Local corticosteroid injection for carpal tunnel syndrome

Local corticosteroid injection versus physical therapy for the treatment of carpal tunnel syndrome: A systematic review and meta-analysis of randomized controlled trials

The comparative effect of commonly used conservative treatments for carpal tunnel syndrome remained controversial. The purpose of this study was to compare the clinical effect of local corticosteroid injection and physical therapy for the treatment of carpal tunnel syndrome. A systematic literature search of PubMed, EMBASE, and Cochrane library was conducted to identify relevant randomized clinical trials published before 21st Mar 2023. Two independent reviewers assayed quality of included studies using the Cochrane collaboration risk of bias tool. Relevant data were extracted and pooled analyses were conducted. Outcome measurements included Boston Carpal Tunnel Syndrome Questionnaire, visual analogue scale and some electrophysiology tests, while the former two were set as the primary outcomes. Subgroup analysis and sensitive analysis were performed and publication bias was evaluated. Heterogeneity among the included studies was examined using the I2 statistic. After selection, 12 studies were identified eligibility for inclusion. Only one study was found to have a high risk of bias. Pooled data of primary outcomes did not show any differences between treatments, and subgroup analysis supported the results. However, patients treated with local corticosteroid injection showed better improvement in distal motor latency (p = 0.002) and compound muscle action potential (p = 0.04). Some studies failed to pass the sensitive analysis, indicating the related analysis might be not so stable. A slight publication bias was observed in subgroup analysis of function scales, among three publication bias test. In conclusion, compared to physical therapy, local corticosteroid injection might have better treatment effects on carpal tunnel syndrome.

Local corticosteroid injection versus placebo for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is a very common clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the carpal tunnel in the wrist. Direct and indirect costs of CTS are substantial, with estimated costs of two billion US dollars for CTS surgery in the USA in 1995 alone. Local corticosteroid injection has been used as a non-surgical treatment for CTS many years, but its effectiveness is still debated.

OBJECTIVES

To evaluate the benefits and harms of corticosteroids injected in or around the carpal tunnel for the treatment of carpal tunnel syndrome compared to no treatment or a placebo injection.

SEARCH METHODS

We used standard, extensive Cochrane search Methods. The searches were 7 June 2020 and 26 May 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-randomised trials of adults with CTS that included at least one comparison group of local injection of corticosteroid (LCI) into the wrist and one group that received a placebo or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was 1. improvement in symptoms at up to three months of follow-up. Our secondary outcomes were 2. functional improvement, 3. improvement in symptoms at greater than three months of follow-up, 4. improvement in neurophysiological parameters, 5. improvement in imaging parameters, 6. requirement for carpal tunnel surgery, 7. improvement in quality of life and 8.

ADVERSE EVENTS

We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included 14 trials with 994 participants/hands with CTS. Only nine studies (639 participants/hands) had useable data quantitatively and in general, these studies were at low risk of bias except for one quite high-risk study. The trials were conducted in hospital-based clinics across North America, Europe, Asia and the Middle East. All trials used participant-reported outcome measures for symptoms, function and quality of life. There is probably an improvement in symptoms measured at up to three months of follow-up favouring LCI (standardised mean difference (SMD) -0.77, 95% confidence interval (CI) -0.94 to -0.59; 8 RCTs, 579 participants; moderate-certainty evidence). Up to six months this was still evident favouring LCI (SMD -0.58, 95% CI -0.89 to -0.28; 4 RCTs, 234 participants/hands; moderate-certainty evidence). There is probably an improvement in function measured at up to three months favouring LCI (SMD -0.62, 95% CI -0.87 to -0.38; 7 RCTs, 499 participants; moderate-certainty evidence). We are uncertain if there is a difference in median nerve DML at up to three months of follow-up (mean difference (MD) -0.37 ms, 95% CI -0.75 to 0.02; 6 RCTs, 359 participants/hands; very low-certainty evidence). The requirement for surgery probably reduces slightly in the LCI group at one year (risk ratio 0.84, 95% CI 0.72 to 0.98; 1 RCT, 111 participants, moderate-certainty evidence). Quality of life, measured at up to three months of follow-up using the Short-Form 6 Dimensions questionnaire (scale from 0.29 to 1.0; higher is better) probably improved slightly in the LCI group (MD 0.07, 95% CI 0.02 to 0.12; 1 RCT, 111 participants; moderate-certainty evidence). Adverse events were uncommon (low-certainty evidence). One study reported 2/364 injections resulted in severe pain which resolved over "several weeks" and 1/364 injections caused a "sympathetic reaction" with a cool, pale hand that completely resolved in 20 minutes. One study (111 participants) reported no serious adverse events, but 65% of LCI-injected and 16% of the placebo-injected participants experienced mild-to-moderate pain lasting less than two weeks. About 9% of participants experienced localised swelling lasting less than two weeks. Four studies (229 participants) reported that they experienced no adverse events in their studies. Three studies (220 participants) did not specifically report adverse events.

