good alternative for the usual care. Considering the prevalence of CTS, the study is of great clinical value to a large patient population.

TRIAL REGISTRATION

Clinical Trials NL44692.008.13 (registered on 19 September 2013).

Median nerve injuries caused by carpal tunnel injections

Local steroid injections are widely used for diagnostic and therapeutic purposes in the management of carpal tunnel syndrome. The median nerve injury is the most serious complication in association with carpal tunnel injections although the incidence is low. A median nerve injury will be presented with shooting pain at the injection time along with other sensory distortion, motor weakness and muscle atrophy. The management includes a conservative treatment and a surgical exploration. Carpal tunnel injections should be used at a minimum only. If such steroid injection is required, an appropriate needle positioning is vital for the nerve injury prevention. The patient should not be heavily sedated and should be encouraged to inform experiences of numbness/paresthesia during the procedure immediately.

Clinical course, costs and predictive factors for response to treatment in carpal tunnel syndrome: the PALMS study protocol

BACKGROUND

Carpal tunnel syndrome (CTS) is the most common neuropathy of the upper limb and a significant contributor to hand functional impairment and disability. Effective treatment options include conservative and surgical interventions, however it is not possible at present to predict the outcome of treatment. The primary aim of this study is to identify which baseline clinical factors predict a good outcome from conservative treatment (by injection) or surgery in patients diagnosed with carpal tunnel syndrome. Secondary aims are to describe the clinical course and progression of CTS, and to describe and predict the UK cost of CTS to the individual, National Health Service (NHS) and society over a two year period.

METHODS/DESIGN

In this prospective observational cohort study patients presenting with clinical signs and symptoms typical of CTS and in whom the diagnosis is confirmed by nerve conduction studies are invited to participate. Data on putative predictive factors are collected at baseline and follow-up through patient questionnaires and include standardised measures of symptom severity, hand function, psychological and physical health, comorbidity and quality of life. Resource use and cost over the 2 year period such as prescribed medications, NHS and private healthcare contacts are also collected through patient self-report at 6, 12, 18 and 24 months. The primary outcome used to classify treatment success or failures will be a 5-point global assessment of change. Secondary outcomes include changes in clinical symptoms, functioning, psychological health, quality of life and resource use. A multivariable model of factors which predict outcome and cost will be developed.

DISCUSSION

This prospective cohort study will provide important data on the clinical course and UK costs of CTS over a two-year period and begin to identify predictive factors for treatment success from conservative and surgical interventions.

Reliability of motor parameters for follow-up after local steroid injection in carpal tunnel syndrome

BACKGROUND

Local steroid injection is one of the treatment modalities for carpal tunnel syndrome (CTS). Symptomatic and electrophysiological improvement has been previously documented. The electrophysiological parameter, which represents the most consistent change after local steroid injection, is not well-known.

OBJECTIVE

The objective of this study was to evaluate the changes in electrophysiological parameters 1 month after local steroid injection and to determine the parameter that is able to depict improvement across the severity spectrum of CTS.

MATERIALS AND METHODS

Forty-seven patients (27 with bilateral disease, 74 hands totally) were included. The electrophysiological parameters studied at baseline included sensory onset latency, sensory nerve action potential amplitude, sensory conduction velocity (CV), distal motor latency, compound muscle action potential amplitude and motor CV. All patients were injected with 40 mg triamcinalone at the wrist. After 1 month, symptomatic improvement from baseline was documented using visual analog score of 100. Electrophysiology was repeated. Paired t tests were done between baseline electrophysiology parameters and those obtained 1 month after steroid injection for significant improvement. Subgroup analyses were performed in hands with mild to moderate (Grade 3 or less by Bland's classification) and severe disease (Grades 4 and 5).

RESULTS

All patients showed a symptomatic improvement. Distal motor latency showed most consistent improvement irrespective of the severity of CTS. In mild to moderate CTS (Grade 3 or less of the classification given by Bland) sensory parameters were recordable and showed significant improvement in addition to distal motor latency. In the subcategory of severe CTS (Grades 4 and 5 of Bland) where sensory parameters are not recordable distal motor latency and the motor CV showed a significant improvement.