AUTHORS' CONCLUSIONS

Local corticosteroid injection is effective for the treatment of mild and moderate CTS with benefits lasting up to six months and a reduced need for surgery up to 12 months. Where serious adverse events were reported, they were rare.

Local Corticosteroid Injections versus Surgical Carpal Tunnel Release for Carpal Tunnel Syndrome: Systematic Review and Meta-Analysis

Introduction: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. This meta-analysis compared local steroid injections (LSIs) versus carpal tunnel release (CTR) for the management of CTS. Neurophysiological parameters, patient-reported outcome measures (PROMs), and the complication rate were investigated. We hypothesized that LSIs may represent an effective and safe alternative to surgical management. Methods: This systematic review was conducted according to the 2020 PRISMA statement. All the clinical investigations comparing LSIs versus CTR for carpal tunnel syndrome were accessed. In March 2022, the following databases were accessed: Pubmed, Web of Science, Google Scholar, and Embase. No time constrains were used for the search. The risk of bias and statistical analyses were conducted using the Review Manager Software 5.3 (The Nordic Cochrane Collaboration, Copenhagen). Results: Data from 1096 procedures were retrieved. The mean follow-up was 12.3 (1 to 58) months. The mean age of the patients was 51.1 ± 4.6. Nocturnal paraesthesia (p < 0.0001) and visual analogue scale (p < 0.0001) were greater in the LSIs cohort. No difference was found in the functional (p = 0.2) and symptom (p = 0.4) subscales of the Boston Carpal Tunnel Questionnaire (BCTQ), median nerve distal motor latency (p = 0.9), median nerve motor amplitude (p = 0.7), median nerve sensory conduction velocity (p = 0.4), or median nerve sensory amplitude (p = 0.3). No difference was found in terms of minor complications (p = 0.9). No major complications were observed within the duration of follow-up. Conclusion: Both CTR and LSIs were effective and feasible in reducing symptoms of carpal tunnel syndrome. Though LSIs led to greater pain relief, this superiority was not permanent. Irrespective of the severity of the symptoms, current evidence suggests that a cycle of LSIs may be considered in patients with CTS. However, patients must be aware that LSIs may not be the definitive therapy, and CTR should be recommended.

Efficacy of Ultrasound-Guided Particulate Versus Nonparticulate Steroid Injection in Carpal Tunnel Syndrome: An Open-Label Randomized Control Trial

Introduction

Perineural corticosteroid injection is an extensively used and accepted treatment for carpal tunnel syndrome (CTS). However, to this date, there is no guideline as to which corticosteroid has to be used as the standard treatment for CTS. Triamcinolone acetonide is a commonly used particulate steroid that can cause permanent nerve injury if it is accidentally injected into the nerve. Conversely, dexamethasone sodium phosphate is a nonparticulate steroid that would not cause permanent nerve damage following accidental injection.

Methods

Mild to moderate cases of CTS, confirmed by nerve conduction studies (NCS), with symptoms greater than three months were recruited. The participants received one session of ultrasound-guided perineural injection by the in-plane axial ulnar-sided approach with 4 mL of either dexamethasone (dexamethasone sodium phosphate 8 mg (2 mL) + 2 mL 0.5% bupivacaine) or triamcinolone (triamcinolone acetonide 40 mg/mL (1 mL) + 2 mL 0.5% bupivacaine + 1 mL normal saline) solution. The parameters assessed were Phalen’s test time (in seconds), visual analog scale (VAS), and Boston carpal tunnel questionnaire (BCTQ) scores at baseline and two and four months, and NCS changes in sensory nerve conduction velocity (SNCV) and distal motor latency (DML) of the median nerve at baseline and four months. Statistical analysis was conducted using the software SPSS version 26.0 (IBM Corporation, Armonk, NY, USA). Independent samples t-test was used for comparison between groups and the paired t-test for improvement within each group. P values < 0.05 were considered statistically significant.

Results

The mean age was 42.64 ± 10.99 in the dexamethasone and 45.22 ± 10.602 in the triamcinolone group cases (P = 0.324).There were 58 females (84.06%) and 11 males (15.94%). Each of Phalen’s test time, VAS, and BCTQ scores significantly improved within both dexamethasone and triamcinolone groups at the second and fourth months after injection (P < 0.05). The NCS parameters (SNCV and DML) also significantly improved in both groups at the fourth month after the injection (P < 0.05). However, there were no significant differences in the improvement of Phalen’s test time between the two groups (P = 0.745), VAS score (P = 0.319), BCTQ score (P = 0.137), SNCV (P = 0.511), or DML (P = 0.753). Postprocedural pain lasted significantly longer in the triamcinolone group (P < 0.05). No major complications were noted in either of the two groups.

Conclusion

Dexamethasone is as effective as triamcinolone in improving the symptoms of CTS and can be used as a safer and more effective alternative in the treatment of mild to moderate CTS cases.

Common peripheral nerve injuries in sport: diagnosis and management

Peripheral nerve injuries are unusual in sport but impact an athlete's safe return to play. Nerve injuries result from either acute trauma (most commonly in contact/collision sports) or from repetitive microtrauma and overuse. Diagnosis of overuse nerve injuries includes nerve localization and surrounding soft-tissue anatomy, and must account for possible causes of repetitive microtrauma, including biomechanics, equipment, training schedule, and recovery. Prognosis is related to the type of nerve injury. Management should not simply be rest and gradual return to sport but should address biomechanical and training predispositions to injury. Understanding the type of injury and the tissues involved will guide appropriate rehabilitation decisions. Recognizing acute care considerations and implementing appropriate strategies can help minimize secondary trauma to an area following acute injury.

Efficacy, safety, and cost of surgical versus nonsurgical treatment for carpal tunnel syndrome: A systematic review and meta-analysis

BACKGROUND

Carpal tunnel syndrome (CTS) is a common peripheral nerve entrapment disease. Either surgical or conservative intervention for CTS patients is needed to choose. We conducted this systematic review and meta-analysis to compare the clinical efficacy, safety, and cost of surgical versus nonsurgical intervention.

METHODS

The eligible studies were acquired from PubMed, Medline, Embase, Web of Science, Google, and Cochrane Library. The data were extracted by 2 of the coauthors independently and were analyzed by RevMan5.3. Standardized mean differences (SMDs), odds ratios (ORs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration Risk of Bias Tool and Newcastle-Ottawa Scale were used to assess risk of bias.

RESULTS

Thirteen studies including 9 randomized controlled trials (RCTs) and 4 observational studies were assessed. The methodological quality of the trials ranged from moderate to high. The difference of clinical efficacy was statistically significant between surgical and nonsurgical intervention, and nonsurgical treatment was more effective (OR = 2.35, 95%CI = 1.18-4.67, P = 0.01). Meanwhile, different results were discovered by subgroup analysis. The pooled results of function improvement, symptom improvement, neurophysiological parameters improvement, and cost of care at different follow-up times showed that the differences were not statistically significant between the 2 interventions. The difference of complications and side-effects was statistically significant and conservative treatment achieved better result than surgery (OR = 2.03, 95%CI = 1.28-3.22, P = 0.003). Sensitivity analysis proved the stability of the pooled results.

CONCLUSION

Both surgical and conservative interventions had benefits in CTS. Nonsurgical treatment was more effective and safety than surgical treatment, but there were no significant differences in function improvement, symptom improvement, neurophysiological parameters improvement, and cost of care. Nonsurgical treatment is recommended as the optical choice for CTS. If conservative treatment fails, surgical release can be taken.

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

Effect of Linum usitatissimum L. (linseed) oil on mild and moderate carpal tunnel syndrome: a randomized, double-blind, placebo-controlled clinical trial

BACKGROUND

Carpal tunnel syndrome is known as the most common entrapment neuropathy. Conservative treatments cannot reduce the symptomatic severity satisfactorily; therefore, effectiveness of Linum usitatissimum L. (linseed) oil on carpal tunnel syndrome, as a complementary treatment, was evaluated in the current study. Linseed oil is a well-known preparation in Iranian traditional medicine and its analgesic, anti-inflammatory and anti-oxidative effects have been shown in previous studies.