CONCLUSION

One month after local steroid injection among the electrophysiological parameters studied distal motor latencies showed most consistent and recordable improvement across the severity spectrum of CTS. This can be used as a single objective parameter to follow-up patients after a local steroid injection to document improvement or relapse. They can also be considered as objective parameter to follow-up patients after surgery.

How to perform local soft-tissue glucocorticoid injections?

Inflammation of periarticular soft-tissue structures such as tendons, tendon sheaths, entheses, bursae, ligaments and fasciae is the hallmark of many inflammatory rheumatic diseases, but inflammation or rather irritation of these structures also occurs in the absence of an underlying rheumatic disease. In both these primary and secondary soft-tissue lesions, local glucocorticoid injection often is beneficial, although evidence in the literature is limited. This chapter reviews local injection therapy for these lesions and for nerve compression syndromes.

Rehabilitation following carpal tunnel release

BACKGROUND

Various rehabilitation treatments may be offered following carpal tunnel syndrome (CTS) surgery. The effectiveness of these interventions remains unclear.

OBJECTIVES

To review the effectiveness of rehabilitation following CTS surgery compared with no treatment, placebo, or another intervention.

SEARCH METHODS

On 3 April 2012, we searched the Cochrane Neuromuscular Disease Group Specialized Register (3 April 2012), CENTRAL (2012, Issue 3), MEDLINE (January 1966 to March 2012), EMBASE (January 1980 to March 2012), CINAHL Plus (January 1937 to March 2012), AMED (January 1985 to April 2012), LILACS (January 1982 to March 2012), PsycINFO (January 1806 to March 2012), PEDRO (29 January 2013) and clinical trials registers (29 January 2013).

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials that compared any postoperative rehabilitation intervention with either no intervention, placebo or another postoperative rehabilitation intervention in individuals who had undergone CTS surgery.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion, extracted data and assessed the risk of bias according to standard Cochrane methodology.

MAIN RESULTS

In this review we included 20 trials with a total of 1445 participants. We studied different rehabilitation treatments including: immobilisation using a wrist orthosis, dressings, exercise, controlled cold therapy, ice therapy, multimodal hand rehabilitation, laser therapy, electrical modalities, scar desensitisation, and arnica. Three trials compared a rehabilitation treatment to a placebo comparison; three trials compared rehabilitation to a no treatment control; three trials compared rehabilitation to standard care; and 14 trials compared various rehabilitation treatments to one another.Overall, the included studies were very low in quality. Eleven trials explicitly reported random sequence generation and, of these, three adequately concealed the allocation sequence. Four trials achieved blinding of both participants and outcome assessors. Five studies were at high risk of bias from incompleteness of outcome data at one or more time intervals. Eight trials had a high risk of selective reporting bias.The trials were heterogenous in terms of the treatments provided, the duration of interventions, the nature and timing of outcomes measured and setting. Therefore, we were not able to pool results across trials.Four trials reported our primary outcome, change in self reported functional ability at three months or longer. Of these, three trials provided sufficient outcome data for inclusion in this review. One small high quality trial studied a desensitisation program compared to standard treatment and revealed no statistically significant functional benefit based on the Boston Carpal Tunnel Questionnaire (BCTQ) (MD -0.03; 95% CI -0.39 to 0.33). One moderate quality trial assessed participants six months post surgery using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and found no significant difference between a no formal therapy group and a two-week course of multimodal therapy commenced at five to seven days post surgery (MD 1.00; 95% CI -4.44 to 6.44). One very low quality quasi-randomised trial found no statistically significant difference in function on the BCTQ at three months post surgery with early immobilisation (plaster wrist orthosis worn until suture removal) compared with a splint and late mobilisation (MD 0.39; 95% CI -0.45 to 1.23).The differences between the treatments for the secondary outcome measures (change in self reported functional ability measured at less than three months; change in CTS symptoms; change in CTS-related impairment measures; presence of iatrogenic symptoms from surgery; return to work or occupation; and change in neurophysiological parameters) were generally small and not statistically significant. Few studies reported adverse events.