METHODS

A randomized, double-blind, placebo-controlled clinical trial was conducted. One hundred patients (155 hands) with idiopathic mild to moderate carpal tunnel syndrome aged between 18 and 65 years old were randomized in two parallel groups. These two groups were treated during 4 weeks with topical placebo and linseed oil. In addition, a night wrist splint was prescribed for both groups. Symptomatic severity and functional status were measured using Boston Carpal Tunnel Questionnaire. In addition, median sensory nerve conduction velocity, motor distal latency, sensory distal latency and compound latency as electrodiagnostic parameters were measured at baseline and after the intervention period.

RESULTS

After the intervention, significant improvement was observed regarding Boston Carpal Tunnel Questionnaire symptomatic severity and functional status mean differences (p <0.001) in the linseed oil group compared with those in the placebo group. Also, regarding the mean differences of both groups, significant improvement of nerve conduction velocity of the median nerve was seen in the linseed oil group by a value of 2.38 m/sec (p < 0.05). However, motor distal latency and sensory distal latency of the median nerve showed no between-group significant changes (p = 0.14 for both items). Finally, compound latency was improved slightly in the case group, comparing mean differences between the groups (p <0.05). No significant adverse events were reported from using linseed oil.

CONCLUSIONS

It seems that linseed oil could be effective in the management of mild and moderate carpal tunnel syndrome, especially in improving the severity of symptoms and functional status. In addition, its effect on electerodiagnostic parameters, especially on the nerve conduction velocity, can be considered as a valuable point.

Effect of vitamin b6 on clinical symptoms and electrodiagnostic results of patients with carpal tunnel syndrome

PURPOSE

Carpal tunnel syndrome (CTS) refers to a cluster of signs and symptoms that stems from compression of the median nerve traveling through carpal tunnel. Surgery is a definite treatment for CTS; however, many conservative therapies have been proposed. The present study set out to assess the effect of vitamin B6 in patients with CTS.

METHODS

Forty patients (67 hands) with mild-moderate CTS were initially selected and randomly assigned into two groups as follows: 1) Case group with 20 subjects (32 affected hands) receiving vitamin B6 (120 mg/day for 3 months) and splinting. 2) Control group with 19 subjects (35 affected hands) only received splinting. One subject from the control group dispensed with continuing participation in the research. Daily symptoms and electrodiagnostic (NCV-EMG) results were assessed at baseline and after 3 months.

RESULTS

Nocturnal awakening frequency due to pain, daily pain, daily pain frequency, daily pain persistence, hand numbness, hand weakness, hand tingling, severity of nocturnal numbness and tingling, nocturnal awakening frequency owing to hand numbness and tingling, and clumsiness in handling objects improved significantly in the vitamin B6-treated patients; even so, only problem with opening a jam bottle and handling phone significantly reduced in the control group. The median nerve sensory latency mean decreased following the treatment; and the median nerve sensory amplitude mean and sensory conduction velocity mean increased.

CONCLUSION

The present study suggests that vitamin B6 treatment improves clinical symptoms and sensory electrodiagnostic results in CTS patients, and thus is recommended for CTS treatment.

Health-related quality of life as a main determinant of access to rheumatologic care

To evaluate a rheumatology outpatient consultation access system for new patients. New patients seen from April 2005 to April 2006 at our rheumatology clinic (n = 4,460) were included and classified according to their appointment type: ordinary appointments (OA) to be seen within 30 days, urgent appointments (UA) and work disability appointments (WDA) to be seen within 3 days. Age, sex, diagnosis, and health-related quality of life (HRQoL) as determined by the Rosser Index were recorded. Logistic regression models were run to identify factors that contribute to each type of appointment. OA was the method of access for 1,938 new patients, while 1,194 and 1,328 patients were seen through WDA and UA appointments, respectively. Younger male patients, and those with microcrystalline arthritis, sciatica, shoulder, back, or neck pain, were more likely to use the faster access systems (UA or WDA), whereas patients with a degenerative disease were mainly seen through OA (<0.001). Subjects with poor (3.96; 95 % CI, 2.8-5.5) or very poor HRQoL (70.8; 95 % CI, 14.9-334) were strongly associated to visiting a rheumatologist through the WDA or UA access systems, respectively, compared to OA. Age, gender, diagnosis, and mainly health-related quality of life are associated with the referral pattern of access to rheumatologic outpatient care. Among new patients subjects with the worst HRQoL were more likely to access with faster methods (UA or WDA) than those with better HRQoL.