AUTHORS' CONCLUSIONS

There is limited and, in general, low quality evidence for the benefit of the reviewed interventions. People who have had CTS surgery should be informed about the limited evidence of the effectiveness of postoperative rehabilitation interventions. Until the results of more high quality trials that assess the effectiveness and safety of various rehabilitation treatments have been reported, the decision to provide rehabilitation following CTS surgery should be based on the clinician's expertise, the patient's preferences and the context of the rehabilitation environment. It is important for researchers to identify patients who respond to a certain treatment and those who do not, and to undertake high quality studies that evaluate the severity of iatrogenic symptoms from the surgery, measure function and return-to-work rates, and control for confounding variables.

Comparison of Knifelight Surgery versus Conventional Open Surgery in the Treatment of Carpal Tunnel Syndrome

Background

A variety of surgical treatment methods for carpal tunnel syndrome are introduced recently, including open surgery, endoscopic and the Knifelight. It is hypothesized that Knifelight method could decrease scar tenderness and time before return to daily activities for patients and is accompanied with less disturbance to fine sensory nerves.

Objectives

To compare the Knifelight instrument and open carpal tunnel release with respect to scar length, operation duration, recovery time needed before return to work and amount of pain three weeks after surgery in patients with neurophysiologically confirmed carpal tunnel syndrome.

Patients and Methods

Fifty nine patients with indication for carpal tunnel release randomly assigned into two groups: open (n=30) or Knifelight (n=29). The patients compared regarding scar length, operation duration, time to return to daily activities and amount of pain at three weeks after operation based on Visual Analog Scale.

Results

There was no significant differences regarding age and sex in the two groups. The scar length, operation duration and time before return to daily activities were significantly lower in the Knifelight group. Although the mean visual analogue scale of Knifelight group found to be lower than the other, it was not statistically significant.

Conclusions

The Knifelight technique is accompanied with advantages over the open surgery regarding operation time, scar length and time to return to daily activities. The pain relieve based on Visual Analog Scale was not statistically different from conventional open surgery.

Therapeutic ultrasound for carpal tunnel syndrome

BACKGROUND

Therapeutic ultrasound may be offered to people experiencing mild to moderate symptoms of carpal tunnel syndrome (CTS). The effectiveness and duration of benefit of this non-surgical intervention remain unclear.

OBJECTIVES

To review the effects of therapeutic ultrasound compared with no treatment, placebo or another non-surgical intervention in people with CTS.

SEARCH METHODS

On 27 November 2012, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL (2012, Issue 11 in The Cochrane Library), MEDLINE (January 1966 to November 2012), EMBASE (January 1980 to November 2012), CINAHL Plus (January 1937 to November 2012), and AMED (January 1985 to November 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any regimen of therapeutic ultrasound with no treatment, a placebo or another non-surgical intervention in people with CTS.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data and assessed the risk of bias in the included studies. We calculated risk ratio (RR) and mean difference (MD) with 95% confidence intervals (CIs) for primary and secondary outcomes. We pooled results of clinically homogenous trials in a meta-analysis using a random-effects model, where possible, to provide estimates of the effect.