Progesterone - new therapy in mild carpal tunnel syndrome? Study design of a randomized clinical trial for local therapy

Background

Local corticosteroid injection for carpal tunnel syndrome (CTS) provides greater clinical improvement in symptoms one month after injection compared to placebo but significant symptom relief beyond one month has not been demonstrated and the relapse of symptoms is possible.

Neuroprotection and myelin repair actions of the progesterone was demonstrated in vivo and in vitro study.

We report the design of a randomized controlled trial for the local injection of cortisone versus progesterone in "mild" idiopathic CTS.

Methods

Sixty women with age between 18 and 60 years affected by "mild" idiopathic CTS, diagnosed on the basis of clinical and electrodiagnostic tests, will be enrolled in one centre. The clinical, electrophysiological and ultasonographic findings of the patients will be evaluate at baseline, 1, 6 and 12 months after injection.

The major outcome of this study is to determine whether locally-injected progesterone may be more beneficial than cortisone in CTS at clinical levels, tested with symptoms severity self-administered Boston Questionnaire and with visual analogue pain scale.

Secondary outcome measures are: duration of experimental therapy; improvement of electrodiagnostic and ultrasonographic anomalies at various follow-up; comparison of the beneficial and harmful effects of the cortisone versus progesterone.

Conclusion

We have designed a randomized controlled study to show the clinical effectiveness of local progesterone in the most frequent human focal peripheral mononeuropathy and to demonstrate the neuroprotective effects of the progesterone at the level of the peripheral nervous system in humans.

Effects of traditional cupping therapy in patients with carpal tunnel syndrome: a randomized controlled trial

We investigated the effectiveness of cupping, a traditional method of treating musculoskeletal pain, in patients with carpal tunnel syndrome (CTS) in an open randomized trial. n = 52 outpatients (58.5 +/- 8.0 years) with neurologically confirmed CTS were randomly assigned to either a verum (n = 26) or a control group (n = 26). Verum patients were treated with a single application of wet cupping, and control patients with a single local application of heat within the region overlying the trapezius muscle. Patients were followed up on day 7 after treatment. The primary outcome, severity of CTS symptoms (VAS), was reduced from 61.5 +/- 20.5 to 24.6 +/- 22.7 mm at day 7 in the cupping group and from 67.1 +/- 20.2 to 51.7 +/- 23.9 mm in the control group [group difference -24.5mm (95%CI -36.1; -2.9, P < .001)]. Significant treatment effects were also found for the Levine CTS-score (-.6 pts: 95%CI -.9; -.2, P = .002), neck pain (-12.6mm; 95%CI -18.8; -6.4, P < .001), functional disability (DASH-Score) (-11.1 pts; 95%CI -17.1; -5.1, P < .001), and physical quality of life (.3; 95%CI .0; .3, P = .048). The treatment was safe and well tolerated. We conclude that cupping therapy may be effective in relieving the pain and other symptoms related to CTS. The efficacy of cupping in the long-term management of CTS and related mechanisms remains to be clarified.

PERSPECTIVE

The results of a randomized trial on the clinical effects of traditional cupping therapy in patients with carpal tunnel syndrome are presented. Cupping of segmentally related shoulder zones appears to alleviate the symptoms of carpal tunnel syndrome.

Surgical treatment options for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome is a common disorder for which several surgical treatment options are available.

OBJECTIVES

To compare the efficacy of the various surgical techniques in relieving symptoms and promoting return to work or activities of daily living and to compare the occurrence of side-effects and complications in patients suffering from carpal tunnel syndrome.

SEARCH STRATEGY

We updated the searches in 2006. We conducted computer-aided searches of the Cochrane Neuromuscular Disease Group Trials Register (searched in June 2006), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 2), MEDLINE (January 1966 to June 2006), EMBASE (January 1980 to June 2006) and also tracked references in bibliographies.

SELECTION CRITERIA

Randomised controlled trials comparing various surgical techniques for the treatment of carpal tunnel syndrome.

DATA COLLECTION AND ANALYSIS

Two review authors performed study selection, assessment of methodological quality and data extraction independently of each other.

MAIN RESULTS

Thirty-three studies were included in the review of which 10 were newly identified in this update. The methodological quality of the trials ranged from fair to good; however, the use of allocation concealment was mentioned explicitly in only seven trials. Many studies failed to present the results in sufficient detail to enable statistical pooling. Pooling was also impeded by the vast variety of outcome measures that were applied in the various studies. None of the existing alternatives to standard open carpal tunnel release offered significantly better relief from symptoms in the short- or long-term. In three studies with a total of 294 participants, endoscopic carpal tunnel release resulted in earlier return to work or activities of daily living than open carpal tunnel release, with a weighted mean difference of -6 days (95% CI -9 to -3 days).