MAIN RESULTS

We included 11 studies including 414 participants in the review. Two trials compared therapeutic ultrasound with placebo, two compared one ultrasound regimen with another, two compared ultrasound with another non-surgical intervention, and six compared ultrasound as part of a multi-component intervention with another non-surgical intervention (for example, exercises and splint). The risk of bias was low in some studies and unclear or high in other studies, with only two reporting that the allocation sequence was concealed and six reporting that participants were blinded. Overall, there is insufficient evidence that one therapeutic ultrasound regimen is more efficacious than another. Only two studies reported the primary outcome of interest, short-term overall improvement (any measure in which patients indicate the intensity of their complaints compared with baseline, for example, global rating of improvement, satisfaction with treatment, within three months post-treatment). One low quality trial with 68 participants found that when compared with placebo, therapeutic ultrasound may increase the chance of experiencing short-term overall improvement at the end of seven weeks treatment (RR 2.36; 95% CI 1.40 to 3.98), although losses to follow-up and failure to adjust for the correlation between wrists in participants with bilateral CTS in this study suggest that this data should be interpreted with caution. Another low quality trial with 60 participants found that at three months post-treatment therapeutic ultrasound plus splint increased the chance of short-term overall improvement (patient satisfaction) when compared with splint alone (RR 3.02; 95% CI 1.36 to 6.72), but decreased the chance of short-term overall improvement when compared with low-level laser therapy plus splint (RR 0.87; 95% CI 0.57 to 1.33), though participants were not blinded to treatment, it was unclear if the random allocation sequence was adequately concealed, and there was a potential unit of analysis error. Differences between groups receiving different frequencies and intensities of ultrasound, and between ultrasound as part of a multi-component intervention versus other non-surgical interventions, were generally small and not statistically significant for symptoms, function, and neurophysiologic parameters. No studies reported any adverse effects of therapeutic ultrasound, but this outcome was only measured in three studies. More adverse effects data are required before any firm conclusions on the safety of therapeutic ultrasound can be made.

AUTHORS' CONCLUSIONS

There is only poor quality evidence from very limited data to suggest that therapeutic ultrasound may be more effective than placebo for either short- or long-term symptom improvement in people with CTS. There is insufficient evidence to support the greater benefit of one type of therapeutic ultrasound regimen over another or to support the use of therapeutic ultrasound as a treatment with greater efficacy compared to other non-surgical interventions for CTS, such as splinting, exercises, and oral drugs. More methodologically rigorous studies are needed to determine the effectiveness and safety of therapeutic ultrasound for CTS.

Splinting for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is a condition where one of two main nerves in the wrist is compressed, which can lead to pain in the hand, wrist and sometimes arm, and numbness and tingling in the thumb, index and long finger. Splinting is usually offered to people with mild to moderate symptoms. However, the effectiveness and duration of the benefit of splinting for this condition remain unknown.

OBJECTIVES

To compare the effectiveness of splinting for carpal tunnel syndrome with no treatment, placebo or another non-surgical intervention.

SEARCH METHODS

We searched the Cochrane Neuromuscular Disease Group Specialized Register (10 January 2011), CENTRAL, NHSEED and DARE (The Cochrane Library 2011, Issue 4), MEDLINE (January 1966 to December 2011), EMBASE (January 1980 to January 2012), AMED (January 1985 to January 2012), and CINAHL Plus (January 1937 to January 2012), using no time limits. We searched the reference lists of all included trials and relevant reviews for further relevant studies.

SELECTION CRITERIA

All randomised and quasi-randomised trials comparing splinting with no treatment (or a placebo) or with other non-surgical treatments were eligible for inclusion. We also included studies comparing one splint type or regimen versus another. We excluded studies comparing splinting with surgical treatment. There were no language restrictions. We included all patients diagnosed with carpal tunnel syndrome unless they had undergone surgical release.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, and performed data extraction. Two authors also independently performed the assessment of risk of bias. We calculated measures of effect as risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI) reported and statistical significance set at P < 0.05 for all outcome comparisons.