AUTHORS' CONCLUSIONS

There is no strong evidence supporting the need for replacement of standard open carpal tunnel release by existing alternative surgical procedures for the treatment of carpal tunnel syndrome. The decision to apply endoscopic carpal tunnel release instead of open carpal tunnel release seems to be guided by the surgeon's and patient's preferences.

Repetitive strain injury

Repetitive strain injury remains a controversial topic. The term repetitive strain injury includes specific disorders such as carpal tunnel syndrome, cubital tunnel syndrome, Guyon canal syndrome, lateral epicondylitis, and tendonitis of the wrist or hand. The diagnosis is usually made on the basis of history and clinical examination. Large high-quality studies using newer imaging techniques, such as MRI and ultrasonography are few. Consequently, the role of such imaging in diagnosis of upper limb disorders remains unclear. In many cases, no specific diagnosis can be established and complaints are labelled as non-specific. Little is known about the effectiveness of treatment options for upper limb disorders. Strong evidence for any intervention is scarce and the effect, if any, is mainly short-term pain relief. Exercise is beneficial for non-specific upper limb disorders. Immobilising hand braces and open carpal tunnel surgery release are beneficial for carpal tunnel syndrome, and topical and oral non-steroidal anti-inflammatory drugs, and corticosteroid injections are helpful for lateral epicondylitis. Exercise is probably beneficial for neck pain, as are corticosteroid injections and exercise for shoulder pain. Although upper limb disorders occur frequently in the working population, most trials have not exclusively included a working population or assessed effects on work-related outcomes. Further high-quality trials should aim to include sufficient sample sizes, working populations, and work-related outcomes.

Local corticosteroid injection for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome is a clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the carpal tunnel in the wrist. Local corticosteroid injection for carpal tunnel syndrome has been studied but its effectiveness is unknown.

OBJECTIVES

To evaluate the effectiveness of local corticosteroid injection for carpal tunnel syndrome versus placebo injection or other non-surgical interventions.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials register (searched May 2006), MEDLINE (searched January 1966 to May 2006), EMBASE (searched January 1980 to May 2006) and CINAHL (searched January 1982 to May 2006).

SELECTION CRITERIA

Randomized or quasi-randomized studies.

DATA COLLECTION AND ANALYSIS

Three authors independently selected the trials and rated their overall quality. Relative risks and 95% confidence intervals were calculated for each trial and summary relative risks and 95% confidence intervals were also calculated.

MAIN RESULTS

We included 12 studies with altogether 671 participants. Two high quality randomized controlled trials with altogether 141 participants demonstrated clinical improvement of carpal tunnel syndrome at one month or less following local corticosteroid compared to placebo injection (relative risk 2.58 (95% confidence intervals 1.72 to 3.87)). One trial compared local corticosteroid injection to oral corticosteroid and at 12 weeks after treatment there was significantly more improvement in the injection group (mean difference -7.10 (95% confidence intervals -11.68 to -2.52)). In one trial, the rate of improvement after one month was greater after local than systemic corticosteroid injection (relative risk 3.17 (95% confidence intervals 1.02 to 9.87)). In one trial, symptoms did not improve significantly more in the injection group at eight weeks after injection compared to treatment with anti-inflammatory medication and splinting (mean difference 0.10 (95% confidence intervals -0.33 to 0.53)). Two injections versus one injection of local corticosteroid did not provide further clinical improvement, mean difference -3.80 (95% CI -9.27 to 1.67).

AUTHORS' CONCLUSIONS

Local corticosteroid injection for carpal tunnel syndrome provides greater clinical improvement in symptoms one month after injection compared to placebo. Significant symptom relief beyond one month has not been demonstrated. Local corticosteroid injection provides significantly greater clinical improvement than oral corticosteroid for up to three months. Local corticosteroid injection does not significantly improve clinical outcome compared to either anti-inflammatory treatment and splinting after eight weeks or Helium-Neon laser treatment after six months. Two local corticosteroid injections do not provide significant added clinical benefit compared to one injection.

Industrial Medicine and Acute Musculoskeletal Rehabilitation. 6. Upper- and Lower-Limb Injections for Acute Musculoskeletal Injuries and Injured Workers

This self-directed study module focuses on the use of corticosteroids and other injections in the treatment of lateral epicondylitis, de Quervain's tenosynovitis, carpal tunnel syndrome, Achilles' tendinitis, and plantar fasciitis. It is part of the study guide on industrial rehabilitation medicine and acute musculoskeletal rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation.

OVERALL ARTICLE OBJECTIVE

To review the medical literature to help clinicians make treatment decisions regarding corticosteroid and other injections in the upper and lower limbs in injured workers.

Carpal tunnel syndrome--a comprehensive review

PURPOSE

To provide a comprehensive review of the management of carpal tunnel syndrome.

METHODS AND RESULTS

A systematic literature review is provided of the history, anatomy, pathophysiology, epidemiology, diagnostic criteria, investigative surgical techniques, results and complications for carpal tunnel syndrome.

CONCLUSION

Surgery for carpal tunnel syndrome requires meticulous attention to history-taking, investigation, counseling, training and surgical technique if unsatisfactory results and complications are to be avoided.

Surgery is more cost-effective than splinting for carpal tunnel syndrome in the Netherlands: results of an economic evaluation alongside a randomized controlled trial

Background

Carpal tunnel syndrome (CTS) is a common disorder, often treated with surgery or wrist splinting. The objective of this economic evaluation alongside a randomized trial was to evaluate the cost-effectiveness of splinting and surgery for patients with CTS.

Methods

Patients at 13 neurological outpatient clinics with clinically and electrophysiologically confirmed idiopathic CTS were randomly allocated to splinting (n = 89) or surgery (n = 87). Clinical outcome measures included number of nights waking up due to symptoms, general improvement, severity of the main complaint, paraesthesia at night and during the day, and utility. The economic evaluation was performed from a societal perspective and involved all relevant costs.

Results

There were no differences in costs. The mean total costs per patient were in the surgery group EURO 2,126 compared to EURO 2,111 in the splint group. After 12 months, the success rate in the surgery group (92%) was significantly higher than in the splint group (72%). The acceptability curve showed that at a relatively low ceiling ratio of EURO 2,500 per patient there is a 90% probability that surgery is cost-effective.

Conclusion

In the Netherlands, surgery is more cost-effective compared with splinting, and recommended as the preferred method of treatment for patients with CTS.

Transforaminal steroid injections for the treatment of cervical radiculopathy: a prospective and randomised study

Steroid injections are often employed as an alternative treatment for radicular pain in patients with degenerative spinal disorders. Prospective randomised studies of the lumbar spine reveal contradictory results and non-randomised and most often retrospective studies of the cervical spine indicate pain reduction from steroid injections. No prospective randomised study on transforaminal steroid injections for the treatment of radicular pain in the cervical spine focusing on short-term results has been performed. Forty consecutive patients were employed for the study. The inclusion criteria were one-sided cervical radiculopathy with radicular distribution of arm pain distal to the elbow and corresponding significant degenerative pathology of the cervical spine at one or two levels on the same side as the radicular pain and visualised by MRI. A transforaminal technique was used for all injections. A positive response to a diagnostic selective nerve root block at one or two nerve roots was mandatory for all patients. The patients were randomised for treatment with steroids/local anaesthetics or saline/local anaesthetic. Only the neuroradiologist performing the blocks was aware of the content of the injection; all other persons involved in the study were blinded. Follow up was made 3 weeks after the randomised treatment by a clinical investigation and with a questionnaire focusing on the subjective effects from the injections. At follow up, there were no differences in treatment results in the two patient groups. Statistical analysis of the results confirmed the lack of difference in treatment effect. Further studies have to be performed before excluding steroids in such treatment and for evaluating the influence of local anaesthetics on radiculopathy in transforaminal injections.

Incidence of common compressive neuropathies in primary care

Apart from carpal tunnel syndrome, there are no population based studies of the epidemiology of compressive neuropathies. To provide this information, new presentations of compressive neuropathies among patients registered with 253 general practices in the UK General Practice Research Database with 1.83 million patient years at risk in 2000 were analysed. The study revealed that in 2000 the annual age standardised rates per 100 000 of new presentations in primary care were: carpal tunnel syndrome, men 87.8/women 192.8; Morton's metatarsalgia, men 50.2/women 87.5; ulnar neuropathy, men 25.2/women 18.9; meralgia paraesthetica, men 10.7/women 13.2; and radial neuropathy, men 2.97/women 1.42. New presentations were most frequent at ages 55-64 years except for carpal tunnel syndrome, which was most frequent in women aged 45-54 years, and radial nerve palsy, which was most frequent in men aged 75-84 years. In 2000, operative treatment was undertaken for 31% of new presentations of carpal tunnel syndrome, 3% of Morton's metatarsalgia, and 30% of ulnar neuropathy.