MAIN RESULTS

The review included 19 studies randomising 1190 participants with carpal tunnel syndrome. Two studies compared splinting with no treatment, five compared different splint designs, one compared different splint-wearing regimens, seven compared splint delivered as a single intervention with another non-surgical intervention, and five compared splint delivered alongside other non-surgical interventions with another non-surgical intervention. Only three studies reported concealing the allocation sequence, and only one reported blinding of participants. Three studies measured the primary outcome, short-term overall improvement at three months or less. One low quality study with 80 wrists found that compared to no treatment, splints worn at night more than tripled the likelihood of reporting overall improvement at the end of four weeks of treatment (RR 3.86, 95% CI 2.29 to 6.51). However, the lack of patient blinding and unclear allocation concealment suggests this result should be interpreted with caution. A very low quality quasi-randomised trial with 90 wrists found that wearing a neutral splint more than doubled the likelihood of reporting 'a lot or complete relief' at the end of two weeks of treatment compared with an extension splint (RR 2.43, 95% CI 1.12 to 5.28). The third study which measured short-term overall improvement did not report outcome data separately per group. Nine studies measured adverse effects of splinting and all found either no or few participants reporting discomfort or swelling due to splinting; however, the precision of all RRs was very low. Differences between groups in the secondary outcomes - symptoms, function, and neurophysiologic parameters - were most commonly small with 95% CIs incorporating effects in either direction.

AUTHORS' CONCLUSIONS

Overall, there is limited evidence that a splint worn at night is more effective than no treatment in the short term, but there is insufficient evidence regarding the effectiveness and safety of one splint design or wearing regimen over others, and of splint over other non-surgical interventions for CTS. More research is needed on the long-term effects of this intervention for CTS.

Optimal case definitions of upper extremity disorder for use in the clinical treatment and referral of patients

OBJECTIVE

Experts disagree about the optimal classification of upper extremity disorders. To explore whether differential response to treatments offers a basis for choosing between case definitions, we analyzed previously published research.

METHODS

We screened 183 randomized controlled trials (RCTs) of treatments for upper extremity disorders identified from the bibliographies of 10 Cochrane reviews and 4 other systematic reviews, and a search in Medline, Embase, and Google Scholar to June 2010. From these, we selected RCTs that allowed estimates of benefit (expressed as relative risks [RRs]) for >1 case definition to be compared when other variables (treatment, comparison group, followup time, outcome measure) were effectively held constant. Comparisons of RRs for paired case definitions were summarized by their ratios, with the RR for the simpler and broader definition as the denominator.

RESULTS

Two RCT reports allowed within-trial comparison of RRs and 13 others allowed between-trial comparisons. Together these provided 17 ratios of RRs (5 for shoulder treatments, 12 for elbow treatments, and none for wrist/hand treatments). The median ratio of RRs was 1.0 (range 0.3-1.7, interquartile range 0.6-1.3).

CONCLUSION

Although the evidence base is limited, our findings suggest that for musculoskeletal disorders of the shoulder and elbow, clinicians in primary care will often do best to apply simpler and broader case definitions. Researchers should routinely publish secondary analyses for subgroups of patients by different diagnostic features at trial entry to expand the evidence base on optimal case definitions for patient management.

Exercise and mobilisation interventions for carpal tunnel syndrome

BACKGROUND

Non-surgical treatment, including exercises and mobilisation, has been offered to people experiencing mild to moderate symptoms arising from carpal tunnel syndrome (CTS). However, the effectiveness and duration of benefit from exercises and mobilisation for this condition remain unknown.

OBJECTIVES

To review the efficacy and safety of exercise and mobilisation interventions compared with no treatment, a placebo or another non-surgical intervention in people with CTS.

SEARCH METHODS

We searched the Cochrane Neuromuscular Disease Group Specialised Register (10 January 2012), CENTRAL (2011, Issue 4), MEDLINE (January 1966 to December 2011), EMBASE (January 1980 to January 2012), CINAHL Plus (January 1937 to January 2012), and AMED (January 1985 to January 2012).

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing exercise or mobilisation interventions with no treatment, placebo or another non-surgical intervention in people with CTS.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed searches and selected trials for inclusion, extracted data and assessed risk of bias of the included studies. We calculated risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CIs) for primary and secondary outcomes of the review. We collected data on adverse events from included studies.

MAIN RESULTS

Sixteen studies randomising 741 participants with CTS were included in the review. Two compared a mobilisation regimen to a no treatment control, three compared one mobilisation intervention (for example carpal bone mobilisation) to another (for example soft tissue mobilisation), nine compared nerve mobilisation delivered as part of a multi-component intervention to another non-surgical intervention (for example splint or therapeutic ultrasound), and three compared a mobilisation intervention other than nerve mobilisation (for example yoga or chiropractic treatment) to another non-surgical intervention. The risk of bias of the included studies was low in some studies and unclear or high in other studies, with only three explicitly reporting that the allocation sequence was concealed, and four reporting blinding of participants. The studies were heterogeneous in terms of the interventions delivered, outcomes measured and timing of outcome assessment, therefore, we were unable to pool results across studies. Only four studies reported the primary outcome of interest, short-term overall improvement (any measure in which patients indicate the intensity of their complaints compared to baseline, for example, global rating of improvement, satisfaction with treatment, within three months post-treatment). However, of these, only three fully reported outcome data sufficient for inclusion in the review. One very low quality trial with 14 participants found that all participants receiving either neurodynamic mobilisation or carpal bone mobilisation and none in the no treatment group reported overall improvement (RR 15.00, 95% CI 1.02 to 220.92), though the precision of this effect estimate is very low. One low quality trial with 22 participants found that the chance of being 'satisfied' or 'very satisfied' with treatment was 24% higher for participants receiving instrument-assisted soft tissue mobilisation compared to standard soft tissue mobilisation (RR 1.24, 95% CI 0.89 to 1.75), though participants were not blinded and it was unclear if the allocation sequence was concealed. Another very low-quality trial with 26 participants found that more CTS-affected wrists receiving nerve gliding exercises plus splint plus activity modification had no pathologic finding on median and ulnar nerve distal sensory latency assessment at the end of treatment than wrists receiving splint plus activity modification alone (RR 1.26, 95% CI 0.69 to 2.30). However, a unit of analysis error occurred in this trial, as the correlation between wrists in participants with bilateral CTS was not accounted for. Only two studies measured adverse effects, so more data are required before any firm conclusions on the safety of exercise and mobilisation interventions can be made. In general, the results of secondary outcomes of the review (short- and long-term improvement in CTS symptoms, functional ability, health-related quality of life, neurophysiologic parameters, and the need for surgery) for most comparisons had 95% CIs which incorporated effects in either direction.

AUTHORS' CONCLUSIONS

There is limited and very low quality evidence of benefit for all of a diverse collection of exercise and mobilisation interventions for CTS. People with CTS who indicate a preference for exercise or mobilisation interventions should be informed of the limited evidence of effectiveness and safety of this intervention by their treatment provider. Until more high quality randomised controlled trials assessing the effectiveness and safety of various exercise and mobilisation interventions compared to other non-surgical interventions are undertaken, the decision to provide this type of non-surgical intervention to people with CTS should be based on the clinician's expertise in being able to deliver these treatments and patient's preferences.

Corticosteroid injection for carpal tunnel syndrome: a 5-year survivorship analysis

BACKGROUND

The purpose of our study was to determine the rate of carpal tunnel decompression (CTD) following local corticosteroid injection for carpal tunnel syndrome (CTS), as well as identifying predictors of requiring further intervention and eventual decompression.

METHODS

All patients diagnosed with CTS in our unit over a 6-year period were prospectively assessed. Patients were diagnosed using a combination of clinical presentation and nerve conduction studies. Patients were managed with open carpal tunnel decompression or corticosteroid injection. There were 1,564 consecutive patients diagnosed with CTS over the study period, of whom 824 (53%) underwent a corticosteroid injection as their primary treatment. We performed a survivorship analysis of these patients and used Kaplan-Meier survivorship methodology to determine the 5-year rate of re-intervention. Risk factors for re-intervention were also determined.

RESULTS

The overall 5-year Kaplan-Meier rate of secondary CTD was 15% at 1 year and 33% at 5 years. The need for secondary CTD was independently associated with female gender, diabetes mellitus and positive nerve conduction studies at diagnosis.

CONCLUSIONS

Steroid injection is an appropriate treatment in carefully selected patients. Those who are female, diabetic and have neurophysiological confirmation of diagnosis have the highest risk of relapse. These results may be used to guide initial treatment and counsel patients about the risk relapse.