Injection with methylprednisolone in patients with the carpal tunnel syndrome

OBJECTIVE

To determine the efficacy of 20, 40 and 60 mg methylprednisolone injections in patients with the carpal tunnel syndrome.

METHODS

Included were patients with signs and symptoms of carpal tunnel syndrome of more than 3 months duration confirmed by electrophysiological tests. Patients were in a double blind trial randomised to treatment consisting of injections proximal to the carpal tunnel with 20, 40 or 60 mg methylprednisolone. Primary outcome was improvement of symptoms requiring no further treatment. These patients were followed for one year.

RESULTS

There were no significant differences in the treatment response between the three randomised groups at one-year follow-up (log rank analysis 1.51, 2 df, 0.4711). In the 20, 40 and 60 mg treatment groups, 56%, 53% and 73% of the patients respectively were free of important symptoms at six months follow-up. Of the patients treated with one or two injections 22% were finally referred to surgery within one year of the first treatment. No side effects were recorded.

CONCLUSION

A single local injection of methylprednisolone 20, 40 or 60 mg results in long lasting improvement in approximately half of the patients. There is a trend in favour of the highest dose. A second injection may further reduce the number of patients requiring surgery.

The role of job strain on return to work after carpal tunnel surgery

AIMS

To examine the impact of job strain (that is, high psychological job demands and low job control) on return to work and work role functioning at two months, six months, or both, following carpal tunnel release surgery.

METHODS

A community based cohort of carpal tunnel syndrome (CTS) patients from physician practices was recruited between April 1997 and October 1998 throughout Maine (USA). 128 patients at two months and 122 at six months completed all relevant questions. A three level outcome variable indicated whether patients had: (1) returned to work functioning successfully, (2) returned to work functioning with limitations, or (3) not returned to work for health reasons. Two job strain measures were created: one, by combining psychological job demands and job control; and two, by dividing demands by control. Ordinal logistic regression was used to identify predictors of the three level work outcome variable.

RESULTS

After adjustment, workers with high demands and high control (active work) were less likely to successfully return to work (OR = 0.22; p = 0.014) at two months. Having a job with higher demands than job control (high strain) predicted not returning to work or returning to work but not successfully meeting job demands (OR = 0.14; p = 0.001), at six months.

CONCLUSIONS

The findings underscore the role of psychosocial work conditions, as defined by the Karasek demand-control model, in explaining a worker's return to work. Clinicians, researchers, and employers should consider a multidimensional and integrative model of successful work role functioning upon return to work. Moreover, since the evidence of the effects of work process changes on the reduction of CTS is very scarce, these findings point to the opportunity for collaborative workplace interventions to facilitate successful return to work.

What can family physicians offer patients with carpal tunnel syndrome other than surgery? A systematic review of nonsurgical management

BACKGROUND

We undertook a literature review to produce evidence-based recommendations for nonsurgical family physician management of carpal tunnel syndrome (CTS).

METHODS

Study design was systematic review of randomized controlled trials (RCTs) on CTS treatment. Data sources were English publications from all relevant databases, hand searches, and guidelines. Outcomes measured were nonsurgical management options for CTS.

RESULTS

We assessed 2 systematic reviews, 16 RCTs, and 1 before-and-after study using historical controls. A considerable percentage of CTS resolves spontaneously. There is strong evidence that local corticosteroid injections, and to a lesser extent oral corticosteroids, give short-term relief for CTS sufferers. There is limited evidence to indicate that splinting, laser-acupuncture, yoga, and therapeutic ultrasound may be effective in the short to medium term (up to 6 months). The evidence for nerve and tendon gliding exercises is even more tentative. The evidence does not support the use of nonsteroidal anti-inflammatory drugs, diuretics, pyridoxine (vitamin B6), chiropractic treatment, or magnet treatment.

CONCLUSIONS

For those who are not able to get surgery or for those who do not want surgery, there are some conservative modalities that can be tried. These modalities include ones for which there is good evidence. It would be reasonable to try some of the techniques with less evidence if the better ones are not successful. Reconsideration of surgery must always be kept in mind to avoid permanent nerve damage.